A recent study by three hospitals in the Bronx, N.Y., has demonstrated the importance of consistent follow-up with patients post-discharge to avoid readmissions. Bronx Lebanon Hospital Center, Montefiore Medical Center and St. Barnabas Hospital partnered with insurers EmblemHealth and Healthfirst to form the Bronx Collaborative. The Collaborative developed a standardized, evidence-based protocol to facilitate patients' transition out of the hospital and prevent readmissions within 60 days of discharge.
The Bronx Collaborative's Care Transitions Program
Under the Collaborative's Care Transitions Program, patients aged 50 and older with Medicare, Medicaid or commercial coverage by EmblemHealth or Healthfirst who were admitted to the medicine service of the participating hospitals were identified by a predictive model as being at risk for a readmission based on their diagnoses and history of previous admissions. The hospitals attempted to implement a series of interventions for these patients. The participating health plans paid hospitals a fee for each patient who received at least two of these interventions:
1. Pre-discharge education.
2. Scheduling of a follow-up physician appointment within two weeks of discharge.
3. A phone call two to three days after discharge to answer questions and review medications.
4. A second phone call one to two weeks after discharge to confirm the patient had the follow-up physician appointment.
5. A third call two to five weeks after discharge to address remaining concerns.
The 60-day readmission rate for the 500 patients who received at least two interventions was 17.6 percent, compared with 26.3 percent for a comparison group of 190 patients who received the current standard care. Another 85 patients who received only one intervention for a variety of reasons had a higher readmission rate, raising to 22.8 percent the overall 60-day readmission rate for patients in the intervention group.
5 takeaways
Janet Kasoff
Two leaders of the Bronx Collaborative share five major lessons learned from this program.
1. Provide consistency. Under the program, the same care transition manager followed the patient from discharge through 60 days post-discharge, allowing the patient and care manager to build a trusting relationship, according to Janet Kasoff, EdD, RN, project manager of the Care Transitions Program and senior director of Montefiore Care Management's Center for Learning and Innovation. "Even though the program and protocol ended at 60 days post-discharge, many patients still contact their care transition manager [as their] navigator through the healthcare system," she says.
2. Adapt evidence-based measures. To create hospitals' protocols for managing patients at high risk for readmission, hospital leaders reviewed the evidence and adapted measures based on their resources and the needs of the patient population. Combining a standardized, evidence-based protocol with flexibility to meet patients' needs was part of the reason for the interventions' success, Dr. Kasoff says. "We looked at the literature and gleaned what was operationally doable," she says. "It has to be flexible and adaptive enough for the population."
3. Awareness changes behavior. The hospitals' focus on care transitions led to a revamping of staff training on the discharge process, according to Anne Meara, RN, MBA, associate vice president of network care management at Montefiore who led the Collaborative's project design team. "We have worked closely with nursing leadership, trying to enhance the orientation around the importance of how a person is discharged — even just getting the right phone number to contact someone post-discharge is vital," she says.
Anne Meara
4. Refine data collection. Eighty-five patients in the study — about 14.5 percent of the total number of patients — received only one intervention for a variety of reasons, such as an unanswered phone call — and they had a much higher readmission rate. The Bronx Collaborative is analyzing data to identify commonalities among this subpopulation of patients who had only one intervention.
One of the challenges of identifying common characteristics of patients who received only one intervention is the collection of relevant data. Factors such as housing and transportation are not collected in a standardized way across hospitals the way medical history is. Instead, this type of information is often found in notes in the medical record or comes from discussion with care transition managers, according to Ms. Meara. Hospitals in the Collaborative are working to refine their data collection methods to better capture information that can help providers proactively identify and care for patients who were not reached by the initial interventions.
"Part of our continuing work is to look across all three organizations at the data collection tools currently used — nursing assessments, social work psychosocial forms — to see where we have commonalities and differences in information collecting and try to establish a minimum dataset of psychosocial indicators that may factor into our predictive model," Ms. Meara says.
5. Collaboration is essential. A key theme of the Care Transitions Program was the importance of collaboration in improving patient care. "Patients access their care in different organizations; to really be able to manage the whole patient, we need to work with others. The Collaborative enabled us to bridge the gap that often exists as people cross transitions not only within, but among organizations as well," Ms. Meara says.
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