Reducing Readmissions: National
Priorities and Lessons Learned
Denise Remus, PhD, RN
Improvement Advisor, Cynosure
Health / HRET HEN
Partnership for Patients
The 40/20 Goal
Keep patients from getting injured or sicker.
Reduce preventable hospital-acquired conditions by 40%.
1.8 million fewer injuries to patients, with more than
60,000 lives saved over the next three years.
Help patients heal without complication.
Reduce all hospital readmissions by 20% .
1.6 million patients will recover from illness without
suffering a preventable complication requiring
re-hospitalization within 30 days of discharge.
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40/20 Goal
 Adverse Drug Events (ADE)
 Injuries from Falls and Immobility
 Central Line-Associated Blood
Stream Infections (CLABSI)
 Catheter-Associated Urinary Tract
Infection (CAUTI)
 Ventilator Associated
Pneumonia (VAP)
 Venous Thromboembolism (VTE)
 Pressure Ulcers
 Safe Surgery / Surgical Site
Infections
 Obstetrical Harm
 Readmissions
AHA HRET HEN
34 states and territories / 1,600+ hospitals
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Hospital Engagement Network Improvement Capacity Structure
Hospitals or Hospital Systems
Improvement Leader Fellow and Collaborative Teams
State Hospital Association
Comprehensive
Data System
Improvement
Advisor
Institute for
Healthcare
Improvement
AHA/HRET Hospital Engagement Network Team
Readmissions are Common and Costly
Medicare rehospitalizations within 30 days after Hospital Discharge $17.4 Billion
Rates still too high…
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With minimal improvement
Latest Hospital Compare release 2008-2011
compared to 2007-2010 showed (30-day readmits):
• AMI rates fell by only 0.1% to 19.7%
• HF rates fell by only 0.1% to 24.7%
• PN rates increased by 0.1% to 18.5%
Only 10 hospitals in the U.S. had better than
expected in all three areas
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New Hampshire Hospitals…
Hospital Compare contains data from 26 NH
hospitals, many with cases to small to calculate
rates. In the latest release:
• AMI rates ranged from 16.4% to 21.2%
• HF rates ranged from 20.2% to 25.9%
• PN rates ranged from 16.1% to 20%
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Challenges continue
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Actual
Discharge Form
Project RED
Brian Jack, MD
We have knowledge…
Models for Improving Care Transitions
• Care Transitions Intervention
• Transitional Care Model
• Project RED (Re-Engineered Discharge)
• Project BOOST (Better Outcomes for Older Adults
through Safe Transitions)
• Transforming Care at the Bedside (TCAB)
• STAAR (State‐Action on Avoidable Rehospitalizations)
• INTERACT II (Interventions to Reduce Acute Care
Transfers) – SNF based
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Are we using it? “Yes”
• Three New Hampshire Hospitals have
readmission rates BETTER than the U.S. rate
• No NH hospitals were significantly worse
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Are we using it? “Maybe”
• In a recent study, 90% of hospitals agreed or
strongly agreed they had written objective of
reducing preventable readmissions (for AMI or
HF)
• The majority of hospitals reported having
quality improvement teams in place, 87% for
HF and 54% for AMI
Bradley, et al, July 2012, Contemporary Evidence about Hospital Strategies for Reducing 30-Day Readmissions,
Journal of the American College of Cardiology
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Are we using it? “No”
The same study found
• Fewer than half the hospitals (49.3%) partnered
with community physicians
• Only 23.5% partnered with other local hospitals
• Inpatient and outpatient prescription records
were electronically linked 28.9%
• Discharge summary was always sent directly to
primary care physician by only 25.5% of hospitals
Bradley, et al, July 2012, Contemporary Evidence about Hospital Strategies for Reducing 30-Day Readmissions, Journal
of the American College of Cardiology
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We must improve – 40/20 Goal
Reduce Harm by 40%
and Reduce
Readmissions by 20%
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A New Path
Leadership Engagement
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•
•
•
Create a sense of urgency
Build will
Shared, common vision for the future
All – board, leadership, physicians, front-line
staff and caregivers
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Bricklayer #1
“Putting a brick on top of another...
