Improving Care Transitions to Reduce Readmissions

For years, preventable hospital réadmissions have frustrated providers, payers, and patients. Nearly one in every five Medicare patients discharged from the hospital is readmitted within 30 days. Although some of those réadmissions can't be helped, owing to an unanticipated change in a patient's condition or a planned follow-up treatment, too many are the result of patient confusion over new medication regimens, inadequate follow-up with primary care physicians, or a family's inability to deal with home care. Government officials estimate 13 percent of Medicare patients are readmitted for such avoidable reasons.1

Preventable réadmissions not only present a quality and patient satisfaction challenge, but they also have significant financial impact. Shifts toward value-based payment, performance transparency in an age of growing consumerism, and increased penalties for readmissions are making réadmissions prevention a high priority for many healthcare finance executives.

In 2012, more than 2,000 hospitals paid readmissionsrelated penalties to the Centers for Medicare & Medicaid Services (CMS), amounting to roughly $280 million. And in FY2014, with the continued ushering in of healthcare reform, CMS may cut up to 2 percent of payment for hospitals that exceed the 30-day réadmissions rates for patients with heart failure, heart attack, or pneumonia.

As hospitals seek to reduce avoidable réadmissions, they will often find greatest opportunities for improvement by focusing on transitions of care. It's this period between when a hospital discharges a patient and when responsibility for adhering to the after-care regimen shifts to the patient or an extended care team that a patient's health status is often most vulnerable.

With this in mind, this HFMA Educational Update, sponsored by Walgreens, focuses on key strategies for hospitals and health systems to improve management of care transitions.

Reconciling Medications at Discharge

Medication reconciliation-the process by which medications prescribed to patients prior to hospitalization are deemed to be congruent with those prescribed at the hospital-poses significant challenges for most healthcare providers. Given that many patients, especially those with chronic conditions, use more than one pharmacy and take medications prescribed by more than one physician, the room for error between hospital and after-care setting abounds.

Sarasota Memorial Health Care System, Sarasota, Fla., an 806-bed regional medical center, is addressing its process of medication reconciliation for heart failure patients in a particularly effective way. Clinicians and pharmacists are working together to review each patient's existing prescriptions and current medications to verify that new prescriptions issued in the hospital properly align.

Because its pharmacy partner integrates data with a third-party data intermediary, Sarasota Memorial can access a patient's medication history, regardless of whether the patient's prescriptions were filled by a retail, mail order, or specialty pharmacy. In addition to ensuring proper medication alignment, pharmacists also can identify when there are any discrepancies with prescriptions, or when prescriptions are no longer necessary and should therefore be discontinued.

"Pharmacists can provide unique insight into medication issues," notes Fred D. Jung, RN, PhD, CPHQ, Sarasota Memorial's executive director of quality and patient safety. Setting up the patient for an accurate and simplified drug regimen this way supports patient safety and encourages proper adherence to medication therapy once the patient leaves the hospital.

"The ability to reconcile medications this way so that we avoid duplicate dosages or drug interactions is a major step forward," Jung says. "The more data we have in front of us in real time, the less likely we will be to duplicate efforts and the better our physicians can make decisions when prescribing medication. Improving processes around medication management not only leads to better health outcomes, but also a better patient experience."

Targeting heart failure patients for introduction of the program was a natural fit. "Almost all heart failure patients will be on extensive medication therapies for an extended period of time," explains Jung. "Because these patients have the most complicated sets of medications to follow, the opportunity was great to bring into play the expertise of an outside pharmacy."

Offering Bedside Medication Delivery

Sarasota Memorial also supports effective medication therapy by offering bedside medication delivery to patients. All too often, patients will fail to fill prescriptions, particularly if they feel too ill to travel or do not understand the importance of immediately starting medication therapy. A 2010 study of a commercially insured population showed that nearly 30 percent of patients do not fill new prescriptions.2 Putting medications directly into patients' hands before they leave the hospital has immense potential for improving medication adherence.

Providing Medication Counseling

Another cornerstone of Sarasota Memorial's medication management program is that pharmacists, rather than other clinicians, counsel patients about medication use prior and after discharge. "The most comprehensive education a patient receives about his or her prescriptions comes from a pharmacist," Jung says. "Counseling from someone with such a high level of medication knowledge is a critical way to get patients started on the right track for medication adherence."

Pharmacists call patients within 48 hours of discharge and again 10 days after discharge. The conversations provide an opportunity to reaffirm patients understand the medication regimen. The pharmacists also validate that patients are keeping to scheduled follow-up appointments with their physicians and can make note of any changes to medication regimens that may have resulted from prescriptions issued at follow-up appointments. Finally, 25 days after discharge, the pharmacist makes a "community integration call" to provide one last check of patients' progress and address any lingering questions.

