With skilled nursing facilities spread thin and under value-based performance pressure, hospital systems are testing new approaches to prevent readmissions.
This article first appeared in the April 2017 issue of HealthLeaders magazine.
Intermountain Healthcare, a Salt Lake City nonprofit health system with 22 hospitals and a broad range of clinics and services, found that ambulation was a key component to reducing readmission rates for complex abdominal and orthopedic surgeries. The problem was ensuring that the postacute care setting, including skilled nursing facilities (SNF) and home health agencies, would enact the ambulation protocol, says Mark Ott, MD, surgeon and chief medical director for the health system's central region, which has five hospitals in Salt Lake Valley.
"Complex abdominal surgeries such as colectomies and pancreatic resections have a high rate of readmissions because of the high-risk nature of some of these patients and the complexity of their surgical operations," Ott says. "With the ambulation protocol, we were able to cut readmissions from 15% to 7%."
Intermountain Healthcare found that patients who walked more after surgery would get out of the hospital sooner; preliminary results are that each additional walk decreased the hospital length of stay by approximately 0.17 days, and lowered rates of readmission to the emergency room or hospital by 50%, Ott says.
However, ambulating patients is a labor-intensive process, and the workload was more than the hospital nurses could handle, says Ott. He and his team worried that if hospital nurses were struggling, SNFs and patients and families at home certainly would not be able to fulfill the protocol without additional resources and help.
To shift the burden off nurses and other staff, Intermountain supplied 1,300 patients with a smartphone, loaded with an activity tracker app the health system developed with Savvysherpa, an ambulation and healthcare analytics company in Minneapolis. Patients are given ambulation goals based on their previous day's ambulation efforts. They also receive an alert when it is time to walk around, and data surrounding the activity is logged and shared with clinicians.
"The patients are given the devices and education at no cost to them. They receive in-person and online education. They also have a call-in number for questions. The patients feel empowered to actively participate in their care and recovery. Whether they go home or to a skilled nursing facility, the program is there to remind them," he says. "And if a patient doesn't follow it, they receive a call from support staff to help get them back on track."
The device approach, Ott says, helps supplement skilled nursing with family and friends or the patient independently to achieve a more consistent outcome.
"Intermountain Healthcare can show a 40% reduction in total cost of the hospitalization for several of our patient populations that participated in the ambulation and enhanced recovery after surgery program, and believes, that the cost savings more than offset the cost of the program. That along with the improved outcomes and patient engagement are why we keep doing this," says Ott.
External forces at work
Intermountain is not alone in trying creative approaches to ward off readmissions.
There are a lot of admissions—and readmissions—from SNFs to Sharp Grossmont Hospital, says Scott Evans, CEO and senior vice president of the 485-staffed-bed facility in La Mesa, California, which is one of four hospitals in the San Diego–based nonprofit Sharp HealthCare system. "Patients are brought in when they are in acute crisis, and then transferred back to their facility once they are stable and well enough to return," Evans says.
Before the organization could reduce those readmissions, it had to study the quality of the care at the facilities. Evans and other leaders started a dialogue among acute and postacute settings to better understand care plans for patients.
"We talked to several nursing home administrators and nursing home organizations to gauge their processing practices. We wanted to better understand how they manage their patients," says Evans.
The team focused on advanced illness management where patients do not want life-saving measures put in place.
"We see patients show up at the hospital in an ambulance from the facility, only to discover that the patient's advanced illness is progressing in a manner that was previously anticipated," Evans says, making the visit potentially unwarranted. "Rather than triaging acute problems, we need to get all parties together to understand the patient's plan, the disease burden, and the likely progression.
"The reality is that some patients will die in a nursing home, and sending them back and forth to an acute care facility may not be aligned with their expressed wishes," he adds.
Sharp Grossmont is in the early stages of addressing this issue and does not yet have data to gauge the pilot program's success, according to Evans.
"We are measuring readmission within 30 days, and tracking information about the care received outside of our hospital: from the time of discharge to readmission, as well as assessing the continuity of care in between that time," he says.
The hospital is now considering the benefits of sending a hospital medical team to a facility when a patient runs into an acute situation.
A 'readmission bundle'
Banner Health, a Phoenix-based integrated health system with 29 hospitals, including three academic medical centers and other related health entities and services in seven states, found that each of its hospitals were trying different things to reduce readmissions. "This led to a chaotic picture that impaired our ability to see what really works," says David Edwards, MD, FACP, chief medical officer for post acute care services at Banner Health.
To better analyze the impact of its disparate interventions, Banner Health suspended all new programs and standardized what would be called "a readmission bundle," says Edwards, a colead on Banner Health's Readmission Initiative. The bundle encompasses core processes that must be done with high reliability.
