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Fresh Take on Hospital Discharges Cuts Readmissions

Cheryl Clark, for HealthLeaders Media, January 8, 2014

A multi-step approach to hospital discharges redefines them as 'transitions' and is driving down readmission rates at Detroit Medical Center.

This article appears in the December issue of HealthLeaders magazine.

The caregivers at Detroit Medical Center's hospitals no longer use the word discharge to describe the process of getting their patients out safely.

"Now the word we use is transition, a much more refined process, to get our patients back into their community," says Suzanne White, MD, the eight-hospital system's executive vice president and chief medical officer.

In fact, White and her colleagues have detailed descriptions of more than 30 steps or checks, with potential interventions, that now take place at specified points within the acute care stay. Some are tailored to where the patient is headed: home versus a skilled nursing facility, for example. But the process begins the moment a person is registered as an inpatient, and often involves agencies or care settings outside the hospital, especially private practice physicians and home health agencies.

For example, there is a specific step on day one to check whether patients have been admitted within the past 90 days and, if so, what the prior transition diagnosis was. If the current admission is actually their second readmission (or third admission), White says, they have the highest risk—a 50% to 60% chance —of being readmitted yet again within 30 days.

A team of hospital personnel springs to action to perform a root-cause analysis of what went wrong in the past.

"The readmission problem is really just a symptom of a very broken system and, in our region, of a very poor support system. … It's never just one reason for a readmission but a variety of causes that require everything to be thrown at efforts to prevent them."

There's a lot at stake for DMC, a hospital system with more than 1,800 licensed beds and where, at most of its hospitals, the number of uninsured and Medicaid and Medicare patients is about 50%.

But with a lot of hard work, DMC is seeing improvement. Readmission rates in January 2012 were as high as 25%, and several DMC hospitals received significant financial penalties. But in January 2013, readmission rates were down to 20%, and down to 15% as of August 2013.

"We have a very difficult demographic to deal with," White says of the metropolitan Detroit area her hospitals serve. Health literacy is poor and educational levels are lower than in many other urban areas.

Recently, hospital statisticians used a generally accepted illness scoring algorithm to rate the complexity of its patient mix, and "we found that our patients are 2.26 times sicker than the average Medicare patient in the U.S., and that makes readmission management even more challenging," White says. Federal readmission penalties, she says, "don't adequately adjust for that."

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