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 2014 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."
So how are they bringing about improvement in readmission rates?
Medication reconciliation
One effective strategy DMC employs involves medication reconciliation at several points during the stay, especially during any in-hospital transition, say from an ICU step-down to a floor unit.
And no patient can leave a DMC hospital without the proper reconciliation checks, not only to ensure that the patient is on the right medications but also to be certain the patient understands what these drugs are supposed to do and how they should be taken. That means making sure old medications are designated in the medical record as having been removed, to avoid represcribing the wrong drugs. That's a mistake the hospital used to make, she says.
It's been a "huge challenge," White says, but hospital officials have inserted a kind of hard stop into the system's electronic medical record. The system "doesn't allow you to print the discharge papers until the medication reconciliation has been completed."
DMC's efforts to ensure that the right drugs are taken frequently includes what DMC calls its First Fill program, in which the hospital dispenses the first several days' worth of medications for patients—particularly those going to nursing homes. "That's so patients actually have their proper medications before they leave the hospital" and so staff can help patients understand what each one is supposed to do and how to take it.
"This is an area where there has just been a tremendous amount of activity to improve our processes," White says.
First physician visit
A review involving 4,000 admitted patients at three DMC hospitals in 2010 has revealed what White calls a "dramatic, very tight" correlation between all-cause readmissions and one simple thing: the timing of the first physician appointment after the patient left the hospital.
"We discovered that the rate of 30-day readmissions correlated perfectly with the number of days between the patient transitioning out of the hospital and when they saw their primary care physician," she says.
If the patient saw the doctor between day one and day four after hospitalization, the chance of readmission would be less than 6%. If the appointment was on the 6th to the 10th day after hospitalization, chance of readmission was between 6% and 13%. And for visits with the doctor on day 25, the chance went up to 29%. "The readmission rate increased by 1% for every additional day between discharge and the first physician visit," she says.
Transition coaches
It's important to equip patients who are returning to their own homes with skills to better "self-manage" their disease, especially if they are at high risk of being readmitted, White says.
That's where DMC's transition coaches, also called hospital-to-home nurses, come in. These individuals from community partnerships, employed and trained by the Detroit Area Agency on Aging, meet the patient in the hospital room when they first arrive and "are really important to helping them understand their disease," White says. "They help build a personal health record that the patient can take to their doctor's office" after they're home."
Using a modification based on Eric Coleman's Care Transitions Intervention coaching model, these coaches also visit patients in the home and help assess environmental issues that could result in them coming back to the hospital.
"Maybe the patient has transportation issues, or maybe there's no food or no heat. Maybe there aren't grab bars in the home, so they do fall risk assessments and depression screening, as well."
One of the best things about this program, White says, is that the same person visits the patient in the hospital and in the home for up to 30 days after discharge. "If the face at your door is someone you've spent time with at the hospital and have worked through a relationship together, that's going to be a comfortable moment to open that door and let that person in," White says. That's especially important in a city like Detroit, when safety among seniors is a concern.
Recently, a related program involving nurses in DMC's hospital-to-home program probably saved a patient's life, White says.
"We had one of our transition nurses appear at a patient's home the day after discharge. The durable medical equipment provider had already been there and hooked up the patient to home oxygen therapy, but it wasn't done the right way," she says.
"When our transition nurse arrived, the patient wasn't doing well. The nurse recognized the problem right away" and restored the patient's breathing. And then, the nurse prepared the patient's lunch.
"That probably avoided a readmission or worse," White says. "It's the kind of individual attention to their whole environment when they return home that's really critical to what I like to call a safe landing."
Preferred providers
DMC is a Pioneer accountable care organization, and that has given the system clout to evaluate quality processes in area home health agencies, especially on measures like patient experience scores, cost, time to onset of services once they're referred, and whether the agency has an electronic medical record system.
"We cannot tell patients who they should choose to provide home health care or which doctors to use, but we can certainly identify those we think are the best partners, those who want to help us reduce readmissions and create safe transitions for our patients," White says.