Isn’t that obvious?”
Bricklayer #2
“Building a wall
for the west
side of a
church”
Bricklayer #3
“Creating a
cathedral that
will stand for
centuries and
inspire people
to do great
deeds”
What percentage of the people you
are trying to engage are:
• Putting one brick on
top of another?
• Building a wall for a
church?
• Creating a
cathedral?
Build Your Infrastructure
• Quality improvement
expertise
• Quality improvement
plan
• Teams
• Resources
• Partners
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Implement Best Practices
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Identify High Risk Patients
Use a Risk of Readmission
Assessment Tool
• Project BOOST 8P
Screening Tool
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Problem medications
Psychological
Principal diagnosis
Polypharmacy
Poor health literacy
Patient support
Prior hospitalization
Palliative care
Project Red Risk Factors
• Depressive symptoms
• Limited health literacy
• Frequent hospital
admissions
• Unstable housing
• Substance abuse
Risk Stratify: Identify those at high risk and
communicate to all providers
High Risk Patients
• Patient has been admitted two or more
times in the past year
• Patient is unable to teach-back, or the
patient or family caregiver has low
degree of confidence to carry out selfcare at home
Nielsen GA, Rutherford P, Taylor J. How-to Guide: Creating an Ideal Transition Home. Cambridge,
MA: Institute for Healthcare Improvement; 2009. Available at http://www.ihi.org.
Potential Process Measure
Indicator Name
Formal Assessment of Patient's Risk of Readmission
(Project RED/BOOST/Other)
Numerator
Number of patients who have risk of readmission
assessed using standard tool (e.g., TARGET Assessment
8P scale or similar)
Denominator
All eligible patients
Patient Self Management Skills
Medication reconciliation and
education
Assess health literacy
Health literacy measurement
tool, available in English and
Spanish, from AHRQ
Teach-back
Teach-Back guide from
Medicare Quality
Improvement Organizations
National Coordinating
Center for the Integrating
Care for Populations and
Communities Aim (ICPCA)
Potential Process Measure
Indicator Name
Patients Receiving Complete Discharge Education
Verified by Teach-Back
Numerator
Patients receiving complete discharge education
verified by Teach-Back
Denominator
All eligible patients
Coordination of Information
Across the Continuum of Care
Patient-Centered Record
Project RED – After Hospital Care Plan Example
Patient-Centered Record
Coleman Personal Health Record
Timely Communication to
Other Providers
• Send completed discharge summary to
primary care physician within 48 hours
of discharge
• Use a concise, standardized discharge
transfer form
Potential Process Measure
Indicator Name
Completion of Discharge Bundle (Project BOOST or
model you are using)
Numerator
Number of discharge care plans with all elements
present (Project BOOST or model you are using)
Denominator
Number of discharge care plans
Adequate Follow-up and
Community Resources
Identify resources needed
• Primary care physician
• Medical home
• Home care
• Family care giver
• Community support (neighbor, friend, church)
• Financial resources
Timely and adequate follow-up
• Open access to appointments
– schedule before patient
leaves
• Leverage IT – technology
innovations to assist in
communication and exchange
of information
• Follow-up phone calls – use
care coordinators, possibly
automated calls
Potential Process Measure
Indicator Name
Timely Transmission of Transition Record
(Inpatients)
Numerator
Patients who had a transition record transmitted
within 24 hours of discharge
Denominator
All discharged inpatients
Measure
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Select Measures
• For each clinical topic, must report
data for at least
1 Process Measure
and
1 Outcome Measure
We have to pick up the pace…
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Readmission Sprint
Race to reduce readmissions
• Focused progress and results oriented goals
• Need baseline data – prefer Calendar year
2011, could use first 6 mo of 2012
• Monitor improvements July to Dec 2012
• Small tests of change and frequent scale
• Bi-weekly Race Checkpoint Calls
• Readmissions Listserv
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Track Readmissions
Outcomes
• 30 or 15 day readmissions
• All patients or specific conditions
such as HF, AMI, PN, COPD
• Consider simple metric – all
readmissions / all discharges
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What can you do by December
31, 2013?
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Go for the Gold!
New Hampshire
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