With Medicare reimbursement on the line, hospital readmissions have recently become a huge focus for hospitals. One hospital, however, was focused on reducing readmissions well before the penalties kicked in.
In 2009, Advocate Sherman Hospital in Elgin, Ill., which was then an independent hospital called Sherman Hospital, adopted reducing readmissions as a hospital-wide operating plan goal. "We took the leap," says Kelly Tarpey RN, director of clinical excellence at the hospital. "It was the right thing to do."
In 2011, after two years of struggling to reduce readmissions, the hospital joined the Better Outcomes for Older adults through Safe Transitions program. Participation in the Society of Hospital Medicine's BOOST project was funded by the Illinois Hospital Association and Blue Cross and Blue Shield of Illinois through their joint program, Preventing Readmissions through Effective Partnerships. BOOST gave the hospital access to mentors and a variety of tools.
Applying teach-back to discharge and follow-up
According to Ms. Tarpey, one of the most valuable BOOST tools for Advocate Sherman has been a tool for educating patients called teach-back. After providing education, staff using teach-back ask patients to repeat instructions in their own words. Having patients teach information back to the provider helps ensure patients understand instructions. In addition to asking patients to restate information, providers also ask patients open-ended questions that force patients to actively demonstrate their understanding of a concept they initially learned through "teach back" instead of passively answering "yes" or "no."
"Patients really want to go home. In fact, they can be so focused on getting home they will say 'yes' and acknowledge understanding to discharge planning and teaching just to leave. But when they get home, they're suddenly confused or at times overwhelmed. Teach-back in the hospital makes the patient stop, listen and really understand what to do when they go home," Ms. Tarpey says.
Success with the teach-back method has led providers to use it not only at discharge, but also throughout the hospital stay and during follow-up calls with patients at high risk for readmission. The hospital already had a process for making discharge calls to all patients within 48 hours. With the introduction of the teach-back method, the hospital added extra discharge calls seven days and 14 days post-discharge for patients with heart failure and other chronic conditions deemed at high risk for being readmitted.
During these clinical calls, nurses ask open-ended questions in the teach-back style to ensure patients are following instructions and to answer any questions. For example, instead of asking, "Did you follow up with your physician?" a nurse may ask "When was the last time you saw your physician?" These open-ended questions allow providers to get more information from patients than a simple "yes" or "no." Using the teach-back approach has prevented medication errors and eliminated patients' confusion, Ms. Tarpey says.
| Standard questions | Questions used with the "teach-back" method |
| Did you see your physician? | When was the last time you saw your physician? |
| Did you take your medication? | What medications did you take this morning? |
| Do you understand when to take your medication? | When are you going to take your medication tomorrow? |
| Have you been weighing yourself daily? | When was the last time you weighed yourself? |
| Have you had any trouble breathing? | How easily have you been able to breathe? |
Gaining buy-in for teach-back
When the nurse manager first introduced the teach-back tool to nurses on a pilot unit, its use was sporadic. To demonstrate the value of the tool, the nurse manager began to ask nurses open-ended questions about teach-back. Instead of asking, "Did you use teach-back today?" she would ask "When was the last time you used teach-back? Show me how you explained these new medications to Mr. Smith." Using teach-back helped nurses engage in a conversation about the tool and how it can help patients. "It became very vivid for them," Ms. Tarpey says. "They became rapid champions for it."
This example shows the flexibility of the teach-back tool for many different situations. "[Teach-back] is so small, so simple; that one little concept has had such an impact in so many areas of our business," Ms. Tarpey says.
Getting results
In 2009, the hospital's 30-day readmission rate for heart failure patients was 26 percent. By the second half of 2011, after the hospital began BOOST, these rates were down to 11 percent. In addition, the hospital went from the 78th percentile to the 94th percentile on the HCAHPS question about patients receiving discharge information.
This improvement is verified by lower readmission penalties by CMS: In federal fiscal year 2013, which based penalties on readmission rates from 2008 through 2011, Advocate Sherman received a penalty of 0.6 percent. For federal fiscal year 2014, which based reimbursement cuts on rates from 2009 through 2012, the hospital received a penalty of only 0.17 — a decrease of 0.43 percentage points. In fact, Advocate Sherman made the sixth greatest improvement in Illinois, where the average penalty is 0.45 for FY 2014, and 89 percent of hospitals received a penalty.
Continuing to improve
Despite this improvement, Advocate Sherman is continuing to lower readmission rates. "We still have a penalty; more importantly, we're still not as effective as we want to be for our patients," Ms. Tarpey says. For example, the hospital recently established weekly readmission huddles where Ms. Tarpey, case management, nursing and service leaders, COO, CNO, ED physicians and leaders of the heart failure and pneumonia teams will meet to review all readmissions from the past week. The group will attempt to identify commonalities among readmitted patients and potential causes of the readmission so in the future they can proactively implement interventions to prevent readmissions for high-risk patients.
"Just start"
The study of readmission reduction interventions is still relatively new, leaving plenty of room for both creativity in trying new interventions and hesitation about a lack of evidence. The newness of the field should not stop hospitals from trying, though, according to Ms. Tarpey. "It's important for people to just start," she says. "There's no simple answer for readmissions. Don't wait for the perfect solution. Just start, and it's amazing how much more control you can have than you think."
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