Automated post-discharge care essential to reducing readmissions

phytel | whitepaper

Readmission

Automated Post-Discharge Care:
An Essential Tool to Reduce Readmissions

Contents
The Challenge
Eliminating Systematic Failures That Begin in the Hospital
and Continue in Fragmented Healthcare Settings
Immediate Causes
New Government Incentives
New Regulations
Affordable Care Act
New Initiatives

Shared Savings Program

Gaps In Care Transitions

Inadaquate Preparation
Poor Educational Techniques
Poor Handovers

Best Practices

IHI’s Patient Centered Approach
Key Changes
Coleman Care Transitions Intervention
Naylor Transitional Model
Automation
Patient Education and Engagement
Connecting Providers With Each Other
Conclusion

The Challenge: Eliminating Systematic Failures That Begin in the
Hospital and Continue in Fragmented Healthcare Settings.
Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged
from the hospital returns there within 30 days,1 and between 50 percent and 75 percent of those readmissions
are considered preventable.2 Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its
beneficiaries, and other payers spend roughly the same amount every year for all readmissions of non-Medicare
patients.3

Immediate Causes
The immediate cause of a readmission is usually a rapid deterioration in the patient’s condition,
related to the patient’s primary diagnosis and/or comorbidities. But in a broader sense, it can be
attributed to systemic failures that begin in the hospital and continue in the fragmented health care
settings that patients move through after discharge.

In a typical scenario, patients receive inadequate preparation for discharge; the handover from the
hospital to their outpatient providers is poorly handled; and patients and their family caregivers are
left to cope on their own with medical issues that they don’t understand.4 In fact, only about half
of discharged patients follow up with their primary-care physicians after they leave the hospital,
and those who don’t are much more likely to be readmitted than those who do see a doctor.5

New Government Incentives
Until recently, some hospitals took the attitude that their responsibility for care ended when the
patient walked (or was wheeled) out the door. Other facilities have used a variety of techniques to
reduce readmissions, with mixed results. But new government incentives, plus a rising awareness
of the need to improve patient safety, are forcing hospitals to place an increased emphasis on
discharge planning and post-acute care.

1. Stephen F. Jencks, Mark V. Williams, and Eric A. Coleman, “Rehospitalizations Among Patients in the Medicare Fee-for-service Program,” N Engl J Med 2009; 360:1418-1428.
2. Mark Taylor, “The Billion-Dollar U-Turn,” Hospitals & Health Networks, May 2008.
3. Jencks, “Rehospitalization: The Challenge and The Opportunity,” presentation, Integrated Healthcare Association conference, Oct. 2009.
4. Suni Kripalani, Amy T. Jackson, Jeffrey L. Schnipper, and Eric A. Coleman, “Promoting Effective Transitions of Care at Hospital Discharge,” Journal of Hospital Medicine 2007;2:314–323.
5. Jencks, Williams, and Coleman, “Rehospitalizations Among Patients,” op. cit.

PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 3

New Regulations and their community partners decrease Shared Savings Program
readmissions over a five-year period ending
Front and center are Centers for Medicare Finally, in 2012, CMS will launch its shared-
in 2016. Through the government-sponsored
and Medicaid’s (CMS’) new regulations savings program for accountable care
Partnership for Patients, CMS will pay
on preventable readmissions. Starting organizations (ACOs), which are groups of
these “community-based organizations”
Oct.1, 2012, hospitals with “excessive“ hospitals and doctors that are committed to
a set amount per discharge for managing
readmissions-rehospitalizations that are raising the quality and lowering the cost of
Medicare beneficiaries at high risk for
significantly higher than expected will lose a care. To receive financial rewards from CMS,
readmission.7
percentage of their Medicare reimbursement these organizations will have to save money,
across the board. In FY 2013, the decrease which will give them a strong incentive to cut
New Initiatives
can be up to one percent of reimbursement, readmissions.9
rising to two percent in 2014 and three Two other CMS initiatives authorized
Nevertheless, it will be difficult for health
percent in 2015.6 by the health reform law are worth
care organizations to decrease readmissions
considering: payment bundling and
In the first year of this program, CMS will significantly in a fragmented, uncoordinated
accountable care organizations. Under CMS’
examine 30-day readmission rates for system. While most of the levers of
recently announced plan for its bundling
patients with heart failure, acute myocardial improvement are known, reengineering
demonstration, providers may choose
infarction, and pneumonia—three of the inpatient processes and engaging patients
among four different options. One option
leading conditions for which patients are and outpatient providers remains challenging.
includes all care provided from admission to
readmitted. Beginning in FY 2015, CMS may Fortunately, new applications of health
the hospital to 30 or 90 days after discharge.
also scrutinize chronic obstructive pulmonary information technology now offer inexpensive
Another would cover only post-acute care for
disorder and several cardiac and vascular ways to automate post-acute-care
up to 30 days.8
surgical procedures. processes. These solutions, which are
In both scenarios, providers would be
discussed later in this paper, can raise the
Affordable Care Act paid on a fee-for-service basis, adjusted
effectiveness of care managers, improve
retrospectively for variance from a budgeted
CMS has also launched other programs the communications between inpatient and
amount. While neither option penalizes
that might contribute to lower readmission outpatient providers, and make it easier for
providers for readmissions, both encourage
rates. To begin with, the agency plans to patients and caregivers to absorb and apply
improvements in the quality of post-acute
spend $500 million—or half of the $1 billion the knowledge required for self-management
care, which should reduce the number of
earmarked in the Affordable Care Act for of complex conditions.
rehospitalizations.
improving patient safety—to help hospitals

6. Neil Gold, “3 Readmissions to Reduce Now,” HealthLeaders Media, March 15, 2011, accessed at http://www.healthleadersmedia.com/content/COM-263665/3-Readmissions-to-
Reduce-Now.html.
7. Ken Terry, “Patient Safety Front and Center,” Hospitals & Health Networks, July 2011.
8. Department of Health and Human Services, “Improving Care Coordination and Lowering Costs by Bundling Payments,” fact sheet, Sept. 21, 2011, accessed at http://www.healthcare.
gov/news/factsheets/2011/08/bundling08232011a.html.
9. Rich Daly and Jessica Zigmond, “CMS Issues Proposed ACO Regulation,” Modern Healthcare, March 31, 2011.


Gaps In Care Transitions: The Five Main Contributors
The literature on transition problems shows there are five main areas that contribute to
preventable readmissions:

• Poor preparation for discharge

• Patients’ low health literacy and comprehension

• Failure or inability of patients to see physicians for follow-up after discharge

• Lack of hospital follow-up

• Lack of communication between inpatient and outpatient providers

Inadequate Preparation
Readmissions occur, by definition, after a patient has left the hospital. Yet the foundation for post-acute care
is laid during the hospital stay—and that preparation is often inadequate. “The hospital discharge process is
characterized by fragmented, nonstandardized, and haphazard care,” note Brian Jack, an expert on hospital
reengineering, and his colleagues.10

Nurses and first-year residents are often placed in charge of discharges. These staffers have many other duties
and may relegate discharges to a lower priority. Making matters worse, there are no clear lines of authority. As a
result, the system sets these individuals up to fail and creates a dangerous situation for patients.

10. Kripalani, et al., “Promoting Effective Transitions of Care.”


A prime safety issue cited by many experts hospital.13 communications to ensure that they are
is missing or inadequate medication Providers are partly responsible for this lack adhering to their medication regimens,
reconciliation at the time of discharge. The of comprehension. Physicians or nurses following up with their outpatient physicians,
medications that patients received in the may rush through their instructions and and looking for danger signs in their own
hospital are often discontinued at discharge, not encourage patients to ask questions. conditions.
while the drugs they were taking before they They may not use the proven “teach-back”
were admitted may or may not be resumed. method of having patients restate the
Dosages may also change.11 instructions in their own words. And they
The Joint Commission has identified may not realize that because of a patient’s
medication reconciliation as a key cognitive issues, his or her family caregiver
requirement for ensuring patient safety. 12
is the one who needs to receive the
The Institute for Healthcare Improvement instructions.14
also cites medication reconciliation as an Another big—and underappreciated—
opportunity to reduce readmissions. So problem is the low health literacy of the U.S.
this is clearly an area where hospitals could population. Roughly 90 million Americans—
contribute to lower rehospitalization rates. nearly half of the adult population--have low

