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Drilling Down on Readmissions

May 13, 2011
by Mark Hagland
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Following an eye-opening study, one hospitalist leader sees much room for process improvement

Earlier this spring, the Waltham, Mass.-based QuantiaMD, an online physician-to-physician learning collaborative, released the results of a study that focused on the need for the training, education, and resources needed in order to help physicians participate in initiatives to reduce hospital readmissions. Over 1,000 physicians nationwide participated in the study.

Significantly, while more than 9 out of 10 physicians working in hospitals believe that reducing readmissions is an important area of endeavor, 71 percent of those surveyed by QuantiaMD told researchers that their organizations’ systems and procedures for averting readmissions among high-risk patients were not very effective. Most also said that their organizations don’t currently provide adequate training and education in that area, with 54 percent saying the current training and educational opportunities at their organizations did not adequately focus on reducing readmissions.

Respondents most frequently reported that they treated patients presenting with the following conditions most commonly associated with hospital readmissions: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pneumonia, coronary artery disease (CAD), and psychiatric illness.

One physician leader working intensively in the area of readmissions work, and who cooperated with QuantiaMD researchers in their study, is Mark V. Williams, M.D., professor and chief of the Division of Hospital medicine at the Northwestern University Feinberg School of Medicine, and principal investigator, Project BOOST, all in Chicago. Project BOOST is a leading-edge program, sponsored by the Society of Hospital Medicine (SHM; the national professional association of hospitalists) that incorporates mentorship and a resource kit developed by Williams and other physicians expert in the field, and which is being implemented in hospitals across the country in order to address readmissions issues.

Williams, who works as a hospitalist at Northwestern Memorial Hospital in Chicago, and who is a past president of SHM, spoke recently with HCI Editor-in-Chief Mark Hagland regarding the implications of the QuantiaMD study for readmissions work in the hospital setting. Below are excerpts from that interview.

What are your reactions to the results of this study?
I think hospitalists are paying attention to this. I think that A) they recognize this as an important issue; and B) I think they don’t feel adequately prepared.

Mark V. Williams, M.D.

You’re in charge of the hospitalists at Northwestern Memorial, correct?
Yes, that’s right. And the study’s respondents represent a sample of hospitalists nationwide who log into the Quantia website. What’s striking is the percentage of physicians who feel they need additional training, combined with the high proportion who feel this is very important. So this provides a sort of unexpected needs assessment that provides insight into this area.

What kinds of areas do you see as ripe for training and education?
Well, I would recommend that this be undertaken in a somewhat different way from the standard conference course or didactic teaching or online work; instead, it demands involvement in quality improvement initiatives. Interestingly, the American Medical Association is now providing CME that can be obtained through participation in a quality improvement project; and the American Board of Internal Medicine provides maintenance of certification credits for when physicians re-certify in their area of specialty; and now you can get those credits for participating in Project BOOST, for example. Go to our website: www.hospitalmedicine.org/boost. That’s the website for the Society of Hospital Medicine. I’m currently editor in chief of our peer-reviewed journal, the Journal of Hospital Medicine.

Within the context of readmissions work, what aspects would be most interesting?

Just participating in those projects, to begin with; and then, an initiative focused on improving the discharge process specifically, such as Project BOOST, will have the salutary effect of reducing readmissions; it also improves patient satisfaction.

What kinds of improvements improve the discharge process and therefore reduce readmissions?

A couple of components: first, identifying patients at high risk for readmissions; second, using checklists that identify things such as potential gaps in care delivery, as we plan patients’ transition from the hospital to home. Among the things that such checklists should contain include materials related to home-use medications such as anti-coagulants and insulin; post-discharge phone call instructions; information to be provided for post-discharge follow-up visits; and this should literally begin at the beginning of the admission, not at the end.

Where are the biggest gaps right now, qualitatively speaking, in all this?
First is having a coordinated regime in hospitals—hospital leaders have not focused on the discharge process strategically. I think the discharge process should be viewed, as it were, as a medical procedure, and we should handle it accordingly. Second, I think there hasn’t been sufficient work on transmission of data from the hospital to the physician office, and this is where IT can play a role. Making sure that the discharge summary is included immediately in the electronic medical record, for appropriate reference by clinicians. And we’ve done that here at Northwestern Memorial. And Kevin O’Leary, M.D., has written a couple of articles on integrating the discharge summary into the patient record; he’s a hospitalist., and is the associate chief of our division of hospital medicine. We got feedback from primary care providers in developing this.

What kinds of explicit advice might you have for CIOs and CMIOs?
I think they need to work with their clinicians on these processes; that’s the key thing. And they shouldn’t try to buy things off the shelf that they then try to collaborate with physicians on; physicians need to be involved upfront.

Anything you’d like to add?
I think there are going to have to be IT solutions in this area, and there are more companies than I can count getting into this area, because they’re seeing it as a potential revenue stream. And CIOs and CMIOs need to look at what their current EHR’s capability is, and see whether they can integrate it all, versus buying a separate package.

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