Six ways to reduce hospital readmissions in 2018

If Innovation Health patients experience redness or itchiness for a wound related to gallbladder surgery, Sunil Budhrani, MD, chief medical officer and chief medical informatics officer at the Falls Church, Virginia-based organization (which is a partnership between Inova healthcare system that serves more than two million people each year, and Aetna) wants to keep them out of the emergency room. That’s why patients receive verbal and written instructions from case workers prior to discharge as to what changes to watch for near the surgical site, a prescheduled follow-up appointment, and a phone number for a nurse to call if they have questions.

If patients do call, nurses can access their claims data and electronic records, says Budhrani. “We know exactly what was done in real time because we’re also an insurance company. We have access to that data when the patient leaves the hospital.” Patients can even consult a nurse by video and then have a follow-up appointment with a physician the next morning.

As a result of these and other efforts, Innovation Health members who receive their care from in-network doctors are 18% less likely to be readmitted within 30 days of a hospital admission than other Innovation Health members. Overall, members treated by in-network physicians end up in the hospital 7% less than members seen in other networks.

Innovation Health’s efforts are a prime example of how improved care coordination and patient education can reduce readmissions. What follows are six more ways hospitals and health systems around the country are reducing readmissions.

1. Teach physicians and nurses communication skills and empathy

Since 2009, the Cleveland Clinic has trained more than 5,000 physicians on empathy skills. This training is required for all staff physicians, says Vicente Velez, MD, an internal medicine hospitalist who leads the Cleveland Clinic’s Center for Excellence in Healthcare Communication. “We know that certain patients get readmitted more than others, and we know the factors of readmission. It’s all about communication skills during transitions of care, and communicating with patients so that they understand their instructions and they’re empowered in their care,” says Velez.

The full-day training course, which nurse practitioners also attend, covers the foundations of healthcare communications-such as establishing rapport with patients-and includes practicing those skills and receiving feedback. Physicians also learn how to ensure patients feel respected and are invested in their care plans, says Velez, who notes that it’s important for physicians to engage patients in these conversations, rather than lecturing at them-and ask patients to relay what they have learned back to physicians. Each class is small and includes 12 participants at most, so everyone receives meaningful practice and feedback.

“[Learning how to communicate with empathy] is immediately relevant regarding readmissions because physicians need to engage patients as they prepare for transitions of care. Absent that type of preparation, patients often show up to the hospital as readmissions,” says Velez.

He advises physicians to ask patients who are struggling to adhere to treatment plans about their fears, expectations, and worries associated with those plans. He cites the example of a patient who kept getting readmitted to the hospital for diabetic ketoacidosis. This patient’s sugar levels were too high and there was acid in his blood, which was the result of his nonadherence to his treatment plan. After this patient was readmitted approximately twice a month for three months, the physician asked him, “What are the barriers to you not using insulin?” The patient told him his sister had taken insulin, and ended up on dialysis as a result. She died shortly after starting dialysis, due to complications associated with the treatment. Thus, the patient’s perception was that insulin had caused his sister’s death. The physician addressed the patient’s concerns, and since this conversation, the patient has adhered to the treatment plan and hasn’t been readmitted, says Velez.

In 2012, the Cleveland Clinic’s average internal readmissions rate was 15%, according to a spokesperson. Because of this and other efforts, the current average internal readmissions rate is 14%, which represents roughly 2,000 fewer patient readmissions per year.

Next: Strategy #2

2. Embed clinicians in hospitals outside your geographic area

Dartmouth Hitchcock health system’s primary goal with readmissions reduction initiatives is to “ensure that the patient gets the right type of care, in the right place, at the right time,” says Sowmya Viswanathan, MD, chief physician executive officer. She notes that the health system, which is headquartered in Lebanon, New Hampshire, has been feeling “a little bit of a push” by payers to control costs through reduced readmissions, but the focus continues to be on patient care.

Dartmouth Hitchcock’s patients-those whose primary-care physicians are affiliated with the health system-can end up in emergency rooms at hospitals in the southern part of the state, which is more populated. “That’s quite a distance for patients to drive back and forth. A lot of them use their local hospitals in the south in their local community to get their care ... that means we need to work hand-in-hand with non-Dartmouth Hitchcock partners to see how we can take care of the patient collectively,” says Viswanathan.

The health system has care managers and social workers in nearby Dartmouth Hitchcock-affiliated outpatient settings-such as primary-care practices and acute- and sub-acute rehabilitation facilities-to help manage the care of the health system’s patients.

Here’s how the flow might work: A Dartmouth Hitchcock patient arrives at Cheshire Medical Center in Keene, New Hampshire, after a skiing accident. After being seen at the emergency room in Keene, 65 miles away from Dartmouth Hitchcock, the care team determines that the patient has an ACL tear and a minor ankle sprain. The patient is also seen by an orthopedist from Cheshire Medical Center, and the care team decides that the patient needs acute rehabilitation for two weeks.

A pivotal member of this care team is the care manager, a Dartmouth Hitchcock staff member, who monitors the patient to determine how she’s progressing in rehabilitation. If, for example, the care manager determines that the patient is ready to leave the rehabilitation facility after eight days-instead of the original 10-the patient is then returned to the care of her Dartmouth Hitchcock primary-care provider for a follow-up appointment. Viswanathan notes that this follow-up appointment could include a check on the patient’s blood sugar levels to ensure that they didn’t cause her fall.

In 2011, the readmission rate for all Medicare patients in Dartmouth Hitchcock’s community was approximately 17%; as result of this and other initiatives at the health system, its readmission rate is approximately 9%. Viswanathan also says that Dartmouth Hitchcock is in the highest percentile for New England for controlling bloodstream infections and hospital-acquired conditions, which is the result of the health system’s efforts to reduce hospital readmissions.

