Posts Tagged ‘readmissions’

Infographic: Coded Severity and Readmission Reduction

December 27th, 2017 by Melanie Matthews

A federal program that has been shown to reduce hospital readmissions may not have been as successful as it appears, according to a new infographic based on a study by University of Michigan researchers.

The infographic examines how the reduction in patients heading back to the hospital could be attributed to how the diagnoses were coded.

A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics
Concerned about escalating hospital readmissions from skilled nursing facilities (SNFs) and the accompanying pinch of Medicare readmissions penalties, three Michigan healthcare organizations set competition aside to collaborate and reduce rehospitalizations from SNFs.

To solidify their coordinated approach, Henry Ford Health System (HFHS), the Detroit Medical Center and St. John’s Providence Health System formed the Tri-County SNF Collaborative with support from the Michigan Quality Improvement Organization (MPRO).

A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics examines the evolution of the Tri-County SNF Collaborative, as well as the set of clinical and quality targets and metrics with which it operates.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Infographic: Reducing Readmissions Through Patient Education

December 18th, 2015 by Melanie Matthews

The importance of care transitions in improving patient safety is illustrated by recent data released by The Joint Commission on sentinel events compiled from January 2014 to October 2015.

The data show a total of 197 sentinel events—from suicide to falls to wrong site surgery—and the root causes included failures in patient communication (127 incidents), patient education (26 incidents) and patient rights (44 incidents). The majority of the patient education failures were related to not assessing the effectiveness of patient education or not providing education. The patient rights failures included absent or incomplete informed consent, and lack of the patient’s participation in their care.

In response to these findings, the Joint Commission released an infographic to help healthcare providers in their efforts to reduce patient readmissions and improve the discharge process.

Providers who signed on for San Francisco Health Network’s Care Transitions Task Force shared not only a professional passion for care transitions work but also the belief that care transitions responsibility should be spread across the healthcare continuum. And once the SFHN task force mined a ‘black box’ of administrative data buried in more than 60 siloed databases across its health network, continuum-wide care transition improvement seemed attainable.

Data-Driven Care Transition Management: Action Plans for High-Risk Patients documents how SFHN’s deep data dive triggered the development of a data dashboard, a hospital discharge database and a set of uniform standards and practices that have streamlined care transitions within its safety net population.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Behavioral Health Diagnoses Can Inflate Readmissions Rates, Hinder Self-Management

April 9th, 2015 by Cheryl Miller

Preliminary data from a Care Transitions Task Force found that when patients with behavioral health diagnoses are excluded from readmissions rates, those rates fall by nearly 4 percent, says Michelle Schneidermann, MD, task force member and Associate Clinical Professor of Medicine for the division of hospital medicine at the University of California, San Francisco, and Medical Director of the San Francisco Department of Public Health, Medical Respite and Sobering Center. Part of the reason for this is this patient population’s inability to follow through on self-management instructions once they leave the hospital.

Question: Among your discharge patients there’s a number of behavioral health diagnoses. Are there any considerations, or challenges to this patient population during care transitions, and any unique follow-up that your organization is doing?

Response: (Dr. Michelle Schneidermann) Yes, this patient population provides a very distinct challenge. The patients are challenged by so many other competing priorities, in addition to having a significant and severe mental health disorder, that it interferes with their ability to organize and follow through with the self-management requirements we place on them when they leave the hospital and their ability to manage chronic illness in general. So, from the patient perspective, it’s incredibly difficult.

From the systems perspective, although we are an integrated network health system, there are limitations on the number of outpatient behavioral healthcare clinics and providers. Plus, we don’t always have providers who are culturally concordant or language concordant, although the network is trying very hard to make that happen.

One of the things we’re working on right now is to tease out what our readmission rate looks like when we pull out all patients who have a behavioral health code. Just initial, very crude, back of the envelope calculations show a significant difference in our readmission rate.

When patients with behavioral health diagnoses are included, our hospital-wide, 30-day all-cause readmission rate is around 12 percent. When you remove patients with the behavioral health diagnosis, the readmission rate goes down to about 8.5 or 9 percent. Again, preliminary data, but it shows you the impact that this patient population has on readmissions and tells the story about the challenges that they personally face when they’re leaving the hospital.

cross-continuum care transitions
Dr. Michelle Schneidermann completed her primary care internal medicine training at UCSF and joined the UCSF faculty in 2003, where she is a member of the Division of Hospital Medicine at San Francisco General Hospital (SFGH). Through her inpatient clinical work and work with ambulatory programs, she has been able to directly witness the successes and challenges of patients’ transitions and generate feedback to the providers and systems that manage their care.

Source: Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs

Infographic: 7 Cities with Highest Readmission Rates

September 22nd, 2014 by Melanie Matthews

The seven cities with the highest hospital readmission rates include: Chicago, Brooklyn, Philadelphia, Baltimore, Manhattan, Boston and Los Angeles, according to a new analysis by Kaiser Health News, depicted in an infographic by Becker’s Healthcare.

