Interdisciplinary care teams, including a transition navigator, are one key to reducing hospital readmissions and improving transitional care.
In the increasingly hot-button realm of reducing avoidable Medicare rehospitalizations, the handoff from hospital to home has become the tipping point, agreed expert panelists at this week's Care About Your Care forum presented by the Robert Wood Johnson Foundation.
"The hospital discharge is either a moment where we can deliver great care, or we could fail," stated Nancy Snyderman, MD, NBC chief medical editor, who led the forum along with RWJF President and CEO Risa Lavizzo-Mourey, MD, MBA. The live event was designed to energize the national conversation about reducing hospital readmissions, the cost of which is estimated at about $30 billion a year.
"All patients need to have seamless journeys back to their communities after a hospitalization," said Dr. Lavizzo-Mourey in her opening remarks.
Of all the innovations in transitional care management presented during the 90-minute webcast, a novel idea emerged: ask the patient what they need.
That was one of the three opportunities for improving readmission rates identified by Eric Coleman, MD, who developed the popular Care Transitions Intervention® a template for transitional care. "We need to better engage patients and family members," he suggested, a tactic that can uncover specific issues that contribute to readmissions, such as lack of transportation or a burned-out caregiver.
Dr. Coleman also implored hospitals to recognize that causes of readmissions are very broad and often outside the scope of what hospitals can accomplish. "A hospital might not be able to address a patient's transportation issue, but an Office on Aging can."
Thirdly, communication and the exchange of health information need to improve, he said.
Another key to successful transitional care management is the spread of innovations and technologies and the adapting of interventions to fit a provider's need. "We need to make sure that the data tools, analytical tools, and decision support tools are used across the board," said panelist Mary Naylor, PhD, RN, of the University of Pennsylvania School of Nursing.
Dr. Naylor helped to implement the Transitional Care Model (TCM), another popular model that provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions.
Of course, all of these interventions come with a cost. Jonathan Blum, MA, of the Centers for Medicare & Medicaid Services (CMS) addressed the issue of reimbursement for transitional care, as well as the federal payor's new Readmissions Reduction Program. "While it's true we are focusing on readmissions, we are also helping hospitals to improve transitions. We are helping them to see what happens to patients beyond the four walls."
As far as payment, CMS is changing how Medicare pays for care, with new models like bundled payments, he said. "It's our job to set the standards and drive performance to meet that standard. We can provide best practices and share learnings."
Learnings were shared during the forum, in the form of winning submissions from RWJ's Transitions to Better Care Video Contest. More than 100 care teams around the country submitted videos detailing the innovative ways in which they are improving care transitions, defined by Dr. Coleman as "the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness."
Among the innovations highlighted during the forum:
- A Transition Navigator at the University of Utah Health Care in Salt Lake City who screens the list of patients admitted daily, interacting with the care team and following the patients all the way through post-discharge. The organization's use of a transition navigator has reduced readmissions by 23 percent.
- Care team members at Cullman Regional Medical Center in Alabama use an iPod Touch to record a physician's discharge instructions in front of the patient, which the patients can later retrieve online. This tactic reduced rehospitalizations by 15 percent.
- Mercy Health in Cincinnati, a self-proclaimed "hotbed of readmissions," began with six nurses and the four pillars of the Coleman model — medication management, prompt follow-up, a dynamic health record, and red flags and alerts — and added one of their own, working through barriers to regime adherence that were ratcheting up readmission rates. The end result was a reduction in hospital readmissions from 16.9 percent in 2011 to 14.5 percent in October 2012, with an estimated savings of $850,000.
The forum was also an opportunity for the foundation to publicize its latest report, The Revolving Door: A Report on U.S. Hospital Readmissions. The report found that despite the spotlight cast on this issue in recent years, readmission rates among Medicare beneficiaries remain virtually unchanged since 2008. For example:
One in eight Medicare patients were readmitted to the hospital within 30 days of being released after surgery in 2010, while patients in the hospital for reasons other than surgery returned at an even higher rate of one in six.
Complicating the challenges of readmissions are individuals with mental health issues, as well as the elderly with advanced illness.
"Revolving door hospitalizations typically happen in the last years of life," said one audience member during the Q&A. "We must begin to have upfront conversations about death with patients long before we refer them to hospice."