Roughly 90 million Americans—nearly half of the adult population--have
low functional literacy. “Such patients typically have difficulty reading and
understanding medical instructions, medication labels, and appointment slips.”
functional literacy.15 “Such patients typically
Poor Educational Techniques
have difficulty reading and understanding
Another challenge is getting patients to medical instructions, medication labels, and
understand what will be required of them appointment slips,” according to one study.16
after discharge. In one study, for example,
What this means is that only oral but also
78 percent of patients discharged from
written instructions must be couched in
the ER did not understand their diagnosis,
terms that somebody with fairly little formal
their ER treatment, home care instructions,
education can understand. It also means
or warnings signs of when to return to the
that many patients require post-discharge

11. Ibid.
12. Susan Baird Kanaan, “Homeward Bound: Nine Patient-Center Programs Cut Readmissions,” California Healthcare Foundation report, September 2009.
13. Edwin D. Boudreaux, Sunday Clark, and Carlos A. Camargo, “Telephone follow-up after the emergency department visit: experience with acute asthma.” Ann Emerg Med. June
2000;35:555-563.
14. Gail Neilsen and Peg Bradke, presentation at Institute for Healthcare Improvement conference, July 13, 2011.
15. Kripalani, Jackson, op. cit.
16. Ibid.


Poor Handovers patients.19

Another glaring deficiency in post-acute While ambulatory-care physicians may
transitions of care is the inadequate be shooting in the dark when they see a
communications between inpatient and recently discharged patient, at least they may
outpatient providers. Here are a few statistics know something about the patient’s history,
that underline the chaotic state of these and they can find out what medications
communications: they’re on. All of that works to the patient’s
advantage. But many discharged patients
• Direct communication between hospital don’t or can’t make an appointment to see
physicians and primary care physicians a doctor within a week of discharge. If the
occurs in only three to 20 percent of cases patient is at high risk of complications and
deterioration, they should be seen within 24
• Only 12-34 percent of doctors have hours, but often this doesn’t happen.
received hospital discharge summaries by
the time patients make their first post-
discharge visits. The range rises to only
51-77 percent after four weeks, affecting
the quality of care in about a quarter of the
follow-up visits. 17
Studies have found that
• Approximately 40 percent of patients discharge summaries
have pending test results at the time of
discharge, and 10 percent of those require
often fail to provide basic
some action; yet, in the majority of cases, information about hospital
outpatient physicians are unaware of these
visits. Some summaries
results. 18
never even reach the
Other studies have found that discharge
summaries often fail to provide basic
primary care doctors who
information about hospital visits. Some are caring for discharged
summaries never even reach the primary
care doctors who are caring for discharged
patients.

17. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and
continuity of care. JAMA 2007;297(8):831-841.
18. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005;143(2):121-128.
19. Kripalani, Jackson, op. cit.


