Background: Measures to reduce hospital readmissions help to improve the quality of care patients receive, as well as reduce healthcare costs. The Institute for Healthcare Improvement’s Triple Aim of improving the quality of care through standardization, decreasing the cost of care by reducing hospital utilization, and patient-centeredness around transitions of care, resonate strongly with readmission reduction philosophies. Although seen as a critical need in healthcare, readmission reduction remains an elusive goal for many medical groups, with financial penalties tied to poor performance as measured by the CMS Hospital Readmission Reduction Program.
Purpose: To implement a longitudinal readmissions reduction program for a selected high-risk patient cohort with front-end interventions in the index admission, transitional interventions, and back-end interventions occurring at the point of medical contact during re-presentation to emergency department.
Description: : A process at our institution was developed to prospectively identify patients with diagnoses of acute congestive heart failure, pneumonia and chronic obstructive pulmonary disease during an index admission. A checklist was completed by the front-line staff to facilitate a safe discharge through items such as scheduled outpatient follow-up, establishment of home care services, avoidance of obstacles to obtaining prescribed medicines, and education about their diagnoses and planned treatments. Upon discharge, patients were enrolled into a transitional care service which further encouraged adherence to appointments and medications, serving as a first contact for any issues that could arise. Finally, a notification was developed for this group of patients to alert staff when they presented to the emergency department within thirty days, prompting communication between inpatient, emergency, and outpatient care providers to facilitate safe return to home or nursing facility where appropriate.
Conclusions: 127 CHF, PNA, & COPD fee-for-service Medicare patients were prospectively identified during their index admission in 2019. Within this group of patients who received the care described above, only 16 patients were readmitted within 30 days of discharge, representing an overall readmission rate of 12.6%. This rate is a significant decrease from a 2018 baseline of 20.0%. A comprehensive, longitudinal program to reinforce standards of care, facilitate transitions, and energize efforts to safely continue care in the outpatient setting has reduced the overall readmission rate of hospitalized Medicare patients with CHF, PNA, & COPD by 7.4%. The next phase of this project will be to scale up efforts throughout the hospital and to other high risk patient cohorts given the massive success of this pilot.