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Reducing Readmissions via “Safe Transitions” at URMC

January 29, 2015
by Rajiv Leventhal
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One medical center’s readmissions reduction program is taking the necessary steps to keep the patient at home.
Marc Berliant, M.D.

Reducing hospital readmissions is one of many initiatives the Centers for Medicare & Medicaid Services (CMS) has launched to help improve the quality of healthcare in the U.S. while reducing costs. However, recent national data shows that nearly one in five Medicare patients winds up back in the hospital within 30 days. As such, patient care organizations across the country have been working on institutionalizing readmissions reduction programs to help bring that number down.

Tied into hospital readmissions, of course, is following the patient along the care continuum, as the meaningful use Stage 2 requirement includes three measures, two of which rely solely on the use of Certified EHR Technology (CEHRT) to electronically transmit summary care records for transitions of care (TOC) and referrals. Indeed, closing the gaps in transitions of care has become an emerging trend for healthcare organizations of all sizes, so much so that we editors at Healthcare Informatics made it one of our Top Ten Tech Trends this year.

Traditionally, efforts to reduce avoidable readmissions have focused on hospitals, but it is becoming clear that many factors along the care continuum influence readmissions, as statistics find that 42 percent of patients in the acute care setting end up in some sort of a post-acute care setting. To this end, three years ago, at the University of Rochester Medical Center (URMC) in Rochester, N.Y., high-level leaders realized that medical groups were working in silos when it came to readmissions strategies, says Marc Berliant, M.D., associate chair for clinical affairs in the department of medicine at URMC. While Berliant attests that this is commonplace in large academic medical centers, he knew that all the different care team groups needed to be pulled together at URMC. “We wanted a multi-disciplinary approach to the problem to reduce avoidable readmissions,” he says.

After some time the “Safe Transitions” program was formed, based on three essential principles, Berliant explains: medication reconciliation at the time of admission, time of discharge, and at time of arrival at primary care provider’s office; refined discharge summaries (rather than just 30-page printouts); and following up post-discharge. “The idea was to change the culture of our primary care network to say, ‘You will see the patient within 48 hours or two business days after discharge.’ Early discharge follow-up is critical to reducing readmissions,” Berliant says. “We also developed a discharge checklist to ensure certain things were being done to accurately prepare patients before discharge. These are the essentials, and have been put in place for almost three years,” he says.

In terms of results, Berliant admits that it’s difficult to see if these specific elements have moved the needle on readmissions. He also wonders if the 30-day readmission rate is truly a reflection of hospital care or how tightly integrated hospital care is with the community. Seven days might actually be a more appropriate measure than 30 days, he says. “Regardless, CMS says that is something we will measure you on and you will be penalized if you don’t meet certain standards. Hospital wide, readmissions have fallen 2.5-3 percent here,” he notes. “We like to think that it’s due partly to these elements that were put in place, but it’s impossible to separate the individual elements that contribute to this, and the literature backs that up.”

Berliant adds that while URMC has reduced readmission rates, there has been a national trend heading in that direction as well. What’s more, patients aren’t yet seeing the value of being seen so early after being released from the hospital, as they might have other in-home visits scheduled,  and might see this as ‘doubling up’ unnecessarily. “Our number of patients seen within two days post-discharge is 45 percent, but there reasons why that number will never be 100 percent, nor should it be.  But it’s better than it was, which was probably zero,” Berliant says.

Technology Helps

Having a robust EHR that now exists throughout the entire spectrum of the care delivery system certainly helps as well, adds Berliant. Notes about the patient discharge can be written to the clinical care managers in URMC’s patient-centered medical home (PCMH) practices via the Epic EHR, he says.  This goal is for patients to take more ownership of their care—and the best way to do that is by engaging them throughout the course of their inpatient stay, Berliant notes.

Another technology piece to the readmissions reduction puzzle at URMC involves a post-discharge phone call, in which hospital and care managers make phone calls with 24 hours of discharge to ensure that patients are taking medicines as planned and affirm that a PCP follow-up appointment is on the calendar. Now, Berliant says, a pilot is being launched where the phone call is automated.

What’s more, thanks to a grant from the Greater Rochester Health Foundation, URMC will launch a virtual care center (VCC) in which a care team member (with a social work background) will notify qualifying high-risk, chronically ill patients that they are being simultaneously “admitted” to a VCC that, invisibly, hustles to engineer a smooth transition to out-of-hospital care or self-care. These rounds are done when the patient is in the hospital or within 30 days of discharge, Berliant says. “By micromanaging this transition period for a set of patients, investigators hope to curb readmissions that squander community resources, threaten emergency room access, and drive up care costs,” he says.

But Berliant adds that if you’re not willing to track in the EHR how the patients are doing post-discharge, as well as get information from the other facilities, it will become very difficult to manage their care. “The further out you go, the less control you have,” he says.  So while lowered readmissions are the main goal of the program, Berliant knows that the hospital’s “frequent flyers” who have multiple significant conditions and perhaps poor socioeconomic statuses might not be touched by any program. “That’s the very frustrating thing, because for those particular patients, it’s going to be hard to move the needle,” he says.


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