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1. Look beyond the data.
Don’t just keep track of which post-acute providers have the most readmissions, advises Cheri Bankston, RN, MSN, director of clinical advisory services at Curaspan Health Group. Go a step further and have discussions with the community provider, dig down to individual cases and find out what happened, Bankston says.
She worked with one hospital that experienced a spike in heart failure patient readmissions from one skilled nursing facility. When the hospital team sat down with representatives of the facility and reviewed patient records, they determined that there were several new staff members on the night shift who were not elevating the heads of heart failure patients, which led to fluid buildup and hospitalization.
2. Consult the palliative care team.
Referring appropriate patients to palliative care is a critical part of reducing readmissions, says Teresa Remy-Detty, DSC, MHA, LNHA, BSN, RN, vice president of post-acute care services for Holzer Health System in Gallipolis, OH.
When the readmission team at the health system analyzed the readmissions, they found that a significant number of patients who were coming back multiple times were having pain issues or were not taking their medications properly and could benefit from a palliative care consultation, she says.
"This was a big piece that wasn’t being covered. We have developed a strong palliative care program with referrals being made in the emergency department. Our team is doing a much better job of educating people on palliative care and end-of-life issues," Remy-Detty adds.
3. Reach out to embedded case managers.
Case managers who are embedded in physician offices and other venues of care can be a great source of information to help you develop a successful discharge plan, suggests Kathleen Miodonski, RN, BSN, CMAC, vice president of clinical operations for Post-Acute Network Solutions, a Rosemont, IL-based company that contracts with managed care organizations to provide care coordination for residents in supportive living facilities, also called assisted living centers.
The embedded case managers know what services can safely be provided in which venue of care. For instance, residents of supportive living centers may be able to get home care services and avoid a skilled nursing facility admission, she says.
"These case managers, who often work face-to-face with patients, know the patients, their family members, and support system. They also are knowledgeable about the benefits and services that their health plan covers. This gives them the expertise to help the hospital case manager develop a reasonable discharge plan that is likely to work," Miodonski says.
The embedded case managers want to be actively involved in developing a discharge plan and want to be informed about what happened in the hospital, she says.
4. Facilitate early discharges.
Get patients, especially the elderly, transferred to the next level of care early in the day, Remy-Detty suggests. "Patients, especially the elderly, transition better when they leave earlier in the day," she says.
Elderly patients who are being discharged to home are usually picked up by a spouse who may be 80 or 90 years old and who may have trouble driving at night. In some places, particularly rural areas, many pharmacies are closed at night, making it impossible for patients who are discharged late to get their prescriptions filled, she points out. "Even one night at home without medication can cause problems," she says.
5. Follow up with assisted living residents.
Don’t assume that patients who are being discharged back to a protective environment like a supportive living facility don’t need follow-up, Miodonski says. Patients who are discharged back from supportive living facilities often are at high risk for readmissions, she adds.
Many are in their 80s and even though they are high functioning enough to live alone, they may not remember what happened in the hospital or what medications they are supposed to be taking and why, she says.
"It’s essential for case managers to communicate with a clinician at the facility where the patient lives and at the patient’s primary care physician office. They need the details of the hospitalization and the treatment plan," she says.