Under healthcare reform, hospitals may face financial penalties for preventable readmissions. Reducing readmissions can thus save hospitals money, improve patient care and create efficiencies. Grand Rapids, Mich.-based Spectrum Health developed a program to prevent readmissions for heart failure patients. Michael Dickinson, MD, director of advanced heart failure, ventricular assist device and heart transplant at Spectrum Health Frederik Meijer Heart & Vascular Institute, describes how the heart failure team focused on follow-up patient visits, transitions of care and an observation unit to help keep heart failure patients at home after discharge.
Hospital to office
Dr. Dickinson says the first step to reduce readmissions is to acknowledge the difficulty of the task. "Don't be overconfident in your ability to reduce readmissions," he says. Once healthcare providers understand and prepare for the challenges of a readmission initiative, they should then examine current processes to identify gaps in care. "It requires a comprehensive look at what's causing the readmissions," he says. Spectrum Health brought in a lean six sigma black belt to assist in this process.
This assessment revealed that at least half of heart failure readmissions occurred before patients saw a physician. To address this issue, Spectrum Health established a "hospital to office" initiative — called H2O — to ensure heart failure patients are seen by a clinician within two to five days after discharge. In this visit, clinicians confirm that patients filled their prescriptions and are taking medications appropriately, ensure they understand their condition and determine if they have had an early recurrence of symptoms.
Spectrum Health assigned physician assistants who rounded on heart failure patients to conduct these patient follow-ups to more accurately assess any need for additional care. "One of the concerns of seeing patients too early out of the hospital is that many times they still look ill," Dr. Dickinson says. If a physician who is unfamiliar with the patient sees the patient directly after discharge, the physician may suggest readmission. Having PAs who saw patients on the day of discharge conducting the follow-up visit allows the clinician to make a more informed evaluation of the patient's progress after discharge and avoid unnecessary readmissions.
Scheduling
In addition to establishing early follow-up visits, Spectrum Health redesigned the process for scheduling patients' appointments. Initially, nurses would call the office's general number to schedule a patient and might be placed on hold, as a patient would be when calling a busy line. "We were paying an employee to stand on hold waiting to get an appointment," Dr. Dickinson says. Under the redesign, nurses now either fax a message to the office for an appointment or leave a message on a separate line dedicated to hospital scheduling.
One of the challenges with this process change was predicting the date a patient would be discharged and thus a possible date for a follow-up visit. Sometimes the department would need to reschedule a patient several times to ensure the visit occurs within two to five days post-discharge. "You have to have a scheduler who is willing to be flexible," Dr. Dickinson says. "It would have been really hard if we didn't have a mature management team tasked with developing this [process]."
Transitions of care
Spectrum Health's evaluation of heart failure readmissions also found that many patients went to a rehabilitation facility after discharge from the hospital. These patients were typically higher risk due to comorbid conditions, age and other factors. To monitor these patients more closely, Dr. Dickinson's team added them to PAs' schedules — not for follow-up visits, because they were in a different facility, but for follow-up phone calls with the patients' new nurse. The PA would ask the new nurse questions about the patient, such as fluid retention and medication adherence. The nurse also had an opportunity to ask the PA questions.
Spectrum Health's continuing care branch also began meeting with the rehabilitation facility's managers to learn more about the organization and determine how they could improve care for the heart failure patients. One strategy was to educate rehabilitation nurses and other rehab staff on the needs of heart failure patients. "Internal medicine physicians and midlevel providers that are medical directors of rehab are usually over-burdened, and there's no special emphasis on heart failure patients," Dr. Dickinson says. The health system team taught staff how to monitor the patients' salt and fluid intake, weight and other symptoms. Before this education, heart failure patients may not adhere to a low-salt diet because there are no food restrictions at the rehabilitation facility. Discussing risks for readmission, such as a high-salt diet, with rehab staff thus improved care for the patients.
In addition, cardiologists and PAs separately rounded on these patients at the facility once a week. The physicians ordered routine blood work to monitor the patients' progress and prevent readmissions.
Observation unit
Another strategy Dr. Dickinson's team used to prevent readmissions was to create a heart failure observation unit. The unit is used for patients who can be effectively managed with a short length of stay and for patients who are at risk for readmission. For instance, if a heart failure patient arrives at the hospital's emergency department post-discharge with a recurrence of symptoms, the heart failure team can care for the patient in the observation unit for up to 72 hours without readmitting the patient, which saves the health system money. "Many times a readmission within 30 days is not a complete failure of the treatment plan, it's just a minor stumble," Dr. Dickinson says. "If you're given the opportunity to correct the stumble, sometimes treatment over just a 24-hour period is sufficient to prevent a full-blown readmission." Pairing an observational unit stay with an H2O visit has proved effective in preventing readmissions at the system.