Next: Strategy #3

3. Treat all patient conditions upon arrival in the ER

There’s one very specific expectation Katherine DiPalo, PharmD, clinical pharmacy manager for heart failure at Bronx, New York-based Montefiore Medical Center, wants to set with patients. “When you come into the hospital with an acute condition, we’ll treat you for that. But we don’t ignore everything else. We’ll focus on what you want to focus on, but we also want to optimize patient care while [you’re] in the hospital, which means [you’ll] also receive treatment for diabetes, heart failure, hypertension, and any other chronic conditions,” she says.

That means, for example, that heart failure patients with diabetes will be discharged from the hospital with follow-up appointments for a diabetes specialist and a cardiologist, she says.

Patients also receive educational materials about the secondary condition. Those materials might cover the following:

• Letting the doctor know if symptoms worsen, such as feeling more tired than usual, gaining more than three pounds in three days, or having heightened swelling in legs, ankles, feet, or belly. Patients are also told to watch out for feelings of anxiety and depression.

• Monitoring weight gain, which can be a sign of fluid retention and a worsening heart condition. Patients are advised to weigh themselves at the same time each day, record their weights, and bring those records to their physician.

• Taking medications as needed and informing doctors if medications aren’t working as directed. Patients are also told to maintain an updated list of medications to share with doctors and to have it on-hand in case of an emergency.

Next: Strategy #4

4. Capture captive audiences with more educational condition-specific materials

Patients staying overnight in the hospital have a lot of downtime, and much of it is spent watching television. That’s one of the reasons Montefiore has devoted a channel to heart condition-specific education. Patients have 24-hour access to information about salt restrictions, medical diuretics, weight monitoring and self-care, and devices such as pacemakers.

Pacemakers, especially, can be very scary for patients, so offering more education is key, says DiPalo. “If you put this information in a pamphlet and hand it over to the patient, that’s not going to cut it. We have specific program times when patients can learn more about this and other advanced heart condition materials.”

Non-heart condition content includes programing on diabetes, which teaches patients how to inject insulin, says DiPalo. Patients learn this skill from their diabetes educators, and the information is reinforced in the video. Patients can access this video content post-discharge as well, via the patient portal, says DiPalo. This is helpful for patients to review with their primary caregiver at home.

The more informed patients are about their condition and how to self-manage it, the less likely it is they will be readmitted. This year, the readmission rate on the four units impacted by this and other evidence-based heart failure initiatives at Montefiore Medical Center is 16.2%; the readmission rate in other units is 20.3%.

Next: Strategy #5

5. Leverage community resources

Preventing readmissions fits in with Orlando Health’s twin goals of keeping patients and its finances healthy, since the health system, a network of community and specialty hospitals based in Orlando, is reimbursed by payers based on its ability to do so, says Tawnya Adkisson, director of care coordination.

Many of Orlando Health’s patients are uninsured and underinsured, says Adkisson, so it focuses on addressing the social determinants that drive patients to land in the emergency room. For seven years, the Reach Team, a group of social work students from the University of Central Florida, has connected with patients to determine the resources they need to be healthy. The students talk to patients to ensure, for example, that they have transportation to follow-up appointments and electricity if their medications need to be refrigerated.

While some managed Medicaid plans will help with transportation costs, Adkisson says Orlando Health might pay for a year’s worth of bus passes or taxis to appointments. And, if patients are about to have their electricity shut off, the team might work with the electricity provider to institute a medical necessity contract.

Members of this team also help determine if wheelchair-bound patients don’t have a ramp to leave their home, and work with community organizations to secure funding to install them, says Adkisson. Absent a wheelchair ramp, patients may have no choice but to call an ambulance. “Our first goal is to optimize community resources where available,” says Adkisson.

If funding isn’t available, Orlando Health pays for services out of its discharge support program. While Adkisson was unable to share specific figures, she says the health system spends an “ample amount” in discharge support each year. “We do budget discharge support needs every single year to ensure that we’re delivering that level of care back to the community,” she says.

Since 2013, when the health system started getting more involved in value-based care, it expanded the use of its Reach Team to physician practices. This means that patients don’t need to go to the emergency room to have access to the Reach Team; rather, they can be referred to the program “right there in the community where they live,” says Adkisson.

In 2012, Orlando Health’s overall readmission rate stood at 16.3%. Today, its readmission rate is 15.7%.

Next: Strategy #6

6. Coaching COPD and pneumonia patients

Bon Secours St. Francis Health System in Greenville, South Carolina, has reduced readmission rates for its COPD and pneumonia patients by following these patients for 90 days. These patients are seen in the hospital by a coach and a disease-specific navigator on their first day in the hospital and on the day of their discharge. They can call a 24-hour hotline for non-emergency issues, and patients are screened for the probability of readmission by using the following tools:

• Risk Readmission Assessment Tool (RRAT) calculation higher than 21, which is the cumulative score of variables such as infection, smoking, obesity, diabetes, and venous thromboembolism.

• More than three emergency room visits in six months.

• More than three impatient visits in six months.

Based on where a patient falls in these metrics, members of Bon Secours’ clinical team review their home setting, set follow-up appointments within seven days, reconcile medications, educate patients on disease processes, and assess their transportation and other socio-economic needs.

In 2016, COPD and pneumonia patients experienced a 30% to 33% 90-day readmission rate. Today, Bon Secours’ COPD patients have a 10% 90-day readmission rate, and pneumonia patients have a 90-day readmission rate of 4.3%.

“These are some of our patients with the greatest need and we are pleased with the specific outcomes,” says Diane Carper, BSN, administrative director of nursing at Bon Secours. “Clearly these processes continue to drive positive outcomes and we will continue to monitor performance across additional populations.”

Aine Cryts is a writer based in Boston.