No one-size-fits-all strategy for readmission reduction

Although reducing readmissions has long been a goal for Ascension Health, efforts reached a peak five years ago when the system began a series of pilot programs that focused on readmissions from the patient's perspective.

For Ann Hendrich, R.N., Ph.D., senior vice president of quality and safety and executive director patient safety organization at Ascension Health, the largest non-profit health system in the country and the world's largest Catholic health system, the biggest challenge is taking some of the more successful pilots and scaling them to fit larger populations.

"One of the cautions is assuming one size will fit all," Hendrich, pictured, told FierceHealthcare recently during an exclusive interview.

Instead, she says, the system, which includes 131 hospitals and 1,900 sites of care in 23 states and the District of Columbia, focuses its efforts on patient population risk and how to design a care model that fits an individual's care needs.

The system aims to adapt care models to where an individual is in his or her health life journey, Hendrich says--noting that, as organizations move toward population health and efforts to reduce healthcare waste, they must consider the greater variability and resources in the community, family support and psychosocial needs of the patient.

Ascension, she says, has launched many successful, diverse pilot programs to eliminate preventable readmissions that focus on the individual needs of a person based on the community he or she lives, the current state of the person's condition and disease, and accessibility to primary care. The goal is to ensure the organization meets the person's needs before he or she needs hospitalization.

In essence, Hendrich explains, the programs aim to create a care coordination pathway that takes into account the person's socioeconomic conditions and available community resources. The programs promote patient education for self care to empower the patient to take care of his or herself. If the patient doesn't have adequate family support, the programs focus on identifying community resources that can prevent the next hospitalization.

In many cases, she says, the patient may not need medical intervention. Hendrich advocates the use of multidisciplinary teams and care navigators who can help align the correct resources with the patient.

Hendrich points to the multi-disciplinary program launched at one of its sites, MissionPoint Health Partners in Nashville, Tennessee, as an example.

Jordan Asher, M.D., chief medical officer and chief integration officer at MissionPoint, pictured right, told FierceHealthcare that, to decrease readmissions, the organization has created a workforce of "healthpartners" or HPs who focus their efforts on transitions of care.

Although most hospitals focus on readmissions within 30 days of admission, Asher says MissionPont considers a readmission beyond 30 days a failure and aims to prevent any readmission.

If a patient within the population that the HP manages arrives at the hospital, the HP will receive a notification from the hospital and visit the patient to begin the discharge process. The HP evaluates the patient to determine risks and barriers to care; when the patient gets home, the HP will visit the patient to conduct a safety check, make sure the patient understands the discharge instructions, verify that his or her medications are correct and get in touch with the doctor if the patient has questions or concerns. The HP will also help resolve transportation problems the patient may have to get to the doctor's office.

One of the most interesting results of the program, Asher says, is that the majority of the interventions have little to do with the clinical problem. Most interventions involve the "disease of life."

"The issues are more like. 'I have a sick husband to take care of and I broke my leg and now I'm sent home and I can't take care of him or me.' It's never a focus of the inpatient stay," Asher explains.

The patient stories also reveal why they may lead to a readmission. For example, a husband and wife with significant health problems continued to return to the hospital, so the HP paid a visit to their home. The HP found a hot water leak in the kitchen; the wife kept slipping and falling. To avoid going into the kitchen, they couple ate processed food, which worsened the husband's heart failure and increased his readmissions to the hospital. So MissionPoint arranged for the couple to get a new hot water heater.

"It's a lot cheaper than a readmission, and we got a company to donate the hot water heater. So it's that type of blocking and tackling that we do," he says.

Henrich believes that, in the future, more organizations will design care models that address these types of reasons for patient readmissions. "We will identify commonalities, common causes across populations and can help design care models that prevent hospitalizations from occurring," she says.