Best Practices: Best Methods for Reducing Readmissions
A great deal of research has been done on the best methods for reducing readmissions. In this section, we
will focus on the Institute for Healthcare Improvement’s (IHI’s) recommendations; the Coleman Care Transitions
Intervention; and the Naylor Transitional Care Model. Other resources for healthcare organizations include the
BOOST program of the Society of Hospital Medicine;20 the Care Transitions Performance Measurement Set of the
Physician Consortium for Performance Improvement;21 and the Transitions of Care Consensus Policy Statement
of the American College of Physicians and five other specialty societies.22

IHI’s Patient - Centered Approach
IHI, a Boston-based nonprofit organization that is leading two transitions-of-care initiatives,
recommends that healthcare organizations create “cross-continuum” teams that involve all
community stakeholders. It advises institutions to use a patient-centered approach that looks at
post-discharge care through a patient’s eyes. By doing “deep dives” into several patient histories,
IHI says, and finding out why the patients were readmitted, it’s possible to understand where the
entire process falls short and begin to fix it.23

Specifically, IHI recommends:
• Focusing on the patient’s journey over time across care settings

• Making discharge preparations early

• Redesigning health education materials using health literacy principles

• Providing intensive care management services for high-risk patients

• Making sure that patients have follow-up appointments with physicians

• Improving communications between inpatient and outpatient providers

By doing “deep dives” into several patient histories, IHI says, and finding out
why the patients were readmitted, it’s possible to understand where the entire
process falls short and begin to fix it.

20. Society of Hospital Medicine website, Project BOOST, accessed at http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.
cfm&CONTENTID=27659.
21. Physician Consortium for Performance Improvement, “Care Transitions Performance Measurement Set,” June 2009.
22. Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-
American College of Emergency Physicians-Society of Academic Emergency Medicine. J Gen Intern Med. 2009 Aug;24(8):971-6.
23. Phytel presentation, “IHI and PCMH Perspectives.”


Recognizing that patients and their caregivers are key parts of the post-
discharge care team, the transition coach visits the patient in the hospital and
again at home and makes three follow-up phone calls.

The key changes that hospitals need Overall, the CTI supports patients in during the first month; telephones the patient
to make, says IHI, are: four areas: weekly; implements a care plan that is
• Enhanced assessment of post-discharge continually reassessed in consultation with
• Making sure patients and/or caregivers
needs the patient, the caregiver, and the patient’s
can manage their medication
primary care physician; and continues calling
• Effective teaching and learning by patients • Giving patients personal health records to the patient monthly after the initial two-month
and or caregivers facilitate communications with providers period.
• Real-time handover communications and promote continuity of care
Randomized controlled trials have shown
• Scheduling, preparing for, and completing that the Naylor model reduces all-cause
• Assurance of post-hospital follow-up. 24
follow-up visits with physicians
readmission rates, increases patient
• Understanding danger signs for their satisfaction, function and quality of life; and
Coleman Care Transitions
conditions and knowing how to respond decreases overall healthcare costs. In one
Intervention to them study, the model reduced the number of
Eric Coleman, MD, a geriatrician at the readmissions at six months by 36 percent,
Studies have shown that the CTI approach
University of Colorado Health Sciences and costs by 39 percent.31
reduces the chances of rehospitalization
Center, and his colleagues have created a
by 40 to 50 percent.27-28 According to a The literature on the efficacy of post-
Care Transitions Intervention (CTI) model that
California Healthcare Foundation report, discharge phone calls has shown mixed
emphasizes the use of a transition coach.25
more than 130 hospitals across the U.S. results. But in one study, 19 percent of
Recognizing that patients and their caregivers
have adopted the CTI model. 29 patients experienced medication-related
are key parts of the post-discharge care team,
issues that were resolved with post-
the transition coach visits the patient in the
Naylor Transitional Care Model discharge calls.32 In another study, 35
hospital and again at home and makes three
percent of patients who received calls
follow-up phone calls. The coach teaches Mary Naylor, Ph.D., RN, and her colleagues
needed significant referral and aftercare
the patients/caregivers, helps them develop at the University of Pennsylvania have
instructions.33 This evidence points to the
self-management skills, and assesses their developed another approach for decreasing
need to reach out to the whole population
learning. While some coaches are nurses, readmissions. Their model involves care
of discharged patients, while stratifying
studies have shown that people with a wide coordination by a transitional care nurse
patients in order to increase the efficacy of
variety of backgrounds can perform this who generally has advanced practice
these phone calls and of care management
function. training.30Following evidence-based
in general.
protocols, the nurse care manager visits the
patient daily during his or her hospital stay;
visits the patient at home during the first
24 hours after discharge and then weekly

