When the Patient Protection and Affordable Care Act established the Hospital Readmission Reductions Program, Adena Health System in Chillicothe, Ohio, took a close look at its readmission rates — and found it would face a 0.19 percent penalty if things didn't change.
So the three-hospital system set internal goals to get readmission rates 3 percentage points lower than CMS' targets, said Bambi Huffman, BSN, RN, vice president of clinical integration for Adena, at the Becker's Hospital Review 5th Annual Meeting in Chicago May 17.
After assessing the situation, the team at Adena found eight major areas of concern, which Ms. Huffman shared during a presentation:
1. Inconsistent patient discharge appointments with primary care physicians
2. Insufficient attention to medicine reconciliation at intake and discharge
3. Varied discharge requirements and forms
4. Underutilized nurse navigation program
5. Low patient understanding for self-care
6. Inconsistent patient education
7. Poor transitions to extended care facilities
8. Patient non-compliance
To address these issues, the system created teams to focus on eight key initiatives
1. Education of staff, physicians and executives. "We began to explain the why and created awareness around CMS and the penalties," Ms. Huffman said.
2. Discharge process and supporting forms. At the beginning of the process, there were seven different discharge forms floating around the system — now the system is down to one. New policies and standard operating procedures were created for a new discharge process.
3. Patient education. One major problem the team uncovered was that patients did not understand the old material, so the system changed and brought in printed material at appropriate reading levels for the patients. Adena providers now also reinforce educational objectives with patients throughout their stay.
4. Primary care physician follow-up appointments. The physicians identified a best practice that patients should visit their primary care provider within five to seven days of discharge. To make that possible, Adena physicians now set aside four appointments in their schedule just for follow-up slots. "They did it and sustained it," Ms. Huffman said, and Adena continues to monitor the system to make sure the appointments happen.
5. Prompt and accurate patient information for extended care facility transfer. "This was such a mess," Ms. Huffman said. To clean it up, a new team, the Adena Post-Transition Healthcare team, was formed. The team brought in the extended care facilities to ask them what Adena could be doing better. Information gleaned from those meetings led to multiple changes, including sending more sufficient supply of medications and improved communications between the hospitals and the extended care facilities.
6. Risk identification and stratification. Providers now use a LACE score to identify patients for nurse navigation or possible palliative care or hospice.
7. Medicine reconciliation and initial supply of medications. Pharmacists now assist with medicine reconciliation and the initial supply of medication is sent with patients who are discharged to an extended care facility. The system is also working on a transportation system to deliver medications to patients who can't make it to a pharmacy, Ms. Huffman said.
8. Engagement and partnership with extended care facilities. A big step was the focus groups with the facilities to evaluate what Adena could be doing better in this area. "One of the things [they said] would be most helpful if we could connect our IT systems," Ms. Huffman said. After a pilot program, Adena is now connected with 15 extended care facilities.
All of these efforts led to dramatic reduction in readmission rates for pneumonia, acute myocardial infarctions and congestive heart failure, and Adena is expecting to have no penalty in financial year 2015.