Nineteen hospitals in Chicago exceeded the national average readmission rate. The infographic details how many hospitals in each of the other cities exceeded the average.

7 Cities with Highest Hospital Readmission Rates

2014 Healthcare Benchmarks: Reducing Hospital Readmissions2014 Healthcare Benchmarks: Reducing Hospital Readmissions documents the latest key initiatives and partnerships to reduce readmissions by patients with these costly conditions and others by more than 100 healthcare organizations. This 60-page report, now in its fourth year, for the first time provides details on partnerships with post-acute care to reduce readmissions from these care sites.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

4 Pillars of SNF/Hospital Partnerships

March 13th, 2014 by Cheryl Miller

Maintaining contact with patients long after the 30-day discharge period when the penalty phase ends for hospitals is one of the four pillars of Torrance Memorial Health System’s post-acute network philosophy, says Josh Luke, Ph.D., FACHE, vice president post-acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention. This can be done telephonically or in-person, and is usually conducted by an ambulatory case manager.

The main component of our post-acute network is to go into each of the seven SNFS once a week and meet with them for a half hour at the most, covering four tactics. The first is to review a list of all of the patients that have been sent from the hospital over to the SNF, specifically focussing on which ones are discharging that week.

The second tactic is to discuss their discharge disposition, and see if they’re going to a home health agency, and if so, if it’s one that we own, or another one in the community. We distinguish this so we can do what’s called ambulatory case management of the patient, which means we want to case manage them once they go home. We don’t just want to forget about them. We want to keep an eye on them and check in on them, whether it’s telephonically or in person, making sure that they continue to do well, not just through the end of the 30-day episode after discharging from the hospital when the penalty phase ends for hospitals, but also for their long term well-being.

The third tactic is to encourage each of our patients going home from the hospital and SNF to make an appointment at our post-acute clinic (CCC) with the physician who does medication reconciliation. She asks the patients to bring in all the medications they were on before they went to the hospital and all those they were prescribed at the hospital. They then sit and have a 45 minute conversation, including guidelines on what their medication plans are moving forward, which ones they should be taking, and which ones they shouldn’t, and making sure, with teach back methodology, that the patient has a clear understanding of what is expected from them in terms of consuming medication once they return home later that day. Those appointments normally take place within the last 72 hours.

The fourth tactic is to review what we call the ‘return to emergency room’ log. In the industry the common term is ‘return to acute’. We don’t allow our SNFs to use that term because we feel they’re responsible for the ‘return to the emergency department (ED)’. What we mean by that is we’re challenging our SNFs to say, “Take charge of what you can control. And what you can control is making sure that patient doesn’t leave your SNF unnecessarily.” We’re not here to say, “Did the patient get admitted or not to the hospital?” We’re here to ask the SNFs if they followed the guidelines that several organizations nationwide have provided that help avoid unnecessary transfers out to the hospital.

Excerpted from 5 Best Practice Prevention Protocols for Reducing Readmissions.

5 Tips for Seniors to Avoid Hospital Readmissions

June 24th, 2013 by Jessica Fornarotto


Nearly one in five seniors who are hospitalized return to the hospital within 30 days, according to a recent Robert Wood Johnson Foundation report. These readmissions are not only often physically and mentally debilitating to the seniors and their families, but contribute greatly to avoidable and unnecessary expenses on the nation’s healthcare system. To help curb these numbers, SCAN Health Plan recently offered seniors five strategies to lessen the chance of readmission.

  1. Ask questions before discharge. When patients are in the hospital, they’re completely dependent on others for care. But once they’re home, they’re in charge of their own recovery, which makes understanding what to do the key. Patients being discharged from the hospital who ask questions and who have a clear understanding of their after-hospital care instruction are 30 percent less likely to be readmitted or to visit the ED than patients who lack this information, according to a recent study from the AHRQ.
  2. Understand medications. This is particularly important if there have been changes to a medication regimen while in the hospital. Upon discharge, dosages are sometimes changed or a drug is discontinued or added. Patients need to be sure about this and to write it down. They also need to be sure to fill all new prescriptions once they’re home.
  3. Make a plan for follow-up care. Patients need to know when to schedule a follow-up visit to their doctor, and to make sure that they have the transportation to get there. Even if they’re feeling good, they should go anyway. The doctor needs to see a patient in order to track how they’re doing and to gauge whether the treatment plan is working. In addition to doctors, does the patient need to schedule home healthcare with a nurse or therapist, or do they have some new durable medical equipment or home-modification needs?
  4. Communicate with care coordinators. Whether a patient has a professional in-home caregiver, a family member nearby, or resides in an assisted-living community, they need to make sure that their caregiver is up to date on the recent hospitalization and how the patient is feeling. This also goes for the patient communicating with their health plan, as many have programs and professionals in place that can assist with care coordination.
  5. Be aware of “red flags” or complications that should be reported. What is considered “normal” for a patient’s post-hospital condition? What degree of pain or swelling is expected? Patients need to know what to look for, whom to call if they are not feeling well, and to have a clear plan of action in place so they know how to respond to a complication.

