Readmissions and the Mechanics of Care Transitions

And we now have an experienced scheduler in the hospital, and she has her scheduling system set up on her own screen, and on the other screen is the Cerner discharge system. And she will look at the two screens and make sure that she schedules Mr. Smith as he’s getting discharged.

So on one level, it’s simple, but processes and workflows are so complex in healthcare and have to be worked out, right?

Exactly. That’s why we needed a systems engineer to help us work all this out. So instead of having six RNs, who are higher-paid, to stand on hold in the hallway trying to get appointments, now we have a system where people can send messages for appointments, and we’re paying a scheduler, not clinicians, to do this. And we’re happy, because we really don’t want to stand around in hallways on hold.

So that was the H2O initiative. It clearly reduced variation, and we have a very high rate of seeing our patients within two to five days. The H2O initiative did reduce variability, and also the us-to-us readmission. It doesn’t cover every single practitioner in the hospital. The next phase is to reinforce the standard of care where every patient goes home with a full arsenal of support.

Also, we learned when we studied the situation that we were reducing readmissions, but that we were losing in the area of patients being discharged to subacute rehabilitation. They go to a rehab hospital, where they get up to two hours a day of therapy, and they’re too infirm or fragile to go home. And in the subacute rehab facilities, no one is seeing them [for follow-up]. Now, you could insist that those patients make [primary care physician appointments], but we tried that, and it was a fiasco. Suddenly, you were forcing them to get into a Heuer lift and an ambulance, and creating great disruption to those patients. So we opted for a phone-based follow-up with them instead, so a nurse is calling up that kind of patient and going over their medications with them in that way.

The second step was actually taking on [the processes in] subacute rehabilitation. We actually own a subacute rehab hospital; so we called them up and met with them. And we discovered that their stays were more like nursing home stays than like rehospitalizations. Here’s one important example, with regard to CHF patients. Now, here’s the thing: in a hospital, we can enforce certain health requirements, such as dietary, but not in rehab. By regulation, they’re not allowed to impinge on patients’ rights, and they can order anything off the menu in the rehab hospital. So it became clear that they needed to shift their model to become educators and advocates, and that ended up being at the nurse level. So we educated their nurses about heart failure, and brought in our team, and created a series of classes on heart failure and why sodium restriction was important. We also asked them to be educators for the patient, modeling it after telehealth programs. In telehealth, you model behaviors for patients and explain things to them. And we developed a flowsheet with a questionnaire, and encouraged the nurses to do blood pressure and weight checks with the patients every day and to rank them low, medium or high; and we also encourage them to help the patients make dietary choice as well, and that’s been very effective as well. That program has been live for about a year now.

What should CIOs and CMIOs know about all this?

I think they should understand that what I call transitional care, or how the patient transitions from inpatient to outpatient, can have a significant impact on readmissions. And looking at processes is really valuable. And I would recommend that they bring clinicians and administrators together around a table to look at this. And if they’re able to find mechanisms within the information system to support this, they’ll find clinician champions.