Ten ways to reduce hospital readmissions

Irvine, California-based ConcertoHealth serves its patients, 97% of whom are eligible for Medicare and Medicaid, at four care center locations in Detroit and three care centers in Seattle. Through discharge planning and post-discharge support infrastructure, use of technology, and "embedding" clinicians with admitting privileges at area hospitals' emergency departments, the healthcare system has reduced readmissions within one year of admission from more than 25% to less than 15%. It has also decreased average lengths of stay from almost 30 days to less than 15 days, says Colin LeClair, senior vice president of business and product development at ConcertoHealth.

LeClairThe health system uses technology from Boston-based PatientPing that alerts staff in Irvine if a patient presents in an emergency room in Detroit or Seattle. At that point, embedded clinicians employed by ConcertoHealth, either nurses or physicians who provide coverage for two or three hospitals, take over the patients' care in the emergency room. That involves actually meeting with the patient and communicating with the hospital about the patient’s primary care provider, relevant specialists, care manager, and their medical history, all with the goal of reducing readmissions and getting the patient into the appropriate care setting. That care setting might be a skilled nursing facility or in-home care supported by a home health agency, for example, says LeClair.

Here are nine other strategies providers across the country are using to reduce hospital readmissions.

1. Increasing patient engagement 

If healthcare providers wait until the day of a patient's hip or knee surgery to worry about preventing readmissions, they've probably missed the boat, says Anthony DiGioia, MD, founder and medical director of the Patient and Family Centered Care Methodology and Practice Innovation Center at the University of Pittsburgh Medical Center (UPMC).

DiGioiaThat's why the medical center considers all of the processes that touch patients, from presurgical preparations such as lab testing to the surgery and the patient stay to the patient's rehabilitation, and keeping in mind the perspective of patients and their families as they design patient care. Keeping the patient's perspective in mind helps drive higher patient engagement, which, along with family engagement, is the best way to reduce readmissions and improve outcomes, insists DiGioia, who is also a practicing orthopedic surgeon.

DiGioia notes that patient falls, either in the hospital or at home after surgery, are of particular concern to patients and their friends and families. In response, UPMC uses the following approach, which is heavily reliant on patient engagement, to help prevent readmissions among its total hip and total knee replacement patients:

• Educating patients three or four weeks before their surgery about what to expect;

• Coaching patients to start their post-operative exercises three or four weeks before their surgery;

• Teaching patients about the medical center’s falls prevention program; and

• Encouraging patients to select a family member or a friend as a "coach."

At 4.8%, three of the 20 hospitals under the UPMC umbrella chosen at random, Magee-Womens Hospital of UPMC Health System, UPMC Presbyterian Shadyside, and UPMC Mercy, are at the national rate of unplanned readmission rate after hip/knee surgery, according to the Hospital Compare website.

Next: Preventing surgical site infections

2. Preventing surgical site infections

New England Baptist Hospital in Boston is reducing readmissions by taking critical look at wound care for hip and knee surgery patients. This is a smart approach, as a 2015 study published in the Journal of the American Medical Association found that surgical site infections are the most common reason for unplanned readmissions.

New England Baptist started with the hospital's wound care committee, which includes eight nurses who are certified in wound care as well as one surgeon. The team researched the best dressing supplies and studied how often wound dressings were being changed and by whom, says Mary Sullivan Smith, RN, senior vice president, chief operating officer, and chief nursing officer.

The team discovered a great deal of variability in how patients' wounds were being dressed, related to the use of proper hand hygiene, the appropriate use of tape, and the different providers who were actually dressing patients' wounds. The team found that dressings were being changed by a physician assistant or a nurse, which meant that many people were picking up a dressing and looking at a wound, which increased the chances of variability, says Sullivan Smith.

The hospital's current protocol involves dressings that may only be changed once before the patient is discharged, some aren't changed at all, says Sullivan Smith. If the dressing is changed, it must be changed by a nurse who follows the appropriate protocols. Patients then remove the dressing at the appropriate time once they get home, she says. 

As a result, fewer staff members are touching patients' wounds and wounds have less exposure to the environment, which means fewer infections, says Sullivan Smith. The wound care team educates the entire clinical team about wound care protocols twice a year to increase awareness, she says.

While the statistical prediction of infection (SPI) for knee surgeries at the hospital,
per the Massachusetts calendar year 2013 Healthcare-Associated Infections Data Report
(the latest statistics available in the hospital's 2014 quality report) is 13.9,
the actual rate of infections is 5 infections; the SPI rate for hip surgeries is 12.2,
but the actual rate at the hospital is 7 infections.