Enabling Successful Self-Care

Once patients leave the hospital, the variables that influence patient compliance become more difficult to control-but they are not insurmountable, as Valley Baptist Medical Center, based in southern Texas, is learning. With a grant from CMS, the organization has implemented a successful community-based care transitions program.

The program, which is led by nurses and social workers trained in supporting transitions of care, works by equipping elderly patients at high risk for readmission with critical knowledge and skills to enable successful self-care during the first 30 days following discharge.

While the patient is still at the hospital, a member of the transitions team will encourage patients to schedule a follow-up appointment with their personal physician within three days of leaving the hospital. Using evidence-based transitions protocols, the team also provides patients and their caregivers with a complete personal health record for the patient; a reconciled list of medications; a timeline for follow-up appointments; and a list of "red flags" that the patient's condition is deteriorating and requires clinical attention.

Once the patient has left the hospital, the team will coordinate a home visit to provide additional education around after-care regimens and address any obstacles the patient may be experiencing that could prevent compliance. Following the home visit, the team will then continue to connect with the patient to ensure self-care efforts progress as intended, with updates occurring by phone two or three times per week.

Having such resources in place to support self-care after discharge can prove particularly valuable. Consider the example of a patient who is prescribed an inhaler to use at home. Although the patient will certainly be instructed on how to use the inhaler prior to discharge, the patient may not fully comprehend the instructions because he or she is still feeling very unwell or is distracted by the idea of going home. The result is that, once home, the patient may find the prospect of using the inhaler too intimidating and will simply leave it unused. Or, confusion relating to the instructions received in the hospital setting may lead to misuse. When ongoing discussions occur outside of the hospital, such situations can easily be remedied.

At Valley Baptist Medical Center, the strength of the program isn't just in counseling patients; it also lies in verifying compliance with after-care regimens.

"One very simple but effective strategy we've incorporated into the program is to give each of the patients a medication storage box labeled with days of the week," says Angela S. Blackford RN, MBA, CCM, system director of care management at Valley Baptist Medical Center. "We quickly found that the medication box not only gives patients an easy way to track their medication use, but also serves as a valuable tool during home visits to help the transitions team monitor patient compliance with medication regimens."

Using Community Extenders

Transitions management also can benefit from community support. In a separate program, Valley Baptist has collaborated with several community organizations to form a program devoted to improving chronic care management to reduce diabetes-related réadmissions. Meeting the needs of this patient population is particularly important given the prevalence of diabetes in the community: The Texas Department of Health estimates 26 percent of the surrounding Texas Rio Grande Valley population is diabetic.

Because Valley Baptist includes two major hospitals near the Mexico-United States border, some of the organization's patients can experience language or cultural barriers that can impede effective diabetes management following a hospital stay. Under the program, "promotoras"-specially trained, lay community members-act as liaisons between program participants and their care team.

"The promotoras function as advocates for these patients, who may need greater support when navigating the healthcare system," Blackford says. "Also, because the promotoras come from within the community, patients often are more open with them when discussing their care and potential obstacles than with a physician or other health professional."

The liasons help patients better understand aftercare instructions and importance of compliance. Frequently, the liaisons will work with patients who have special dietary needs to create meal plans and identify appropriate grocery lists.

With its multi-pronged approach to readmission management, Valley Baptist has reduced its overall rate of réadmissions from 28 percent in 2011 to 13.7 percent as of November 2013.

Smoothing Transitions with SNFs

Risk of readmission does not exist solely in the home setting. Transitions to skilled nursing facilities (SNFs) also are important to manage. Among Sarasota Memorial's heart failure patients, approximately one-third are discharged to a SNF.

Poor communication between care providers at different sites is a common contributor to avoidable readmission. When a hospital receives patients from SNFs through its emergency department (ED), it may not have the most up-to-date information about the patient's medical history and medications. By the same token, following a patient's hospital stay, it's not uncommon for a nursing facility to receive an incomplete copy of the patient's medical record.

To facilitate more successful transitions of care between settings, Sarasota Memorial has focused on improving such communications. The organization created an IT process that allows neighboring SNFs to securely access its electronic record system. When a SNF sends a patient to the ED, it is able to seamlessly supply the hospital care team with current health information for the patient from its records. The electronic process gives the emergency care team a much more robust view of the patient's medical history and medications. In the same way, the hospital provides a convenient source for the SNF to receive complete and accurate information about the patient's episode of care.

Another way hospitals can improve care transitions with SNFs is by sharing readmissions data and collaborating on process improvement. Such conversations may lead to better understanding when particular circumstances indicate an emergent situation versus one that can be addressed on an outpatient basis. Hospitals and SNFs also can work together to ensure coordination of a patient's end-of-life wishes and that care plans appropriately support them.

Endnotes

1 Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Promoting Greater Efficiency in Medicare, Washington DC, MedPAC, 2007.

2 Improving Prescription Medication Adherence Is Key to Better Health, PhRMA, January 2011.