Physicians, hospital administrators and even politicians are eagerly searching for ways to reduce hospital readmissions. But there's one closely involved party that isn't typically consulted in this search: the patient.
The Institute for Healthcare Improvement (IHI) wants to change that. As part of its State Action on Avoidable Rehospitalizations (STAAR) initiative, the IHI has developed a procedure for interviewing patients who return to the hospital to determine the causes, both individual and systemic, of readmission.
“We're not relying on what we wrote in the chart. We're listening to what the patient says happened. It's a huge paradigm shift,” said Amy Boutwell, MD, MPP, a hospitalist, founding director of the STAAR initiative and director of health policy strategy at IHI.
The program does, of course, use information from a readmitted patient's chart. The STAAR initiative requires all participating hospitals (which currently number over 120) to conduct assessments of five readmitted patients, then analyze the results. The assessments include a chart review, focusing on issues such as discharge planning, outpatient follow up and patient education.
But the assessment also includes interviews with the patient, family or anyone else who can provide useful information. “Maybe they interview the home health nurse who decided to send the patient back to the emergency room that day, or the doctor in the office practice,” said Dr. Boutwell.
The interview, which has been standardized on a worksheet http://www.acphospitalist.org/archives/2011/04/readmission1.pdf developed by the IHI, starts with a simple question, “How do you think you became sick enough to come back to the hospital?” Then it drills down into inquiries about follow-up care and adherence to medication and diet.
A multidisciplinary group of inpatient and outpatient providers gathered by the hospital to focus on readmissions discusses the results of these assessments. These cross-continuum teams are another requirement of the STAAR program.
“The hospital has to reach out to the nursing home, the office practice, the skilled nursing facility, the community-based support service agencies and invite them onto their team,” said Dr. Boutwell.
Readmission reviews are the first task facing the cross-continuum teams. “It immediately focuses on the patient and the numerous opportunities that everybody around that table has to improve the experience of that patient or these five or 10 patients that they've interviewed,” said Dr. Boutwell.
If the patient interview has pointed to a lapse in care that likely led to the readmission, for example a patient missing an appointment or not getting home care, the team will dig deeper. “The conversation around the room is, ‘They didn't. OK, well, why? Was it because in this case we tried to make an appointment and we couldn't? Or we referred them for home health and somehow they didn't qualify?’ It's that kind of granular detail that the frontline team needs,” Dr. Boutwell said.
Once they've got the details on the problem, the team starts to look for solutions to prevent similar readmissions in the future. “Some of the problems are pretty straightforward and can be solved easily,” said Jan Fitzgerald, RN, director for quality at Baystate Medical Center in Springfield, Mass.
One problem area that many STAAR participants, including Baystate, have chosen to work on is patient education. “We found the hospital did not do a good job communicating to the patient what their problem was, what they needed to know and why it was important that they comply with plan of care, including the discharge instructions,” Ms. Fitzgerald said.
In response, the hospital's patient education strategy was revamped to provide simplified plans for patients and use teachback techniques (having patients repeat and/or demonstrate new knowledge or skills back to the clinician providing education) to improve patients' comprehension and ability to care for themselves.
Involving outpatient providers in the teams helped in these improvement efforts, too. “We made sure that the home care nurses and the disease management programs are teaching exactly the same thing as the hospital,” said June Stark, RN, director of case management and quality support services at Tufts Medical Center in Boston. “We're bridging the teaching experience.”
Readmission reviews also showed the teams that some readmissions could have been predicted while the patient was still in the hospital. Both Baystate and Tufts have started looking for patients particularly likely to be readmitted as part of their admission processes. “Now we have a standardized ‘Who's at high risk for readmission?’ assessment that's done for all patients. Right at the beginning you know who is at greatest risk and you can build a discharge plan to prevent the failure,” said Ms. Fitzgerald.
Both hospitals continue to use readmission interviews, even though the STAAR program only required five of them. “It's such a simple tool, but it focuses on the right things. It gives you the information that you need in a very short time,” said Ms. Stark.
This was a somewhat unexpected benefit of the interview program, according to Dr. Boutwell. “We've learned that some teams find this so absolutely compelling and essential that they're doing it on every single readmitted patient,” she said.
The hospitals have also reaped the expected benefits of the program. Baystate and Tufts have seen declines in readmissions for congestive heart failure (a diagnosis targeted with the interviews and improvement efforts) of 30% and 50% respectively since joining STAAR.
The interviews do point out the limitations of any hospital's ability to reduce admissions, however, according to Ms. Stark. She described the case of a patient who gives the right answer to every question in the readmission review—she sees her primary care doctor and specialist, takes her medication, follows her diet—yet still keeps coming back to the hospital. “We can't get in their heads,” Ms. Stark said. Some patients may not disclose the issues that led to readmission, even when asked, while others may return for reasons beyond their own and their clinicians' control.
Hospitals also vary in their level of participation, Dr. Boutwell noted. While some facilities have large, frequently meeting cross-continuum teams and ongoing interviewing of readmitted patients, others have created teams out of providers who were already affiliated with the hospital. “It absolutely spans the spectrum from checking off the recommendations and taking a modest step forward, to some teams have taken this and it's flourishing in ways we would never have imagined,” she said.
The STAAR leaders would like to imagine that their efforts will lead to improvements even in hospitals that are not currently participating. The materials, including the worksheets used for the readmission reviews, are available for free online.
“We're hoping that as a result of sharing the early successful approaches of this demonstration project, other hospitals will take from what we're doing and use it if it's helpful to them,” Dr. Boutwell said. “We want nothing more than to see all hospitals in the U.S. commit to improving transitions by focusing on caring for patients across settings and over time.”