Going Outside the Hospital for Help: How Readmissions Have Been Reduced at El Camino

“You’re looking for something that could contribute to an event,” explains Walton.  “This could include diagnoses such as congested heart failure, pneumonia, stroke, or sepsis. Other factors include whether the patient’s primary care physician (PCP) was identified in the patient’s active medical record. Each of these factors leads to another ‘point.’ So you’re looking at various factors, and adding up these ‘points.’ Then you’re saying [person X’s] readmission probability is higher than [person Y’s], and therefore when [X] comes in, we are focused on what will that mean when we discharge him or her. Basically, it’s a statistical predictor based on what that patient has experienced and how other patients with similar conditions would show up statistically.”

And according to Pat Kearns, M.D., medical director of El Camino Hospital’s Senior Health Center, the hospital has been able to identify groups at low, moderate, and high risk for readmission—rates for those groups ranged from 1 percent for the low-risk group to 11 percent for the moderate-risk group, and 27 percent for the high-risk group. “Adjustments were made as a result. For example, the PCP is now identified in 60 percent of patients’ medical records,” Kearns said in the case study. In addition, El Camino Hospital added a banner across a patient’s medical record indicating whether the patient is at low, moderate or high risk readmission. The ability to easily identify these high-risk patients alerts all care team members, enabling everyone to intervene early and plan ahead.

SHARED RESPONSIBILITY

In the past, says Walton, a major reason why patients were leaving El Camino and returning was because when they got to an SNF, there wasn’t enough follow-up from the hospital or enough support for the staff and physicians in the nursing facility. “So we have become more of a virtual unit, as opposed to two organizations handing off a customer, if you will. And that phenomenon is possible because of the willingness of all the caregivers and nurses in both organizations to make this better for the patient. Now, the SNFs will know in advance that they are going to get a patient, so there is dialogue that starts in discharged planning that is much more interactive, and there are discussions with the family that is much more interactive,” says Walton.

And even more responsibility is put on the caregivers when it comes to avoiding unnecessary and costly trips to the emergency room (ER) and hospital, adds Walton. “In the old days, if there was something happening with the patient that made the caregiver nervous, there would be an order to send him or her right to the [ER]. But now, due to the entire transition team following the patient, there is greater responsiveness and more eyes and brains focused on the patient.”

Many times, when a caregiver is frightened and has to make a judgment call, talking to a physician or a trained geriatric nurse online in a face-to-face conversation will help settle the caregiver down, and that will often lead to the right decision made for the patient, says Walton. “It’s important to remember that the SNF is not a hospital; so while the natural reaction might be to send patients to the hospital, often what is necessary is something much simpler such as changing the IV. If a caregiver has the confidence and the feedback loop to allow that to happen, it won’t put the patient at risk or cause undue anxiety for anyone.”

While proud of the results so far at El Camino, Walton emphasizes that all hospitals will have success reaching out to nursing homes. “There is a handoff problem in the U.S., and it’s an expensive one, in terms of things such as duplicate tests. The government uses a lot of our tax dollars on Medicare patients, and they tend to move between hospitals, doctor’s offices, SNFs, and back. It becomes a circle. So the more hospitals can support that journey and do the right thing at the right time, the more likely the cost profile for Medicare patients will improve. Again, technology is just one small tool. It’s the program, the funding of the nurses, the leadership, the focus, and the dedication that makes it happen.”