Background: In 2014, the organization created the RRT, a multidisciplinary team that reviews care of frequently admitted patients, strategizes how to help these patients, and coordinates care to develop a treatment plan. Of the patients reviewed, the team delivered a 47% decrease in readmissions.
Purpose: The RRT addresses the needs of complex, chronically ill patients with multiple clinical and social needs.
Description: The core team members include: social workers, case managers, nurses, physicians, nurse practitioners, emergency department (ED) case managers, complex case management staff, patient relations staff and palliative care representatives. Ad hoc members include community partners from skilled nursing facilities, assisted living facilities, home health care agencies, dialysis centers, community case management, community support organizations, and managed care payers. The involvement of community partners has been instrumental in keeping all team members closely connected, ultimately ensuring a positive impact on patients.
Referrals target patients who have multiple readmissions and/or ED visits. The referral for case review is scored for appropriateness. This organization developed a scoring tool that accounts for patient utilization patterns (e.g., ≥3 hospital admissions or ED visits in the last 90 days), the number of chronic conditions, and social issues. The RRT discussion focuses on a care plan to improve coordination and decrease preventable readmissions and ED visits.
The Hospital Medicine Service plays a key role in caring for these patients. A treatment plan developed by the RRT serves as a guide for care, with recommendations to help decrease cost, utilize appropriate care, and decrease length of stay. This plan includes assigning the patient to a recommended service, unit, as well as assigning a service based provider (APP), to care for the patient during each hospitalization.
Conclusions: Of the 130 unique patients reviewed (January 2014-June 2016), 23 (18%) expired within six months of their final team review date. Ten patients who had more than one review encounter during the time frame were excluded as their pre- and post- review periods overlapped.
Of the remaining patients (n=97), there was a 47% decrease in readmissions and ED visits between six months prior and after the Readmission Review Team’s intervention (746 vs 398, p<0.001). Additionally, the total variable cost showed a decrease of over $2.4 million ($3,555,221 vs $1,141,464, p<0.001). The average length of stay decreased 42% (3.6 vs 2.1, p<0.001) which equates to 1.5 days per encounter or a total of 146.2 days.
The RRT showed a statistically significant impact in reducing hospital readmissions and ED visits among patients identified and reviewed by the team. The RRT provides increased care coordination for vulnerable patients with complex needs both within and outside of the hospital walls.