Background: High hospital readmission rates have both clinical and financial consequences which are associated with worse healthcare outcomes for our patients and costly financial penalties for the hospital. The average cost of a readmission estimated to be at $15,200 and adds burden on hospital systems, resources, and cause further harm to our patients, leading to reduced experience scores from patients.Stanford Hospital’s 30-day all-cause readmission rate was at 12.7%, higher than the national average. Internal evaluation indicated multiple gaps in transitions of care, including follow up, medication reconciliation, and warning signs. It was also found that there is no patient centered discharging questionnaire or standard assessment of patient discharge comprehension. Here, we apply a patient centered approach to improving these gaps.
Purpose: The medicine units at Stanford had a 17.3% average readmission rate, significantly higher than national average for Academic Medical Centers per Vizient, and higher than Hospital average. Surveys of providers, nursing, and patients indicated gaps in follow up care, medication management, and patient education. With this initiative, we aim to improve the patient experience Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores for the medicine unit cluster from composite 65.7% to 73.4% and improve readmissions on these units by 3% by improving patient understanding of discharge by utilization of a Discharge Planner by August 2025.
Description: Hospitalists completed surveys on readmitted patients they have cared for which indicated >50% of readmissions and possible preventions were felt to be due to a lack of transitions of care. A patient facing document was created that serves as a learning tool, quick reference, and guide with the goal of improving this transition of care. This document included questions on patient perceived understanding, primary care name and appointment, warning signs, point of contact, and medication changes. The patient is given this document during their stay to complete, and before discharge is reviewed by nursing who informs the care team of gaps in knowledge. The document is copied for data and the patient retains a copy for home reference.
Conclusions: After initiating this Discharge Planner document, the pilot units improved by almost 4% and the HCAHPS score on medicine communication has improved by 10%. This improvement appears to be independent of general change in readmissions. More data will be available as the pilot continues and expands to further units. The document being a paper form is more prone to being lost and takes time to complete, which can cause strain during busy periods. Patient involvement and understanding of discharge is vital to successful medical treatment and the prevention of readmissions as shown by this improvement in HCAHPS scores and readmissions. This must be balanced against resources surrounding complex discharges and providing high quality discharge.
