Rehospitalizations cost thousands of dollars each time they occur, seriously disrupt the lives of the patients and their families, and expose patients to new risks associated with being hospitalized. The Centers for Medicare and Medicaid Services (CMS) estimate that the total costs are well above 15 billion dollars.
Many factors can account for rehospitalizations. Some are planned, some patients experience unavoidable complications, and some rehospitalizations may be for conditions completely unrelated to the initial hospitalization. Rehospitalization rates vary—ranging from a rate above 23% in Louisiana and Nevada to rates below 14% in Vermont and Wyoming. One thing is clear: there is strong agreement that many rehospitalizations can be avoided if the best practices for preventing them were universally adopted.
Baystate Medical Center
In October 2009, BMC joined the State Action on Avoidable Rehospitalizations (STAAR) collaborative sponsored by the Commonwealth Fund and the Institute for Healthcare Improvement (IHI). The focus of STAAR is to reduce rehospitalizations by focusing on 4 distinct areas. BMC has put in place many interventions described below on our pilot units - Springfield 3M (general medical patients) and Springfield 4 (heart failure patients).
1. Perform Enhanced Admission Assessment for Post-Hospital Needs by including family caregivers and community providers as full partners in completing standardized assessments, planning discharge, and predicting home-going needs; reconciling medications upon admission; and initiating a standard plan of care based on the results of the assessment.
2. Provide Effective Teaching and Enhanced Learning by identifying all learners on admission; customizing the patient education process for patients, family caregivers, and providers in community settings; and by using “Teach Back” and “Ask Me 3” daily in the hospital and during follow-up phone calls to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care.
3. Conduct Real-Time Patient and Family-Centered Handoff Communication by reconciling medications at discharge and providing customized, real-time critical information to the next care provider.
4. Ensure Post-Hospital Care Follow-Up prior to discharge:
- High-risk patients: scheduling a face-to-face follow-up visit such as arranging for a BVNAH home care visit, care coordination visit, or expediting a physician office visit to occur within 48 hours after discharge.
- Moderate-risk patients: making a follow-up phone call within 48 hours and helping to schedule a physician office visit within five days. During the post-discharge call, educational content is reinforced and validated so patients have a clear understanding of what they need to do to be successful in staying out of the hospital.
Our results since implementing these interventions have yielded positive trends in our rehospitalization rates and many of the interventions are now being spread across all nursing units.
Baystate Mary Lane Hospital
BMLH has also begun participating in the State Action on Avoidable Rehospitalization (STAAR) initiative. Important steps to avoiding readmissions have been identified in the post discharge follow-up processes. Working with our BMLH Hospital Medicine Providers and Community Providers, we have studied the attendance and timeliness of patient follow-up in the office, and the effectiveness of the on-line “Discharge Summary” template.
Baystate Franklin Medical Center
A new multi-faceted program is currently being implemented at BFMC in conjunction with area agencies and nursing homes to help patients with heart failure so that they have fewer readmissions.
Our future work will be focused on continuing to spread interventions which can impact rehospitalizations across BH.
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