A Tool to Reduce Readmissions at BMC
Originally found in the BMC Brief: http://www.bmc.org/bmc-brief/4422.htm
What happens to our patients when they leave the hospital? Sometimes we see them at clinics, sometimes we never see them again, but too many end up back in the hospital within 30 days. Hospitals are traditionally set up to care for patients during an acute episode, but preventing readmissions can be an important part of care, both for positive patient outcomes and for the hospital’s performance on quality metrics tied to funding. As a result, a team at BMC is working to create a hospital-wide strategy for preventing readmissions.
“In some ways it may seem counterintuitive to try to keep people out of the hospital,” says Carrie Solomon, Senior Manager of Strategy Implementation. “But we’re a whole system, not just the hospital, and we want to care for the whole patient, not just an acute care episode. Some people who come in are just sick, but many have other issues that drive health problems, and we can utilize primary care, specialty care, other hospital programs, and community resources to help keep people from needing acute care.”
BMC is working on a hospital-wide strategy to reduce unnecessary readmissions that seeks to address the complex clinical and psychosocial issues that many at-risk patients face, such as homelessness or substance use disorders. BMC’s readmissions rate has been trending down due to the work departments have been doing to prevent readmissions, and the hospital has made it a priority to continue this downward trend. Performance on readmissions is tied to $15 million in funding from the state and federal government, but reducing readmissions is also important to help BMC prepare for upcoming policy changes.
“While there are currently some penalties for readmission rates, we know health reform is coming,” says Alexandra Yurkovic, MD, Medical Director of Strategy Implementation. “The reality is that up until now, each readmission was more money for the hospital, but when there’s a Medicaid accountable care organization, things will be very different, and keeping people out of the hospital will be a priority. But what this really means is that financial incentives are catching up with what feels clinically right – to keep our patients as healthy as possible.”
Solomon and Yurkovic worked with BMC’s data analytics team to pinpoint the biggest drivers of readmission, based on a year’s worth of BMC patient data, and identified 14 key factors. Those factors are used to calculate a score – in real-time – for every patient admitted to an adult medical inpatient unit. The scores are displayed in eMERGE patient charts upon admission so that providers and ancillary services can identify patients at the highest risk of 30-day readmissions and focus targeted interventions and resources where they will make the biggest difference.
Patients are segmented into four groups, with a focus on the two most at-risk cohorts: super utilizers, who represent five percent of admissions and have a 63 percent chance of being readmitted, and high-risk patients, who represent 15 percent of admissions and have a 54 percent chance of being readmitted. Moderate risk patients, who represent 30 percent of admissions and have a 17 percent chance of being readmitted, will receive lower-touch interventions such as post-discharge phone calls.
Super utilizers and high risk patients receive high-touch interventions to help reduce readmission rates. An inpatient pharmacist meets with each patient to conduct a patient interview focusing specifically on medication history and medication reconciliation. A social worker also meets with each patient to perform a psychosocial evaluation to find out what non-medical issues could lead to a patient’s readmission. In addition, an order set will come up in eMERGE for physicians to follow and ensure that patients get any specialty care they need while admitted.
When super utilizers and high-risk patients are discharged from the hospital, they will leave with a follow-up appointment scheduled at a time that they have specifically said will be convenient for them. A pharmacist double checks each patient’s medications before they leave, and follows up with a phone call within two days to check in on the patient and make sure there are no medication issues. Additionally, all patients will receive improved discharge paperwork, which will have key information up front about red flags, who to call if there are issues, follow-up appointments, and medications.
The hospital is also working to ensure that patients continue to receive the services they may need post-discharge. This includes working with BMC primary and specialty care clinics and developing partnerships to leverage community resources such as Boston Healthcare for the Homeless to meet the complex psychosocial needs of patients and support improved transitions of care.
Super utilizers also receive additional attention. A super utilizer team, led by case manager Colby Bowden, RN, a pharmacy technician, and a social worker manage super utilizers during their admission and for 30 days post-hospitalization to support patients’ transitions out of the hospital. They meet patients at the bedside during their hospitalization, and then call each patient weekly to monitor clinical, medication, and psychosocial needs. If any issues arise, the team helps the patient get appropriate care, and serves a general liaison between the patient and needed services. If a patient in this program is not readmitted within 30 days, they “graduate” from the program and are reenrolled if they are admitted to the hospital at a later date.
In addition, the hospital is also targeting certain conditions that are associated with high readmission rates, such as sickle cell disease, substance use, or congestive heart failure. Patients with those conditions will also receive increased attention. Nurse practitioners will help manage patients with these clinical conditions across the care continuum, providing care during admission and seeing patients for follow up soon after discharge. This program is currently in place for patients with sickle cell disease and other programs will go live in the next few months.
“Preventing readmissions can be challenging because so many people touch patients before, during, and after their hospital stays,” says Yurkovic. “Everything we’re doing is a work in progress, but everyone involved is very excited by and engaged in this work. The hospital has a very collaborative environment, which makes a big difference for our work, and ultimately for our patients.”
Source: The BMC Brief