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Readmission Reduction Strategies

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Following is the full conversation of Episode 1 of the Hospital Readmissions Reduction Podcast.

Michael: Welcome to the Hospital Readmissions Reduction Podcast, brought to you by BESLER Consulting. This is the podcast for hospital leaders seeking insights and strategies they need to help reduce readmissions at their organizations. I’m Mike Passanante, your host for this podcast. Today we’re going to take a special deep dive on readmission reductions strategies.

I’m joined today by Dr. Edward Niewiadomski. Dr. Niewiadomski has over three decades of experience in direct patient care and healthcare administration. He’s the former Senior Vice President of Medical Affairs and Chief Medical Officer for Community Acute Care Facility in New Jersey. Dr. Niewiadomski, welcome.

Dr. Niewiadomski: Yes, thank you, Michael.

Michael: There are so many factors that play into how a hospital can choose their approach to reducing readmissions. You have patient population, measures under the HRRP, hospital resources, geographic constraints. How do you even start? How do you go about figuring out where to focus your efforts?

Dr. Niewiadomski: I think, first and foremost, we have to start with the top. And the organizational leadership, both the administrative leadership and medical staff leadership need to champion the cause that readmission reduction is a priority within the organization. And once you have identified that, then you will have complete buy-in from the balance of the organization and departments.

Michael: That makes sense. So you begin to develop your focus, you’ve got the buy-in, how do you select strategies to employ? What are some of the ways a hospital can screen patients, for instance, who are likely to readmit?

Dr. Niewiadomski: That’s a very good question. And the Institute for Health Improvement clearly states that you need to identify those patients who are at high risk for an unplanned readmission within 30 days. They don’t say what tool you should use, but they recommend using something. One of the tools, that’s most widely studied, is called the LACE score.

Once you identify that patient who has a high risk what you need to do is you need to create a process where there is a mandatory referral for that patient. And that patient needs to avail themselves to any of all of the resources that the organization commits in readmission reduction strategies. So the entire team needs to be aware of those patients who are at risk and therefore can end up with a positive outcome at the end of their hospital stay and into the discharge period.

Michael: Okay. Let’s say you’ve figured out which patients you need to focus on, which conditions you want to focus on, what do you do specifically?

Dr. Niewiadomski: The literature has identified several strategies that have been well studied and demonstrated some very good outcomes and results. I’d like to reference this one article in particular. This came out of Yale University and appeared in the journal, Circulation. And although this study came out with recommendations and looked at a sub-cohort of heart failure patients, the strategy that they proposed can really apply to all the core measures of the Hospital Readmissions Reduction Program. And again, as a reminder, our core measures are heart failure, acute myocardial infarction, pneumonia, COPD, and total joint, total hip and knee replacement. If you implement these strategies you will have very good results in reducing your unplanned readmissions.

And I’d like to delineate them. First and foremost, you need to partner with your physicians. Physicians play a critical role in the results as it relates to readmission reduction strategies. They provide care both in the acute-care setting and in the outpatient setting, and having patients readily available to come back for follow-up visits and accessibility to their primary care physicians upon discharge is critical. No longer is it acceptable for a follow-up visit to occur two or three weeks post-discharge. We need to get those patients back into the primary care office within days of the discharge.

Secondly, it’s been identified that collaborating with local facilities is key. A lot of our patients may not go home, they may go for rehab or to a SNF facility. We need to have very good relationships and communications between the organizations so that continuity of care can be established and readmissions mitigated.

A third item is assigning a nurse for medication reconciliation to medication plans. Among the various caregivers it was identified that the nurse is best equipped to provide insight for the patient into their medications, why they’re taking certain medications, what each medication is used to treat, the doses, the frequency and looking for complications of the medications.

The fourth item was scheduling follow-up appointments for patients in the pre-discharge period. For example, while a patient is in the hospital we will have studies that may not be warranted during the episode of care, but upon discharge we want the patient to come back. It’s no longer acceptable to leave the patient on their own with a 1-800 number to call back to the hospital or try to make the arrangements for, say, a follow-up MRI or a laboratory study. We need to have a firm date and time for those patients to come back and say, “On Tuesday at 10:30 you will come back to the hospital and have your follow-up CAT scan or MRI.” Additionally, as it relates in the post-discharge period, test results that were not available prior to the patient’s discharge need to be followed up on.

We see length of stays being compressed whereas years ago they used to be measured in 7, 10, 12 days. The average length of stay across the country is measured about 4 to 4 1/2 days. The acute episode of care is being compressed into that three to four day period, so we may not get all the results back prior to the patient being discharged. If a patient is discharged and the result comes back, we need to make sure we follow up with that patient. And I’m not just talking about a critical care or a critical result or a critical item like a potassium of 1.2 or a hemoglobin of 4, I’m talking about a data point that may be trending towards an abnormal level or out of range. Let them know that their potassium is starting to run a little low and get them back on potassium supplementation earlier, this may avoid an unplanned readmission.