Only .8% of New England Baptist Hospital's hip, knee, and spine surgeries result in unplanned 30-day readmissions per 1,000 patients, reports the hospital; all-cause 30-day readmissions are 1.2% per 1,000 patients, according to its 2014 quality report. The hospital is actively working to meet its aspirational goal of zero readmissions for its patients, according to its quality report.

Next: Putting nurses back in the classroom

3. Putting nurses back in the classroom

Newton-Wellesley Hospital, which is located 13 miles outside Boston in suburban Newton and is part of Partners HealthCare, took 20 of its nurses out of the hospital and sent them to a conference organized by the Cambridge, Massachusetts-based Institute for Healthcare Improvement (IHI), a nonprofit focused on driving healthcare improvement worldwide, to learn about ways to improve patient care.

Thurlo-WalshOne of the tools the nurses brought back to their patients was the "teach back" method, which involves nurses educating patients about what they should be doing once they get home after being discharged from the hospital, and then asking patients to explain those instructions in a way that the patient understands, says Bert Thurlo-Walsh, RN, vice president of quality and patient safety.

For example, nurses tell congestive heart failure patients that they need to be careful about eating foods with high salt content, as these foods may cause them to retain water and then have trouble breathing, says Thurlo-Walsh. Patients are also advised to monitor their ankles for signs of weight gain. Patients are then asked to explain what this dietary advice and monitoring of health signs means to them, says Thurlo-Walsh.

These conversations, which were once driven by a paper-driven work flow, are now built into the hospital's EHR-driven work flow and that alone has had increased compliance from less than 50% to more than 90%, says Thurlo-Walsh. Newton-Wellesley's readmissions rate for all surgical procedures has gone down from 11.4% in 2012 to 10.8% as of April 2016, according to the hospital.

Next: Using whiteboard-based care plans

4. Using whiteboard-based care plans

Ineffective care transition processes lead to both adverse events and higher hospital readmissions and costs, reports The Joint Commission. In 2015, the Health Research & Educational Trust, a Chicago-based nonprofit research and educational affiliate of the American Hospital Association, recommended the use of whiteboards to improve the communication of care plans across the entire care team.

The use of whiteboards is a technique used successfully at New England Baptist Hospital, for patients who have undergone hip or knee surgeries. Staff members keep the white boards in their hospital rooms updated with their goals for their day, the latest status on their medications, and their pain levels.

The whiteboards, which also function to keep patients and their family members engaged in the patients' care, are updated by the care team in real time with the latest information on their rehabilitation and their level of independence as they move along with their progress in the hospital, says Sullivan Smith.

"We're very interested in making sure [patients] are taking the right pain medications so they can participate in their therapy and can move towards the best function that that can," she says. Still, she notes that the clinical team is also very concerned about the opioid crisis that's taking hold in Massachusetts and around the country. Thus, it's a balancing act: We want patients to be taking these medications when they need to be, and not taking them if they don't need to, she says.

Next: Reducing blood transfusions

5. Reducing blood transfusions

A 2013 study published in the Journal of the American College of Surgeons found that blood transfusions are one of the post-operative occurrences that lead to increased risk of readmissions.

That's why other healthcare systems might learn from UPMC's initiative to reduce the number of blood transfusions for total joint replacement patients.

To accomplish that goal, in 2009, the medical center launched its Comprehensive Blood Management Program, which initially included three components: establishing a trigger for blood transfusions, using volume expanders for hypovolemia (or when the liquid portion of the blood is too low), and identifying patients with anemia and bleeding risk factors.

The initial results were a significant reduction in transfusion rates, from 14% of total knee replacement patients and 9% of total hip patients to 8% and 4%, respectively, says Timothy Levison, who directs quality management and clinical outcomes for the Bone and Joint Center at Magee-Womens Hospital of UMPC. These rates remained steady, he says, until 2012, when UPMC started using Tranexamic Acid (or TXA) to further reduce transfusion rates to 1% for total knee and 2% for total hip surgeries.

DiGioia notes that less invasive surgical approaches, such as using smaller incisions to repair the bone or put in an implant mean less exposure to soft tissue and bone, have also helped to reduce the medical center's transfusion rates.

Next: Preventing pressure sores

6. Preventing pressure sores

A 2012 study published in the Journal of the American Geriatrics Society revealed that patients who developed pressure sores were more likely to die during their hospital stay, have generally longer stays in the hospital, and be readmitted within 30 days of discharge.

