Cut readmissions with discharge 'passports,' communication

Discharge planning and provider communication helped Philadelphia hospitals reduce readmissions by 7 percent, according to a report released last week by The Health Care Improvement Foundation. Most of the hospitals involved screened patients that are at risk for readmissions and provided them with checklists and reminders about medications and appointments, developing what they call "passports."

Twenty-nine Philadelphia area hospitals participating in the Preventing Avoidable Episodes (PAVE) Project tested strategies for care transition and readmission prevention and found that discharge planning and provider communication processes showed significant improvements; they prevented 400 patients from unnecessary hospitalizations.

The Centers for Medicare & Medicaid Services (CMS) estimates that each avoided readmission saves on average $9,600, meaning the reduction in readmissions saved the hospitals $3.8 million in the third quarter, according to a press release last week.  Further, the project helped the region's hospitals avoid an estimated $7 million in potential Medicare penalties for high readmission rates in fiscal year 2013.

"Many readmissions are unavoidable due to the complexity and severity of patients' medical conditions," Health Care Improvement Foundation President Kate Flynn said in the press release. "Nevertheless, each hospital discharge represents an opportunity to better coordinate prompt and effective follow-up care, keep patients from returning to the hospital, and save thousands of dollars in hospital costs."

PAVE, which involves 150 healthcare professionals at 47 organizations, developed passport tools to encourage provider coordination as patients transition between care facilities (e.g., from a nursing home to hospital to physician's office). The hospital care transitions passport is a document with contact information for key departments, and the payer passport contains the payer contact information to be used by hospital utilization management, emergency department and discharge planning staff. The hospital discharge passport is a set of standards that incorporates all of the critical components of an effective care transition at the time of hospital discharge. The medication passport outlines a set of standards to help providers across the continuum of care reconcile and share information about patients' meds.

Among the strategies, hospitals:

  • Educate patients about their medical conditions
  • Provide transition coaches or nurses to help patients and families understand medical needs and care
  • Provide patients with checklists and other reminders
  • Provide patients with detailed discharge plans
  • Coordinate with patients to make follow-up physician and testing appointments
  • Send discharge summaries to patients' primary care physician
  • Conduct nurse-to-nurse handoffs when discharged patients transition to nursing homes or other care settings

For more information:
- here's the press release (.pdf)
- read the Philadelphia Business Journal article
- read the Information Week article
- visit the PAVE website on the passports

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