The federal government is serious about transitions of care. The first tactic in the works is to take money away from organizations with high rates of avoidable readmissions (starting in 2012). Now it is giving money – half a billion worth – to help facilities and organizations strengthen their transitions programs and keep patients safe, secure – and less costly – at home.
Part of the Partnership for Patients is the Community-Based Care Transitions Program (CCTP) demonstration project,
which has set aside $500 million for community-based organizations and acute care hospitals “to help patients safely transition between settings of care,” according to CMS.
In light of these initiatives, Case In Point Weekly investigates the leading practices that high-performing facilities are currently engaged in to bolster their transitions of care, avoid unnecessary readmissions to their facility, and stay one step ahead of the coming penalties from the federal government.
Strategies for Enhancing Transitions of Care
We all know the statistics – one in five, or 20 percent, of patients that leave a hospital return to take another go-round through the hospital’s intake process within 30 days of their initial discharge, resulting in a net expenditure of $17 billion to Medicare every year. It is estimated that nearly half of these readmissions are avoidable.
In addition to the best-practice initiatives above, another factor stood out – namely, a precise focus on transitions of care to ensure optimal outcomes. As the report states: “Hospitals with low readmission rates also seek to ensure smooth transitions as their patients are discharged – helping to avoid the deterioration in health status that often brings patients back to the hospital.”
The four leading hospitals – McKay-Dee Hospital in Ogden, Utah; Memorial Hermann Memorial City Medical Center in Houston, Texas; Mercy Medical Center in Cedar Rapids, Iowa; and St. John's Regional Health Center in Springfield, Mo. – seek to pinpoint individuals who are at the highest risk of readmissions and create an action plan to increase the chance of an effective post-discharge plan.
Taking the four hospitals as a guide, here’s what researchers discovered to be the six prevailing lessons for reducing readmissions and streamlining transitions.
- Start at the top. The most from-the-top-oriented, overriding factor that the hospitals all shared was their investment in quality care. Simply put, adherence to quality standards – and simply caring for patients correctly – can start the patient’s course through the healthcare system off on the right track and ultimately result in fewer needs for readmissions.
- Utilize health IT. The information technology (IT) tools at your disposal are one of the most effective ways to integrate care across settings. These tools include electronic health records, patient registries and software that can identify the risk of individuals and populations.
- Engage early. For the cohesive, transition-oriented strategies of care management and discharge planning, research shows it is best to start the programs early in the course of care. This will create a hole-less path through which the patient can travel, both during and after the inpatient stay. According to researchers, these initiatives should target high-risk patients and place an emphasis on constant communication among the entire care team.
- Educate for self-care. The best programs make sure that patients can manage the conditions that put them in the hospital in the first place. That way, they can repeat an unnecessary recurrence. Be sure to tailor the education to the patient’s particular situations; as a recent study from the Agency for Healthcare Research and Quality shows, poor health literacy results in more hospitalizations.
- Keep the connection. Following discharge, it is vital to keep in touch with patients – especially those at high-risk – through follow-up telephone calls, remote patient monitoring and other programs and technology devices. At Mercy Medical Center, after the facility began to provide all cardiac patients with a telemonitoring device upon discharge, readmission rates dropped 47 percent, and length of stay fell nearly 60 percent.
- Use the community. Facilities should align themselves with community-based providers to create a comprehensive path along the continuum of care. For example, three of the hospitals in this study grant community physicians access to their patient’s electronic medical records, and two of the hospitals urge physicians to hold a follow-up conversation within at least one week of discharge.
Learn more about the benefits of strong transitions in the Case In Point Webinar
Securing Care Transitions to Prevent Avoidable Readmissions: How Strong Transitions of Care Boost Quality, Save Costs on May 25 at 12:00 p.m. EST
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Readmission has to be with the doctor. If he was not able to see the patient holistically, the patient will come back. More time with each patient and family in active listening, is necessary. Talking to patients, one of the reasons for re-admission is the hope they will have the test, as MRI or SCAN that they are not able to afford.
Secund, the educational training should be obligatory to the patient if he/she wants to recieve service again. Sometimes the resources are there and the patients do not go to the educational program.