Romilla Batra, M.D., vice president and medical director of SCAN, says that readmission rates for seniors can also be reduced by enrolling in a health plan that has a strong emphasis on integrated care and care management. She points to a 2012 study released by Avalere Health that compared 30-day all-cause hospital readmission rates between California dual-eligible (Medicare and Medi-Cal) individuals in traditional Medicare versus those enrolled in SCAN Health Plan. The independent study found that SCAN’s dual-eligible members had a hospital readmission rate that was 25 percent lower than those in fee-for-service.

“Industry-wide efforts are underway to bring down readmission rates including new rules passed as part of the Affordable Care Act that charge additional fees to hospitals with excessive readmissions,” said Dr. Batra. “But ultimately it is still the consumer themselves who can play the biggest role through common sense and following these five easy steps.”

Infographic: Improving Care Transitions with Quality Improvement Organizations

February 18th, 2013 by Melanie Matthews

In communities where hospitals, other healthcare providers, and community services work together to coordinate evidence-based hospital discharges and provide better support in the community, hospital admissions and readmissions can be reduced.

Led by the Colorado Foundation for Medical Care (CFMC) as a national coordinator, 14 QIOs participated in a three-year project in which the QIOs convened medical, community, and social service providers and facilitated community-wide quality improvement activities to implement evidence-based improvements in patient care transitions.

The QIOs’ efforts included community organizing, technical assistance in implementing best practices, and monitoring of participation, implementation, effectiveness, and adverse effects. The program resulted in a 6 percent drop in hospitalizations and rehospitalizations, per 1,000 beneficiaries in the first two years. The average community netted about $3 million dollars in annual savings for Medicare. These findings were released by the Journal of the American Medical Association (JAMA) in “Associations between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries.”

A new infographic illustrates the strategies used by the QIOs and results achieved.

Quality Improvement Organizations

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual
healthcare data. Click here to sign up today.

You may also be interested in this related resource: Care Transitions Toolkit.

Infographic: Real World Strategies for Reducing Readmissions

December 12th, 2012 by Patricia Donovan

reducing readmissions

We’ve all seen the numbers on potentially avoidable Medicare readmissions, but new penalties from CMS for subpar readmission rates pack a little more punch into these often-published stats from CMS, the AHRQ, MedPac, and other sources. The hard truth is that more than 2,200 hospitals will lose a portion of their inpatient Medicare rates in FY 2013.

Proactive data analysis is one way to keep readmissions penalties at bay. And this new infographic from the Healthcare Intelligence Network consolidates the protocols and strategies many organizations are using to dramatically reduce the number of Medicare beneficiaries that return to the hospital within 30 days, drawing from responses from our annual Reducing Hospital Readmissions survey.

Among their ideas:

  • Follow-up appointments and phone contact shortly after discharge;
  • The use of transition coaches in hospitals, nursing homes and SNFs;
  • Group physical activity sessions that focus on physical, social and emotional well-being;
  • Upping use of telehealth and fall risk assessments.

We invite you to embed this infographic on your own Web site using the code that appears beneath it. Also, share it via your social media channels. A deeper dive into the latest trends to reduce hospital readmissions is reflected in 2012 Healthcare Benchmarks: Reducing Hospital Readmissions.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics. Click here to sign up today.

Other Infographics from HIN:

8 Successes Achieved by Diabetes Management Programs

August 23rd, 2012 by Jackie Lyons

Patient-Centered Diabetes Management: Driving Outcomes with Education and Behavior Change

Large payoffs in patient compliance, patient satisfaction and medication adherence resulted from programs aimed at managing diabetes, according to respondents to HIN’s 2011 “10 Questions on Diabetes Management” survey. In their own words, respondents described the greatest successes achieved by their diabetes management programs:

1. “Our greatest success is knowing the impact we have already made helping our patients, friends and families realize that they are not alone in this battle. We have produced results time and time again, proving this epidemic can be managed.”

2. “Diet and nutritional talks and cooking demonstrations have stirred consciousness and thoughtfulness towards dietary protocols.”

3. “The indigent population we manage through our program has had only one hospital admission for a diabetes-related problem in 2011. That’s impressive!”

4. “Improved mental status and treatment compliance in other spheres.”

5. “High level of patient engagement; increased patient-provider contacts and communication; and reduced hospitalizations and overall costs.”

6. “Significant ROI in one year using randomized control trial (RCT) methodology.”

7. “More knowledge of the condition and decrease in gaps in care.”

8. “Standardization of diabetes management programs, incentives, benefit enhancements and enhanced methods to reach members who opt out of one-on-one nurse coaching.”

2012 Healthcare Benchmarks: Diabetes Management provides more actionable data from the 83 responding organizations on current diabetes management programs and their impact on population health outcomes and healthcare spend.