Why hospitals should adopt transitional care to reduce readmissions

It's no wonder that more and more readmission reduction success stories have appeared in media outlets, including FierceHealthcare and its sister publications, in recent months. Hospitals must do something to prevent getting hit with Medicare readmission penalties. 

Earlier this month the Centers for Medicare & Medicaid Services announced that 2,225 of the nation's hospitals will receive payment reductions totaling $227 million for excess readmissions in the second round of penalties that start Oct. 1.

And though many have criticized CMS for the harsh fines, particularly those levied against hospitals that treat poor patients, some good has come out of the program. Hospitals across the country have responded with initiatives that have improved care and reduced readmissions.

This week we learned that 107 Florida hospitals were able to drop readmissions by 15% over two years, in effect preventing 1,500 patients from readmitting within 15 days and reducing costs by at least $25 million. How did they do it? By focusing on five areas--all high-quality and low-cost patient care approaches that hospitals across the country can implement fairly quickly. The hospitals:

  • Make sure patients and caregivers understand their medications--and other care instructions--at the time of discharge;
  • Follow up with a phone call or visit to patients to make sure their questions are answered
  • Establish partnerships among all providers involved in a patient's care, in order to improve handoffs and share information
  • Discharge patients to settings that can provide the care they need
  • Schedule follow-up visits with their physicians
  • Evaluate the patient's end-of-life care wishes

But these Sunshine State hospitals aren't satisfied with a mere 15% reduction in readmissions. Their goal is to achieve a 20 percent drop by the end of December 2013, according to the Florida Hospital Association's Five Years of Quality Report.

Funding via the FHA's Partnership for Patients network--a nationwide project of CMS and coordinated through the American Hospital Association's Health Research & Educational Trust--will help Florida hospitals create hospital discharge advocates who will provide medications to patients prior to discharge and establish strong partnership with post-acute providers to ensure that patients are transitioned safely to the next level of care. This clear communication will help facilities better care for newly arrived patients--and thereby, reduce the need for rehospitalizations.

A renewed focus on transitional care also helped North Carolina hospitals reduce readmissions by 20 percent among the sickest and poorest patients in the state. Transitional care services depended on the individual needs of patients and ranged from a brief assessment, a hospital bedside visit prior to discharge, service coordination, medication reconciliation, a home visit by a nurse care manager or a comprehensive medication review by a clinical pharmacist.

The research team found that those who received transitional care were 20 percent less likely to be readmitted in the subsequent year, compared with clinically similar patients who received usual care. 

"What was unique and gratifying was that we were able to replicate this all over the state of North Carolina," C. Annette DuBard, a senior vice president of informatics and evaluation at Community Care of North Carolina, a physician-led program that focuses on helping poor people get healthcare and avoid hospitalization, told the Raleigh News & Observer. "It's not specific to any one hospital or any healthcare system."

Florida and North Carolina aren't unique. Three New York hospitals in the Bronx have also witnessed a drop in readmissions by encouraging caregivers to rely on a "personal touch" when working with patients. The collaborative uses predictive modeling to select patients most likely to readmit. They offered these patients a working telephone and provided four interventions while they were in the hospital and for 60 days post-discharge.

Nurse care transition managers provided personal contact by holding a pre-discharge education session, scheduling a follow-up visit with the patient's physician, and making post-discharge phones calls to discuss medications and verify the follow-up visit took place. The results? Of the 500 patients who received two or more personal contact interventions, only 17.6 percent bounced back to the hospital within 60 days of discharge, compared to 26.3 percent of 190 patients who received standard care.

What has your experience been with transitional care? Have you tried any of these approaches and have they reduced readmissions at your facility? Have you had success using other methods? Let us know in your comments. - Ilene (@FierceHealth)