Background: Patients discharged to post-acute care facilities are at higher risk for re-admissions compared to those discharged home. Mount Sinai Hospital (MSH) discharges a significant number of patients to Terence Cardinal Cooke Health Care Center (TCC), a post-acute care nursing facility in Manhattan. In 2013, MSH discharges by the hospitalist service to TCC had an average 30-day re-admission rate of 21%.
Purpose: To decrease the re-admission rate from TCC by 30% by engaging front line providers at both facilities through a formal discussion about care transitions and systematic review of specific readmission cases.
Description: Each two-week block, an MSH hospitalist is designated as the Quality Officer and meets with members of TCC. During the first phase of the project (beginning in March 2014), participants reviewed issues related to any discharges in the prior two weeks, then focused on readmission cases chosen by TCC. Participants evaluated these cases in an open discussion, highlighting failures of communication or systems-wide errors. Participants were responsible for disseminating lessons learned to their respective groups.
The second phase of the project began in January 2015 with the institution of a more formalized review process, which included the development of a Readmission Case Review Worksheet (adapted from the INTERACT Hospital to Post-Acute Care Transfer Form). This worksheet identifies patients at risk for re-admission (such as those with high risk comorbidities); highlights specific deficiencies in communication (such as failing to send a medication list); categorizes reasons for readmission (such as a rapid change in clinical status); and identifies potential solutions for cases deemed avoidable. Cases were randomly selected and reviewed by both parties prior to the conference, and participants discussed and finalized the worksheet together.
Two of the 23 cases reviewed through this new process were deemed avoidable. Discussion of these cases prompted changes in several processes, including providing a method to readily access the contact information of discharge providers, and developing a more effective workflow for transitioning patients requiring nocturnal continuous positive airway pressure. Since implementation, front line providers at both institutions noted subjective improvement in hand-off communications. However, the readmission rate of the hospitalist service for patients discharged to TCC has not changed.
Conclusions: This collaborative effort between our hospital and a local nursing home has improved the flow of information by fostering a working relationship between providers, and creating regular, structured opportunities to exchange information. Benefits have included identification of systems-level issues that have led to quality improvement initiatives. As the project continues, our goal is to translate the subjective improvement in communication into an objective improvement in re-admission rates.