In its 2014 quality report, New England Baptist Hospital notes that it has a rate of 0.7% of patients who acquire pressure sores during their hospital stay, that's compared to the national average of 1.2% among peer orthopedic specialty hospitals.

The first thing New England Baptist Hospital does to prevent pressure ulcers is have patients evaluated by a nurse on the wound care team to determine whether they have any skin problems, which can be the case with elderly patients who live in nursing homes, says Sullivan Smith. Then the wound care nurse documents their assessments and provides a plan of care to their entire care team.

Some practical approaches the hospital uses to prevent pressure sores include providing all patients with mattresses that have a pressure redistribution feature to promote skin integrity and adding protection for high-risk patients by placing air mattress overlays over their mattresses, says Eileen Galvin, director of case management at New England Baptist Hospital. The hospital's wound care-certified nurses are also available to consult and share their experience for identified higher-level skin interventions and management, she says.

Next: Training the entire care team as navigators

7. Training the entire care team as navigators

At UPMC, you can't find anyone who's hired to serve as a care navigator for patients. Instead, everyone on the care team, including the patient's family members, function as navigators, says DiGioia

"One of the things patients always say about our program is they can't believe that everyone is on the same page all the time, and that's from the office to the floor to the therapy office," he says.

While UPMC doesn't hire patient navigators, per se, DiGioia says providers view patients' selected coaches as their "free navigators," since these friends and family members have a vested interest in helping to take care of the patient, and they do so at no cost.

Employing the use of patient navigators is a smart move, as it can lead to reduced readmissions.

For example, the use of care navigators among patients 60 years and older led to a 4% reduction in 30-day readmissions; according to a 2015 study published in the Journal of General Internal Medicine.

Next: Keeping skin surfaces sanitary

8. Keeping skin surfaces sanitary

Using an antiseptic cleanse can help reduce surgical site infections in patients, according to a 2015 study published in The Cochrane Central Register of Controlled Trials. That's why, at New England Baptist Hospital and at many hospitals around the country, patients are asked to bathe with a chlorhexidine wash as part of their presurgery preparations.

Based on research conducted on best practices for preventing infections, one of New England Baptist's nurses recommended about a year ago the use of a chlorhexidine cleansing cloth for patients to use the morning of their hip or knee surgery. That practice is now part of the clinical team's protocols, says Sullivan Smith, who notes that patients will typically clean the surgical area with the cloth or nurses will do it for elderly patients or those who can't reach the surgical site themselves.

The chlorhexidine cleansing cloth protocol is in addition to the hospital's recommendation that patients shower with a chlorhexidine wash to prepare for their surgery, says Galvin, who notes that some patients aren't compliant with those protocols; and that's problematic because noncompliance can lead to infections.

This is a good example of how the hospital tries to identify potential problems and solve them before they become problems, says Galvin. "For us, that's part of the patient-centered model of care, where we focus on the individual care plan for any potential barriers and intervene ahead of time so these problems don't become serious for our patients," she says.

Next: Preventing falls while encouraging mobility

9. Preventing falls while encouraging mobility

As DiGioia noted previously, falls are a common problem with joint replacements, and that's the case while the patient is in the hospital for the procedure and once they return home.

At UPMC, the protocol is to get patients out of bed the night of their surgeries. Still, patients are counseled that they shouldn't try to get out of bed without a nurse or someone else right there with them, he says. "The night of surgery, we encourage them to always call [if they need help getting around]. That's an example where it's about patient education. We're doing rapid rehab, but we're educating patients on the potential problems if they fall," says DiGioia.

The challenge is that many patients want to be independent, and they don't want to bother the nurse if they have to get up to go to the bathroom. "You hear that all the time, that they don't want to bother the nurses. But the nurses and the other staff here say very explicitly, 'No problem. Call us with those kinds of things.' It's about engaging patients in their own care," he says.

UPMC uses bed alarms, signs about the risk of falling in patient rooms, and preoperative education pamphlets on the dangers associated with falls and the ways to prevent them. In addition, all staff members are trained on fall prevention, says Levison.

The medical center has cut patient falls among joint replacement patients by more than 50% since these interventions were implemented. In 2012, before the falls prevention program started, there were 26 patient falls. In 2015, there were 12 patient falls, says Levison. He points out that, while the national fall rate is 3.92 falls per 1,000 patient days, UPMC's fall rate is 2.71.

"We continue to monitor our falls very closely and the falls working group has begun to spread the best practices recognized within the orthopedic population across other service lines and throughout the entire hospital," he says.

Aine Cryts is a writer based in Boston.