Home Care Unplugged: Partnering to Reduce Readmissions / ED Visits Beverly Bowell, RN, BSN, ACM Jennifer Rudzinski RN, MSN, ACM
Background
Goals
Methods: Assessment Phase
Transitioning from hospital to home is often perilous for patients, but health system accountability and greater care continuity during the process can help.1 Patients repeatedly struggle with understanding their care needs, discharge orders and follow up recommendations. Having the correct resources in the home improves processes for care transitions, enhances patient and caregiver satisfaction, and adherence to care plans.
• Partner with home health care (HHC) to identify, review, and attempt to prevent 7 day readmissions and ED visits. • Improve transitions of care to prevent unnecessary health care system use. • Provide real time communication of issues and collaborate to assist patients promptly. • Enhance communication between the hospital, HHC, and patients and families in order to obtain more efficient care delivery.
• Development of HHC Campaign: CALL US FIRST! o Education to ensure patients call HHC before presenting to the ED o HHC available to assist patients to prevent readmissions (i.e. Malfunctioning Equipment, Medication Adherence and Constipation) • Front Load Visits – more frequent visits for patients in high risk categories and at risk for readmission. • Medication reconciliation/ review discharge Instructions • Connect with physicians to identify interventions at home: o Pain Medication Adjustments o Bowel Regimen o Feeding Tube Enzymes
One of the toughest challenges for hospitals in their effort to reduce readmission rates is not only to provide quality follow up care, but also understand and anticipate what the patient will need once at home. Home care is one of the best options.2 In order to assist patients across the continuum of care, identify and prevent 7 day readmissions, a concurrent review was conducted. The 7 day readmission timeframe was chosen to review as it best captures hospital attributable readmissions.3 The review revealed that 7.8% of patients discharged to home with home care returned to the hospital. To address these readmissions, bridge any transition inconsistencies, and improve overall processes, an interdisciplinary team was created comprised of inpatient care management, home health care leadership and clinicians. References 1
Medscape Kuehn, B.M. (2018, May 14) Study Identifies Patient, Family Needs at Discharge 2 The Direct Impact Home Care May Have at Reducing Hospital Readmissions by Valerie VanBooven, RN BSN, Editor in Chief of Homecare Daily.com/January 16, 2018 3 Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators Of Quality Of Care David Chin-Heejung Bang-Raj Manickam-Patrick Romano - Health Affairs - 2016
Methods: Development Phase • Care management (CM) completed a concurrent review of all 7 day readmissions from January 2018- September 2018. Of the 258 avoidable readmission/ED visits identified during this timeframe, 24% were for the following reasons: o Malfunctioning Equipment - 48 o Medication Adherence - 10 o Constipation - 5 • Data reviewed with HHC partners and processes formulated to address trends. • Communication template developed for reporting avoidable readmissions to CM. • Re-education developed for CM and identified nursing areas.
Outcomes
Methods: Implementation Phase • CM communicates directly and concurrently with HHC via email to alerts of avoidable readmissions/ED visits. • HHC clinicians evaluate and provide real time feedback to hospital CM. • Re-educate CM staff regarding triggers to consult HHC includes: o Patients refusal of Skilled Nursing Facility placement o Non–adherence with medication/care plan • Avoidable findings shared with hospital nursing leadership: o Malfunctioning Equipment – enhanced DC teaching and ensure HHC referral is ordered at discharge. o Medication Adherence – medication reconciliation with focus on new discharge medications. o Constipation - bowel regime ordered at DC and Pt. education for prevention.
Post implementation of HHC initiatives shows an overall decrease in 7 day readmissions. Oct 2017 – Jan 2018 = 7.8% vs. Oct 2018 – Jan 2019 = 6.5%
Conclusions Collaboration with CM and HHC has reduced avoidable readmissions and ED visits and increased communication between care settings.
Next Steps • Follow up phone call from hospital to patients who refused HHC at discharge. • Increase HHC referrals for patients at risk. • Improve process for weekend HHC referrals.