"You absolutely cannot restrict care, but you can identify who you think are the preferred providers." DMC gives patients and their families a list, emphasizing they have the right to choose whoever they want. That strategy is so successful that DMC is looking to use the same type of analysis to evaluate skilled nursing facilities and their physicians, especially regarding their readmission track record.
"We've developed quality metrics to look at a physician's readmission rate, asking questions like, 'Did they reconcile medications during the patient's office visit?' and 'Are they managing ambulatory-sensitive conditions appropriately?' "
Lack of transition science
Among the other items on the DMC list are checks to make sure patients have prevention care, such as pneumococcal vaccination. And the hospital system has produced educational videos for a variety of conditions, such as congestive heart failure.
There's an effort to not just have the patient "teach back" what they've been told, which means merely repeating words, but to actually demonstrate what they have been instructed to do so the coaches can witness that the patient understands. "Show me what you're going to do if you become short of breath, or show me how you're going to take these medications in the afternoon versus at bedtime," White explains.
But unlike infection prevention bundles or surgical checklists, the science behind effective transition is poorly developed. No one thing on the list, if omitted, is certain to place the patient at higher risk of readmission, she says. "Transition care is in the early stage of quality measurement," White says. It's a wide-open area for further research.
Defining responsibilities
Leora Horwitz, MD, a researcher, assistant professor of medicine, and expert on hospital-to-home transitions at 1,541-bed Yale-New Haven Hospital, says many providers liken the challenge of managing patients at home to that of "solving world hunger" because the issues are so diverse and complex.
That's why her hospital is taking aggressive steps to dissect the process in an effort to make it more efficient and accountable in terms of what doctors, nurses, and pharmacists are supposed to do to prepare for the patient's departure.
"Up until now, we've left each to their own devices," Horwitz says. "Doctors may or may not discuss the diagnosis or medication changes, the after-care plan, or the home care needs. The nurses may or may not do those separately. And hospitals may not have pharmacists involved in creating medication lists. Instead, everyone does that as time permits."
But, she says, hospitals "that are serious about this, like ours is now," want to make these processes standard and specific, defining who is responsible for what. That way, the transition process will be done more effectively and efficiently. No pieces will be missed, and nothing will be done three or four times in different ways by different caregivers.
So in recent months, Yale-New Haven has staffed people "to literally follow doctors and nurses around, literally 24/7, including weekends, to write down everything providers do that seems related to discharge care, including how much time it takes," Horwitz says. In this way, "we can get a clear sense of how effectively that work gets done during the course of a hospitalization."
The project includes, for example, the half-hour that an intern might spend on hold with a doctor's office trying to schedule a follow-up appointment. "Is that a good use of the intern's time? We want to reorganize that work to make it more effective."
Horwitz's recent paper in JAMA Internal Medicine described a survey of patients at her hospital during 12 months ending in April 2010. The survey found that only one-third of patients got a follow-up appointment with a physician before their discharge, and less than two-thirds of patients with heart failure were advised to limit salt intake.
Perhaps most important, one-quarter of the discharge instructions did not use "intelligible language to describe the reason for hospitalization" and one-third of patients could not clearly describe their diagnoses.
HCAHPS and transition planning
Starting soon, three questions dealing just with the discharge process will be added to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, first for reporting purposes only. However, they are candidates that may eventually be used to influence payment in the value-based purchasing incentive program.
They are:
- During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left
- When I left the hospital, I had a good understanding of the things I was responsible for in managing my health
- When I left the hospital, I clearly understood the purpose for taking each of my medications
And when those answers start coming in, White says, "we'll start to know whether the patients feel these efforts are helping, but we don't yet have a good measurement system in place to look at that."
White says that hospital teams "still have a lot to learn about which readmissions are avoidable and which are not. Readmissions to some extent are a marker of poor quality of care." And by preventing them, she says, "we know we are delivering higher-quality care."
Reprint HLR1213-8
This article appears in the December 2014 issue of HealthLeaders magazine.