"The board of directors chooses a limited number of initiatives to focus high-level leaders' attention on by tying management incentives to performance on these initiatives. In 2014 and 2015, there was an initiative to focus on decreasing preventable readmissions by focusing on creating a reliable process for patients at high risk for readmissions. In patients identified as high risk for readmission, we focused on medication reconciliation, setting up an appointment within seven days of discharge, and teaching the patient about their disease process utilizing the teach-back method. We measured our performance in each of the areas and were able to improve the reliability to do this," Edwards says.
In addition, Banner is developing a program to predict which patients are at highest risk for readmissions, how to prepare patients best for discharge, and how to transition patients to the correct next level of care with expectations for that level.
"The key for us is to transition high-risk patients to the right level of care and have that level of care performed well rather than focusing on a readmission number," he says.
Banner owns a home health agency, a home-based palliative care program, ambulatory case management, and iCare—a remote, patient home–monitoring program—and works with these affiliated programs to better patient transitions and to identify improvement opportunities. Some examples include reviewing readmissions between hospitals and the postacute entity and improving communication between Banner ER staff members and the medical directors of SNFs.
"We have measured critical factors in transitioning patients, making meaningful contact within 72 hours, medication history within 72 hours, and having a care conference for patients on service 30 days or more. We worked to improve our performance in those areas. Additionally, we have developed aligned postacute providers—SNFs, SNFists, home health agencies—with whom we have quarterly or more frequent meetings to review data, readmissions, and other quality issues identified. We have worked to identify areas of improvement in a collaborative manner with them," says Edwards.
Banner uses its telehealth program, eSNF, to enable communication between SNF nurses and nurse practitioners at Banner's eICU to potentially prevent readmission.
"eSNF allows a nurse in a SNF to connect with a nurse practitioner working in our eICU for questions or evaluations. The NP can evaluate patients who are deteriorating or have fallen, or ones that they have questions on. The NP can place orders on patients in the SNF, make recommendations for transfer to the ER, or have the patient be evaluated the next day by a physician. In addition, the NP is able to access the SNF chart to see clinical information recorded there," says Edwards.
Kim Henrichsen, RN, MSN, vice president of clinical operations and chief nursing officer at Intermountain Healthcare, says Intermountain readmission rates are low; however, administrators think there is still opportunity to further reduce avoidable readmissions by collaborating with providers such as SNFs in the postacute care settings.
A little over two years ago, Intermountain invited nearly 100 SNFs across Utah to apply to collaborate with the health system through its health plan. Intermountain informed the facilities that to be considered as a preferred postacute collaborator, they would need to maintain high quality ratings, be willing to share their quality data, adopt appropriate Intermountain evidence-based clinical protocols, and be willing to accept patients from all payer sources—at any time of day or night—as well as being willing to develop expertise in caring for certain clinical conditions.
Henrichsen and the team realized the initial group of SNFs was too broad and narrowed the network for the second year of the collaboration to 52. Selection criteria included but was not limited to the number of Intermountain patients cared for in the clinics, clinical quality based on CMS Star Ratings, patient satisfaction reported by CMS, and staffing levels. Each SNF was evaluated on over 80 criteria to determine which of them would be selected to participate in the Quality Improvement Initiative with Intermountain and SelectHealth.
Once the field was winnowed down, Intermountain selected a few of the participating SNFs and began working with them to improve care specifically for heart failure patients as a pilot project.
"Skilled nursing facilities are doing the best they can with the amount of resources they have. It's a daunting task for them to deliver that care, so we have to partner with them."
Like Sharp Grossmont, Intermountain recognized the need for SNFs to have more access to medical providers to prevent avoidable complications and readmissions. "In most cases where patients were readmitted to the hospital, the skilled nursing facility may not have identified the deteriorating patient soon enough, or felt they didn't have timely access to the medical providers who could manage the situation," Henrichsen says.
The Southwest region of the system is testing the impact of having health system advanced practice nurses round at the SNFs on Intermountain patients, and early results show a reduction in readmissions. In the Central region, neurologists—who have been skeptical about stroke patients going to SNFs because they don't think these patients get the rehabilitation or interaction they need to regain function—are working with a small number of SNFs to lift their expertise.
"Skilled nursing facilities are doing the best they can with the amount of resources they have. It's a daunting task for them to deliver that care, so we have to partner with them," Intermountain's Ott says. "If we want patients who come through the hospital to do well, we need to invest in devices, follow-up calls, and visits to stay connected to them so that issues get detected early."
Henrichsen adds, "We have assumed risk as a delivery system, and we believe that by working collaboratively with skilled nursing facilities, we'll improve care for our patients and members, reduce hospital readmissions, reduce complications, and reduce length of stay, which all contribute to decreased healthcare costs."