24. Nielsen and Bradke presentation, op. cit.
25. Kanaan, “Homeward Bound,” op. cit.
26. Coleman Eric A; Parry Carla; Chalmers Sandra; Min Sung-Joon. The care transitions intervention: results of a randomized controlled trial. Archives of internal medicine
2006;166(17):1822-8.
27. Ibid.
28. Eric A. Coleman, Jodi D. Smith, Janet C. Frank, DrPH, Sung-Joon Min, Carla Parry, and Andrew M. Kramer, “Preparing Patients and Caregivers to Participate in Care Delivered Across
Settings: The Care Transitions Intervention.” J Am Geriatr Soc 52:1817–1825, 2004.
29. Kanaan, “Homeward Bound.”
30. Ibid.
31. Naylor, M.D. et al. 2004. J Am Geriatr Soc 52:675–84.
32. Vicky Dudas, Thomas Bookwalter, Kathleen M. Keer, Stephen Z. Pantilat, “The impact of follow-up telephone calls to patients after hospitalization.” American Journal of Medicine, The
Vol. 111, Issue 9, Supplement 2, Pages 26-30.
33. The Journal of Emergency Medicine, Volume 6 (1988).


New automation tools can greatly facilitate the range of
best practices designed to improve post-discharge care
and reduce readmissions.

Automation Assessing Patient Risk
The approaches outlined above have been Some patients who are at high risk for
shown to work with certain kinds of patients, readmission can be identified in the hospital.
and they can also be cost-effective with Certain conditions, such as congestive heart
particular subpopulations. But, without the failure, make readmission likely; but, in many
aid of automation, they cannot reach all cases, comorbidities are responsible for
patients who have been discharged from rehospitalization.34 So some patients who are
the hospital. Moreover, their approach to not obvious candidates for readmission may
patient education is not as cost-effective slip through the cracks. Other factors, such
as it could be, because it relies on one-to- as adverse drug events because of poor or
one communications between patients or no medication reconciliation, can also lead to
caregivers and coaches or nurses. unexpected ER visits or readmissions.35
The existing models are also labor-intensive Ideally, hospitals should use predictive
in other respects. The coaches and nurse modeling to identify high-risk patients who
case managers in the Coleman and Naylor are likely to be readmitted if they don’t
models can handle only a limited number receive appropriate care after discharge.
of patients. And, while human contact is Utilized widely by managed care plans,
essential in high-risk cases, automated predictive modeling software analyzes
approaches can perform many of the basic hospital data, claims data on utilization and
tasks required to support patients during the comorbidities, and patient surveys to stratify
post-discharge transition. patients by risk level.
New automation tools can greatly facilitate
the range of best practices designed to
improve post-discharge care and reduce
readmissions. Among the areas where
automation can pay off in higher quality and
lower costs are:

• Risk stratification of patients

• Post-discharge communications with
patients

• Patient education and engagement
19%
of patients experienced medication
• Closing provider communication loops
related issues were resolved with
post-discharge calls