And lastly, the sixth strategy that this Yale study identified is identifying items and ways to share information with the attending physicians. A lot of times the attending physician in the outpatient setting will not be the physician taking care of the patient in the inpatient setting. Usually, the doctors focused on outpatient care relegate the care of their patients to hospitals. And so upon discharge in the follow-up visit, it’s important to have the information of what has transpired during that episode of care – discharge summaries, medication list, consultant’s reports, admission history, and physical and those type of things. That data, those reports need to be readily available to the patient’s physician for that follow-up visit to make that visit most productive.

Michael: It’s a great information and it makes complete sense. One of the things that I wanted to drill in a little bit more are discharge treatment plans. Now you have eluded to some of that coming out of the study, what I would really like to share with our listeners is, what are some of the pitfalls? What are some of the things that can go wrong in the course of developing and deploying a discharge plan that could have the potential to bring a patient back to the hospital?

Dr. Niewiadomski: That’s a great point. It’s great to have great ideas and great plans. It’s the execution of those that really makes the difference and proves for a good outcome. We need to be very aware of the patient’s ability to access and actually execute the plan. What I mean by that, if a patient doesn’t have access to get back to a facility for a follow-up chest X-ray or a CT scan, access to transportation, access to making that appointment, those types of things, that patient may not get the care as needed. Access to their medications, we can write all the prescriptions all day long, if the patient doesn’t have a means to pick up their prescriptions at the pharmacy or to actually pay for that medication, they may never get it. The ability to monitor their well-being at home, we always tell the patient, especially our heart failure patients, if you are gaining weight make sure you let someone know that so we can instruct you to watch your sodium intake, watch your fluid intake, maybe you may need an extra dose of a diuretic throughout the day. But if a patient doesn’t have a scale, they can’t monitor their weight. So we don’t ask that question, we tell the patient, “Weigh yourself daily,” but they don’t have a scale, they can’t do that. And the patients are a little reluctant and to say, “Well, I don’t have a scale,” because sometimes they’re not as forthcoming for various reasons of what they have at home. So, we may miss that opportunity to make an important intervention for a patient.

Michael: Makes a lot of sense. So, you’ve got the buy-in from leadership, we’ve implemented a program that the patients are leaving the hospital we think the program’s working. How does the hospital go about measuring the impact?

Dr. Niewiadomski: We’ve been in various hospitals talking about readmissions and one of the things that we picked up on very quickly is that hospitals are committing resources, both personnel and dollars. They’re throwing a lot of time and energy towards readmission reduction strategies. But when it comes back and you ask the question, how can you validate results it’s not so clear that they can, despite the fact that they spent literally a hundreds of thousands of dollars in implementing these strategies. So, what’s needed is really a good fluid and manageable analytic tool that will help you monitor the results of your readmission reduction strategies. Looking not only what happens during the inpatient stay but most importantly what’s happening in the post-discharge era and then able to capture those patients when they come in. And going back and looking at where the system failed where their readmission strategies were not successful. So, having a good database to help the team manage their strategies and validate outcomes is paramount.

Michael: So, readmission reduction strategies, they’re not short-term engagements or programs, let’s face it. Over the long-term, how do you keep hospital leadership engaged? Whether you are a member of that hospital leadership or you are on a team or a committee that’s responsible for reducing readmissions, how do you keep the leadership on for the long haul?

Dr. Niewiadomski: I think you need to have, first of all, as you spoke about the buy-in from leadership, both medical staff and hospital leadership which you really need to embed it into the fabric of the day-to-day processes within the hospital. You had mentioned that readmission reduction strategies are long-term strategies and you’re spot on. If you look at some of the strategies currently out there, for example, the BOOST program, Better Outcomes Through Optimizing Safe Transfers, or SAFE Transitions, those programs are year-long programs just to implement and it really touches every piece of the organization. This is from the Society of Hospital Medicine, and they partnered with the Joint Commission on this in developing the BOOST program. It’s a very intensive mentoring program that really changes every process that the patient is accessing, both in the inpatient episode of care and upon discharge. And once these things start to click along, and they are embedded in the fabric, they have a higher likelihood of longevity and a much, much higher likelihood of successes.

Michael: Well, certainly reducing readmissions is a key initiative for really any hospital in the country now, and I think you shed some light on how to go about forming a strategy and keeping the leadership engaged. So I certainly appreciate your time today, as I’m sure all of our listeners do. Thanks for joining us.

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