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Pre-admissions screening helps cut readmission rate
Discharge planning begins before the hospital stay
A pre-admission screening and educational program for patients having elective surgery has helped slash readmissions among patients treated at Geisinger Health System from nearly 20% a year ago to about 10% today.
"One of the big keys in preventing readmissions is knowing in advance that patients are at high risk for readmission and working with them and their family members to overcome the challenge. We have expanded the walls of the hospital to provide pre-admission assessment and testing and post-admission follow up," says Susan Standish Wallace, MS, RN, MCCL, NE-BC, director of care management for the health system with headquarters in Danville, PA.
As length of stay has decreased, it has become challenging for care managers to complete the teaching that patients need in order to take care of themselves after discharge, Wallace points out.
"Today, our patients heal and recover in other settings — in rehabilitation facilities, long-term care hospitals, or at home. Our efforts to teach the patient how to handle his or her illness has to stretch beyond the limits of the hospital stay," she adds.
A few years ago, the average length of stay at Geisinger was seven to eight days. This enabled the care managers to start post-discharge education on Day 6 or 7, when the patients were feeling well enough to learn.
"Now our average length of stay for all DRGs is less than five days. Even though the length of stay is shorter, patients' needs are the same," Wallace says.
Discharging elderly patients
Many elderly patients have multiple comorbidities, which make their post-discharge needs more acute. In addition, anesthesia tends to stay in the system of geriatric patients for a long time, making it difficult for them to comprehend post-discharge education while they are in the hospital, Wallace points out.
The problem is compounded for patients who live in rural areas, some as far as 300 miles from the hospital. Since rural home health agencies and nursing homes have limited capacities, taking a proactive approach to discharge planning and giving the agencies a heads up early in the hospital stay helps the care managers meet the patients' post-discharge need in a timely manner, she adds.
At Geisinger, patients who are coming in for elective total joint replacement surgery and the majority of those scheduled for elective general surgery receive a risk assessment and a comprehensive screening and education call before admission.
The information lets the care managers who will coordinate care for the patients after admission, get a head start on discharge planning, and work to overcome obstacles and challenges to a timely discharge.
"Pre-screening patients helps us identify patients who may have difficulty learning how to care for themselves after discharge and to identify a family member or caregiver who can be here for the teaching prior to discharge," Wallace says.
Patients who are having elective total joint replacement surgery complete a risk assessment form in advance and attend a class that helps them understand their surgery and what they will need after discharge.
When patients receiving elective general surgery go to the clinic for their preoperative visit, clinic staff complete a risk assessment form and pass the information on to the hospital staff.
Patients in both categories also receive a pre-admission screening call that helps them understand what kind of assistance they will need after discharge.
Before patients are admitted for surgery, Cynthia Faust, LPN, calls them at home and gathers additional information, which she places in the medical record; the unit-based case managers can follow up with more teaching and transition planning while the patient is in the hospital.
Faust makes sure the patients understand that they will need someone to stay with them and that they need to make arrangements in advance for their pets if there could be an issue in their care.
"I make sure they have someone lined up who can get their groceries and medication during the time they can't drive so they have adequate supplies of things they might need, like diabetic test strips," she says.
When patients live alone, Faust identifies someone who could care for them after discharge and calls to ensure that the person will be available.
In addition, care managers on the unit make sure that patients have scheduled follow-up visits with their primary care physicians before they leave the hospital.
"Research has shown that it is important for a patient being transitioned from the hospital setting to be seen by their primary care provider within 72 hours and that the longer the time they wait before their primary care visit, the bigger the risk that the patient will return to the emergency department or be readmitted," Wallace says.
Geisinger's hospitalists alert patients' primary care physicians about the hospital visit within a few days after discharge. In many cases, the hospitalist at Geisinger calls the primary care physician to update him or her on the patient's condition.
The hospital is working on a pilot project to e-mail a brief synopsis of the discharge summary to the primary care physician on the day of discharge.
In addition, patients who are chronically ill and at high risk for readmission are referred to Geisinger's advanced medical home (also known as ProvenHealth Navigator), a community-based pilot program whereby Geisinger embeds RNs in physician practices to closely follow chronically ill patients. Some of the patients receive home monitoring equipment with which to record their blood pressure, blood sugar level, weight gain, and other vital signs. The information is transmitted to the doctor's office where the staff can intervene if necessary to help the patient avoid a visit to the emergency department or a readmission.
"With unscheduled admissions, we're working on doing a better job of evaluating patient learning. Our nurses, physicians, and care managers use a teach-back method to make sure that patients understand their post-discharge instructions," she says.
Using the "teach-back" method, staff ask the patient to repeat the information and tell them why it's important.
(For more information, contact: Susan Standish Wallace, RN, MCCL, NE-BC, Director of Care Management, Geisinger Health System. E-mail: email@example.com.)