34. Nielsen and Bradke presentation, op. cit.
35. Kripalani and Jackson, op. cit.


During the critical 24 to 72 hours after histories from integrated primary care
discharge, an automated phone survey systems.
can be used to measure the satisfaction of
discharged patients with their care while Patient education and
gathering data on their risk factors. This engagement
information allows a computer program to
Automation can also provide better, more
calculate a risk score. Based on that and
consistent patient education that overcomes
on answers to condition-specific questions,
health literacy problems and ensures that
alerts about high-risk patients can be
patients understand the information they’re
transmitted to hospital care managers or
receiving. This is an enormous opportunity
triage nurses.
to help patients increase their confidence
In addition, if patients don’t understand and their ability to do self-management
discharge instructions or would like to be while reducing the amount of time and labor
contacted by the hospital for additional required to boost patients to that level.
follow-up, they can be transferred
Web-based, audiovisual educational
automatically to a hospital nurse help line or
materials are available, and some of them
a call center.
even provide links back to providers so that
If a patient has been identified in the hospital they can see whether patients have viewed
as high-risk, a nurse or transition coach the materials.36 But these programs lack the
should follow up with that patient at home or ability to test the patients on what they’ve
in the next care setting. learned and make sure they’re applying
Home telemonitoring may also be indicated, that knowledge to their own care. Digital
particularly for patients with heart failure. coaching tools can fill this gap and help
Signals from monitoring equipment alert patients manage their conditions as much as
care managers when the patient’s condition they can on their own. 37
deteriorates.
But for low- or medium-risk patients,
the automated survey approach can
establish whether the patient needs further During the critical 24 to 72 hours after
professional assistance.
discharge, an automated phone survey
Moreover, the system can tell the hospital
staff whether or not the patient has a follow- can be used to measure the satisfaction
up appointment with a physician. And if it
is connected with an outpatient registry, it
of discharged patients with their care
can supplement hospital data with medical while gathering data on their risk factors

36. Emmi website, www.emmisolutions.com.
37. Mari Edlin, “Digital health coaching brings care management to everyday life,” Managed Healthcare Executive, Jan 1, 2011.


Connecting providers to each The use of EHRs could speed the delivery
other of these summaries; but, as one observer
notes, hospitals and ambulatory-care
As the statistics cited earlier show, the
practices frequently use different systems
communication between hospital physicians
that are incompatible.41 In the future,
and ambulatory-care doctors is generally
health information exchanges will probably
subpar. There a number of reasons for this,
overcome this barrier. Meanwhile, healthcare
including a shortage of time, the difficulty
systems could investigate the use of the
of reaching outpatient providers, and
Direct Project protocol to “push” information
the inherent problems of phone and fax
from one EHR to another. 42
communications.
The patient outreach system described
Conclusion
earlier can help close the communication
loop in one significant respect: If ambulatory By preventing readmissions, healthcare
care providers are using the same system to organizations could improve patient
contact patients with preventive and chronic health and safety while responding to new
care needs, that service can also be used to government incentives and penalties. A
notify primary care physicians and outpatient patient-centered, automated approach is
care managers when patients in their panels the most efficient and cost-effective way
are admitted to the hospital and after they to make sure that all patients who have
are discharged. This alone would fill a been discharged are properly taken care
significant communication void. of. But such a model must be judiciously
combined with high-touch care management
The Physician Consortium for Performance
to address the needs of high-risk patients
Improvement and an article in the Journal
appropriately.
of Hospital Medicine38-39 both recommend
providing a transition summary to primary
care doctors within 24 hours, rather than
waiting for discharge summaries to be
prepared and transmitted. Such a summary,
which could be communicated by phone, fax
A patient-centered, automated approach is
or e-mail, would include discharge diagnosis, the most efficient and cost-effective way to
medications, results of procedures, pending
test results, follow-up arrangements, and make sure that all patients who have been
suggested next steps.40
discharged are properly taken care of.

38. PCPI, “Care Transitions Performance Measurement Set.”
39. Kripalani and Jackson, op. cit.
40. PCPI, “Care Transitions Performance Measurement Set.”
41. Kathleen Louden, “Creating a Better Discharge Summary: Is Standardization The Answer?” ACP Hospitalist, March 2009.
42. Janice Simmons, “Direct Project Gets Widespread Industry Support,” Fierce EMR, March 24, 2011, accessed at http://www.fierceemr.com/story/direct-project-gets-widespread-
industry-support/2011-03-24.


Automated post-discharge care essential to reducing readmissions

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (19)

Semelhante a Automated post-discharge care essential to reducing readmissions

Semelhante a Automated post-discharge care essential to reducing readmissions (20)

Mais de Phytel

Mais de Phytel (16)

Último

Último (20)

Automated post-discharge care essential to reducing readmissions