Last week our Patient Safety Tip of the Week “Project RED” focused on the rehospitalization after discharge from the hospital. We’re continuing that discussion this week because of the tremendous potential impact of this problem on both our healthcare system and your individual facilities.
In the olden days of quality improvement we used to focus on readmissions within a short timeframe (typically 7 days or 15 days). We did that because most studies had shown that readmissions within that timeframe were most often associated with quality problems and that readmissions beyond that were not. We, of course, were very parochial in our thinking! Essentially, what we were saying was “anything else is someone else’s fault”! We were not thinking about our role in the much larger healthcare continuum.
It is very clear that quality and patient safety issues are a major reason for rehospitalizations. So if a patient is rehospitalized because of a failed handoff (eg. inadequate information getting to the PCP after discharge) it doesn’t matter whether that rehospitalization occurred within 15 days or 30 days or even longer.
A recent paper (Friedman 2009) looking at the relationship between the AHRQ Patient Safety Indicators (PSI’s) and rehospitalization showed that the rate of readmission within 1 month increased by 44% after a safety event and by 50% within 3 months after a safety event. Theirs was a primarily surgical population but we anticipate that the percentages would be similar or even higher in a primarily nonsurgical population.
So how does your facility approach the issue of rehospitalizations? If you are like most facilities, you probably track them (by either the 15-day or 30-day interval) and report them monthly in a manner not likely to point to an actionable steps. We advocate, on the other hand, doing a “mini-RCA” (root cause analysis) at the time of the readmission. That is the time when you are likely to have available the most pertinent information about the patient and the circumstances leading to readmission. Not only do you have the admission H&P and ER notes available, but hopefully there has been some communication with those providing care outside the hospital and you probably have accessed the old hospital chart as well. So you have at hand all the tools you need to identify those factors contributing to the need for rehospitalization.
We actually recommend that you establish a database (could be a simple spreadsheet) having categories for the common reasons leading to readmission. Keep in mind that there may be, in fact likely will be, more than one factor contributing to that rehospitalization. Many of you keep such databases now for looking at “avoidable days” or “delay days” when doing utilization management on your inpatients. Well, develop a similar list for “reasons for readmission”, for example:
Discharge summary did not get to caregiver
No visit with PCP (or other scheduled provider)
No home care visit
Patient did not understand discharge instructions
Medication reconciliation failure
Patient did not take recommended medications
Patient dietary indiscretion
Pending test result not followed up on
Delayed complication from hospitalization
Another huge consideration is patients returning from long-term care (LTC) facilities or skilled nursing facilities (SNF’s). The study we mentioned in last week’s column (Jencks et al 2009) on Medicare data showing 19.6% of all patients discharged from an acute care hospital are rehospitalized within 30 days did not include patient who had been discharged to long-term care. That undoubtedly would have increased the percentages even more since residents of long-term care have much higher hospitalization rates in general.
In the past, that was more of a concern for managed care organizations, who were concerned about the cost of acute care hospitalizations. However, now that Medicare is considering bundling payment to include not only the acute hospital stay but also all aftercare, acute care facilities must begin to look at where their patients are being discharged to and where their readmissions are coming from.
Many managed care organizations have utilized the Evercare™ model developed by United Health. In that model, nurse practitioners working in conjunction with geriatricians visit patients in long-term care facilities frequently. They identify and treat early those conditions with deterioration before acute hospitalization is necessary. They are critical in both coordinating care and triaging patients to the most appropriate level of care. One study (Kane et al 2003) showed the program reduced hospital admissions and ER visits 45-50%, with resulting considerable financial savings.
This may require establishment of new partnerships. Some hospitals already have long-term care facilities, rehab facilities, substance abuse programs, and home health care as part of their system. But many hospitals get those readmissions from other institutions that are not part of their current systems. They must be able to develop creative methods to help ensure that patients discharged to those facilities will not need rehospitalization soon. That may be scary for some but it is clear that in the healthcare system of the future we all need to get out of our silo thinking and think about how to deliver for our patients and society the safest and most effective care at a reasonable cost.
Friedman B, Encinosa W, Jiang HJ, Mutter R. Do Patient Safety Events Increase Readmissions? Medical Care 2009; published ahead of print 23 March 2009
Jencks SF, Williams MV, Coleman EA.. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. NEJM 2009; 360: 1418-1428
Kane RL, Keckhafer G; Flood S, Bershadsky B, Siadaty MS. The Effect of Evercare on Hospital Use. Clinical Investigations. Journal of the American Geriatrics Society. 51(10): 1427-1434, October 2003.