Developing the observational unit was not easy, however. Creating a schedule to staff the unit 24/7 was a challenge. Dr. Dickinson said a multidisciplinary workgroup spent one to two years planning the unit before it went live. The unit also represents a new culture of healthcare. "You're creating a staff environment where staff appreciate that their job is to try and help patients get home as quickly as they can."
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Hospital to office
Dr. Dickinson says the first step to reduce readmissions is to acknowledge the difficulty of the task. "Don't be overconfident in your ability to reduce readmissions," he says. Once healthcare providers understand and prepare for the challenges of a readmission initiative, they should then examine current processes to identify gaps in care. "It requires a comprehensive look at what's causing the readmissions," he says. Spectrum Health brought in a lean six sigma black belt to assist in this process.
This assessment revealed that at least half of heart failure readmissions occurred before patients saw a physician. To address this issue, Spectrum Health established a "hospital to office" initiative — called H2O — to ensure heart failure patients are seen by a clinician within two to five days after discharge. In this visit, clinicians confirm that patients filled their prescriptions and are taking medications appropriately, ensure they understand their condition and determine if they have had an early recurrence of symptoms.
Spectrum Health assigned physician assistants who rounded on heart failure patients to conduct these patient follow-ups to more accurately assess any need for additional care. "One of the concerns of seeing patients too early out of the hospital is that many times they still look ill," Dr. Dickinson says. If a physician who is unfamiliar with the patient sees the patient directly after discharge, the physician may suggest readmission. Having PAs who saw patients on the day of discharge conducting the follow-up visit allows the clinician to make a more informed evaluation of the patient's progress after discharge and avoid unnecessary readmissions.
Scheduling
In addition to establishing early follow-up visits, Spectrum Health redesigned the process for scheduling patients' appointments. Initially, nurses would call the office's general number to schedule a patient and might be placed on hold, as a patient would be when calling a busy line. "We were paying an employee to stand on hold waiting to get an appointment," Dr. Dickinson says. Under the redesign, nurses now either fax a message to the office for an appointment or leave a message on a separate line dedicated to hospital scheduling.
One of the challenges with this process change was predicting the date a patient would be discharged and thus a possible date for a follow-up visit. Sometimes the department would need to reschedule a patient several times to ensure the visit occurs within two to five days post-discharge. "You have to have a scheduler who is willing to be flexible," Dr. Dickinson says. "It would have been really hard if we didn't have a mature management team tasked with developing this [process]."
Transitions of care
Spectrum Health's evaluation of heart failure readmissions also found that many patients went to a rehabilitation facility after discharge from the hospital. These patients were typically higher risk due to comorbid conditions, age and other factors. To monitor these patients more closely, Dr. Dickinson's team added them to PAs' schedules — not for follow-up visits, because they were in a different facility, but for follow-up phone calls with the patients' new nurse. The PA would ask the new nurse questions about the patient, such as fluid retention and medication adherence. The nurse also had an opportunity to ask the PA questions.
Spectrum Health's continuing care branch also began meeting with the rehabilitation facility's managers to learn more about the organization and determine how they could improve care for the heart failure patients. One strategy was to educate rehabilitation nurses and other rehab staff on the needs of heart failure patients. "Internal medicine physicians and midlevel providers that are medical directors of rehab are usually over-burdened, and there's no special emphasis on heart failure patients," Dr. Dickinson says. The health system team taught staff how to monitor the patients' salt and fluid intake, weight and other symptoms. Before this education, heart failure patients may not adhere to a low-salt diet because there are no food restrictions at the rehabilitation facility. Discussing risks for readmission, such as a high-salt diet, with rehab staff thus improved care for the patients.
In addition, cardiologists and PAs separately rounded on these patients at the facility once a week. The physicians ordered routine blood work to monitor the patients' progress and prevent readmissions.
Observation unit
Another strategy Dr. Dickinson's team used to prevent readmissions was to create a heart failure observation unit. The unit is used for patients who can be effectively managed with a short length of stay and for patients who are at risk for readmission. For instance, if a heart failure patient arrives at the hospital's emergency department post-discharge with a recurrence of symptoms, the heart failure team can care for the patient in the observation unit for up to 72 hours without readmitting the patient, which saves the health system money. "Many times a readmission within 30 days is not a complete failure of the treatment plan, it's just a minor stumble," Dr. Dickinson says. "If you're given the opportunity to correct the stumble, sometimes treatment over just a 24-hour period is sufficient to prevent a full-blown readmission." Pairing an observational unit stay with an H2O visit has proved effective in preventing readmissions at the system.
Developing the observational unit was not easy, however. Creating a schedule to staff the unit 24/7 was a challenge. Dr. Dickinson said a multidisciplinary workgroup spent one to two years planning the unit before it went live. The unit also represents a new culture of healthcare. "You're creating a staff environment where staff appreciate that their job is to try and help patients get home as quickly as they can."
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