Re-engineered discharge cuts readmissions
Components include education, follow-up
Before North Broward Medical Center in Deerfield Beach, FL, re-engineered its discharge process two years ago, 29% of patients were being readmitted within 30 days. Now, the figure has dropped to 15%.
When the hospital began the initiative in the wake of the Centers for Medicare and Medicaid Services (CMS) proposal to penalize hospitals with excessive discharges, a multidisciplinary team examined data from CMS and from the Agency for Health Care Administration, which administers the Florida Medicaid program, looking specifically for patients with congestive heart failure, pneumonia, and myocardial infarctions, says Gavin Malcolm, LCSW, regional manager for case management for the medical center.
The team examined the records of patients admitted within 30 days and interviewed them to determine the reasons for the readmissions. Their findings were somewhat of a surprise. The team expected that there would be a difference in readmission rates by payer but determined that readmission rates for patients with Medicare, Medicaid, commercial insurance, and self-pay patients were virtually the same, he says.
The expectation was that the readmissions were caused by a major systems issue or another major problem but it boiled down to the fact that patients didn't understand their disease, the importance of follow-up visits to their primary care physician and why they should follow their treatment plan, Malcolm says. "The review was definitely eye opening. We determined that you can give patients medication but if they don't understand why they need to take it, they aren't likely to continue to take it when they start feeling better," he says.
In one instance, one readmitted heart failure patient reported that he couldn't weigh himself because he didn't have a scale at home. "That seems basic to the heart failure treatment plan but nobody asked him the question," he says.
The key to a successful readmissions reduction program is to make sure that everyone who comes in contact with the patient owns the educational process and understands that it's not just the job of case management and social work, Malcolm says. "Education is an ongoing process and not just something that happens when the patient is at the door, ready to leave," he adds.
Under the new process, the night shift nurses are involved in the discharge plan. The discharge paperwork is drawn up ahead of time and reviewed by the night nurse so that any discrepancies or medication reconciliation issues are picked up by the nurse and not discovered when the patient is ready to leave, he says. The night shift nurses go over the discharge plans with patients who are being discharged and ask questions to determine their ability to manage at home. For instance, they ask if the patient has food at home. "Obviously, patients aren't going to leave the hospital and go shopping for groceries. If they don't have food, we contact an organization that provides home delivered meals so the patients will have food for a few days," he says.
Another key to the success of the plan is to ask patients questions and encourage them to ask questions, Malcolm says. "The idea is to communicate to patients that it's important to us that they ask questions. The older generation tends to feel that they're being a burden when they ask questions and we want to constantly reinforce that we want them to ask any questions they have so they can know as much as possible when they go home," he says. The entire staff, including the non-clinical staff, such as social workers and dieticians, they reinforce the need for patients to ask questions when they make rounds and invite them to ask questions.
In addition to writing the discharge orders, physicians reconcile medication, and if the patients are getting new medication, making sure they understand not to take their old medications.
The nurse managers and the nurses on the floor call patients two days after discharge to make sure that all the patients' questions are answered, and to find out if there are other issues, such as home health workers not showing up. They make sure the patients have a number to call with questions and concerns, and they have their medication and understand how to take it.
The hospital pharmacists also make post-discharge calls to patients being discharged with four or more medications. They review the medication again and answer questions. If patients have been prescribed a new medication, the pharmacists make sure they have it. In most cases, the hospital pharmacy brings the medications to the patient's room before discharge, giving the patient an opportunity to ask questions.
The hospital has begun having an experienced nurse case manager make a home visit to follow up on patients who are at high risk for readmission. "We see this job as an important aspect of the total program and are transitioning the case manager to focus entirely on patients in the community," he says.
The case manager visits patients in assisted living centers as well as individual homes. "Our data showed that half of the readmitted patients came from assisted living centers. When we began looking into the situation, we found that assisted living facilities are not as supportive as many people assume," Malcolm says.
For instance, if residents in an assisted living center don't feel like going to the dining room for dinner, they often don't ask to have their meals delivered because they don't want to be a burden. "We found that in some cases, preventing a readmission was as simple as having someone deliver food to their rooms or making sure they had easy-to-prepare food in their rooms," he says.
Source
For more information, contact:
- Gavin Malcolm, LCSW, Regional Manager for Case Management, North Broward Medical Center, Deerfield Beach, FL. Email: [email protected].
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