Borrow best practices for hospital readmission reduction programs

Hospitals and health systems can pull the best practices from some of the leading models for hospital readmission reduction programs, adjusting the strategies for the individual institutions, said Jan DeRoche, an independent healthcare consultant.

"You do you own thing," DeRoche said at Opal Events' Medicare Advantage Strategic Business Symposium on Tuesday in Arlington, Va. In addition to borrowing strategies that recent literature proves to be effective, hospitals can create institution-specific programs, adjusting them, as needed, DeRoche noted.

Among the recent innovative models are Project RED (Re-Engineering Discharges) from Boston University, BOOST (Better Outcomes for Older adults through Safe Transitions) from the Society of Hospital Medicine, the Care Transitions Program® by Eric Coleman, and the Traditional Care Model by Mary Naylor. Some common practices spanning these models to keep patients healthy from hospital to home include the following:

Engage patients and family members: Key to reducing hospital readmissions is engaging patients and family members. Often, providers find that even though patients say they understand medical instructions at the hospital or a visit, they might second-guess themselves when they return home, according to DeRoche. Providers can apply the teach-back process with patients, improving their health literacy and possibly patient outcomes.

Implement medication reconciliation: Tied to patient engagement is medication reconciliation, with providers encouraging patients to take an active role in their health. Providers also can work with pharmacy staff to address any discrepancies with medications that may cause inadvertent complications. For example, a pharmacy member could introduce herself to the patient during the inpatient stay or visit and let the patient know that she will be calling the following day about medications. Having that follow-up helps ensure medication adherence, and thus, reduces hospital readmissions.

Follow up with patients after discharge: Transitional coaches, such as nurses, follow up with patients after discharge, either with a home visit--which is ideal--or with a telephone call between 24-72 hours, depending on the model. Separate from a case manager, the transitional care coach helps navigate the patient through the system and mentors the family with the goal of preventing readmission and improving care.

Identify at-risk patients: Forty-three percent of the general population is in the high-risk category, according to DeRoche. To focus in on those patients, some programs look at length of stay, acuity of admission, comorbidity index, and emergency room visits in the past six months as indicators of possible readmissions. By assigning each of those measures a point value, the combined factors help providers pinpoint who might be at risk for a readmission and intervene as appropriate.

Test small changes first: Based on the Institute for Healthcare Improvement methodology, programs can test small changes with rapid cycles. For instance, a nurse might ask for a particular report on a patient's progress for one day. The following day, the nurse and providers might adjust the process to improve upon the previous day. Measuring the success (or failure) of the change in a rapid cycle and repeating it helps improve processes, first on a small scale.

"Tweak it based on [providers'] recommendations, getting staff more engaged. Then over time, you're able to bring in more people into it and spread it to other departments and units," DeRoche said.

For more information:
- check out the Project RED website
- see the BOOST website
- find the Care Transitions Program® website
- check out the Transitional Care Model website
- see the conference event page details
- see the IHI guides

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