Mastering Readmissions: Laying the Foundation for Change

On the Parkland side, Amarasingham, an internal medicine hospitalist by background, and his clinical improvement team, have been working since December 2009 with a real-time risk-stratification data model that identifies congestive heart failure (CHF) patients at the highest levels of clinical risk, within hours of admission. “Every heart failure patient who is admitted gets risk-stratified using this model; and people in the highest-risk group get extraordinary interventions,” Amarasingham notes. The risk-stratification model has been worked out to a considerable level of refinement, incorporating 34 variables, some clinical, and others social and demographic. What's more, Amarasingham says, “The advantage of the electronic medical record in this context is that it captures all this data, and we have a mathematical model to produce this risk score.”

HAVE ORGANIZATIONS CREATED THE ELECTRONIC HEALTH RECORD PLATFORM TO BE ABLE TO LEVERAGE THE CLINICAL DATA OR NOT? IF YOU DON'T HAVE THAT AS A BASIS, IT BECOMES REALLY TRICKY TRYING TO REDUCE READMISSIONS, BECAUSE YOU'RE BASICALLY FLYING BLIND OTHERWISE. -ED MARX

So what happens once a CHF patient has been identified as being at the highest level of risk? “A number of things,” says Amarasingham. “Our software program will notify a heart failure ‘SWAT team’: a heart failure nurse practitioner, who will spend a lot of time with them; a pharmacist will spend an hour with the patient; a nutritionist will conduct a sodium-knowledge test and educate them and understand their dietary history; and an R.N. case manager will spend time working with them on the social work issues involved. And on discharge, the case manager will be heavily involved in medication reconciliation and making sure the discharge information is correct.” Then, within 24 hours of discharge, one of the nurse case managers will do a phone follow-up with each discharged patient, and ensure that that patient is seen within seven days of discharge at the hospital's heart-failure clinic, followed by a primary care physician visit within 30 days.

The result? At press time, Amarasingham and his colleagues were early in the process of data analysis on this program, but, he says, they are seeing very significant reductions in subsequent readmissions.

Meanwhile, at Texas Health Resources, Velasco, a cardiac surgeon by training, has been helping to lead colleagues in the THR system in a CHF program that is using a four-component care management protocol derived from the Transforming Care at the Bedside collaborative, begun in December 2009 by the Cambridge, Mass.-based Institution for Healthcare Improvement (IHI).

Among the IT-facilitated advances currently being made at THR hospitals, nurses doing the post-discharge follow-up phone-based assessment are now recording their notes into the health system's ambulatory EHR. What's more, Velasco says, “The next phase of that is to expand that to an interactive, Web-based encounter,” whose notes will be available to patients through the personal health record linked to the ambulatory health record (both products of the Verona, Wis.-based Epic Systems Corp., whose EMR is the core clinical IS for both THR and for Parkland). Already, says Velasco, strides are being made in reducing CHF-related readmissions.

But what is particularly exciting is that the Parkland and THR teams are currently laying the foundation for a metropolitan area-wide investigation into readmissions, in order to be able to assess what the rates of readmissions are for CHF patients to hospitals other than the ones to which they were originally admitted. Velasco and Amarasingham are excited about the research effort, even though the community-wide aspect of it may not yield any direct reimbursement benefits to either hospital organization under the emerging healthcare reform regulations. But both believe it's the right thing to do for patients and for the healthcare system.