Optimizing transitions of care to reduce rehospitalizations
ABSTRACTTransitions of care—when patients move from one health care facility to another or back home—that are poorly executed result in adverse effects for patients. Fortunately, programs can be implemented that enhance collaboration across care settings and improve outcomes including reducing hospital readmission rates.
KEY POINTS
- Traditional health care delivery models typically do not have mechanisms in place for coordinating care across settings, such as when a patient goes from the hospital to a skilled nursing facility or to home.
- Transitions can fail, leading to hospital readmission, because of ineffective patient and caregiver education, discharge summaries that are incomplete or not communicated to the patient and the next care setting, lack of follow-up with primary care providers, and poor patient social support.
- A number of programs are trying to improve transitions of care, with some showing reductions in hospital readmission rates and emergency department visits.
- Successful programs use multiple interventions simultaneously, including improved communication among health care providers, better patient and caregiver education, and coordination of social and health care services.
Ineffective patient and caregiver education
The Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century,29 noted that patients leaving one setting for another receive little information on how to care for themselves, when to resume activities, what medication side effects to watch out for, and how to get answers to questions. Of particular concern is that patients and caregivers are sometimes omitted from transition planning and often must suddenly assume new self-care responsibilities upon going home that hospital staff managed before discharge. Too often, patients are discharged with inadequate understanding of their medical condition, self-care plan,23,24 and who should manage their care.30
Up to 36% of adults in the United States have inadequate health literacy (defined as the inability to understand basic health information needed to make appropriate decisions), hindering patient education efforts.31–33 Even if they understand, patients and their caregivers must be engaged or “activated” (ie, able and willing to manage one’s health) if we expect them to adhere to appropriate care and behaviors. A review found direct correlations between patient activation and healthy behavior, better health outcomes (eg, achieving normal hemoglobin A1c and cholesterol levels), and better care experiences.34 This review also noted that multiple studies have documented improved activation scores as a result of specific interventions.
No follow-up with primary care providers
The risk of hospital readmission is significantly lower for patients with chronic obstructive pulmonary disease or heart failure who receive follow-up within 7 days of discharge.35–38 Of Medicare beneficiaries readmitted to the hospital within 30 days of discharge in 2003–2004, half had no contact with an outpatient physician in the interval between their discharge and their readmission,2 and one in three adult patients discharged from a hospital to the community does not see a physician within 30 days of discharge.39 The dearth of primary care providers in many communities can make follow-up care difficult to coordinate.
Failure to address chronic conditions
Analyses of national data sets reveal that patients are commonly rehospitalized for conditions unrelated to their initial hospitalization. According to the Center for Studying Health System Change, more than a quarter of readmissions in the 30 days after discharge are for conditions unrelated to those identified in the index admission, the proportion rising to more than one-third at 1 year.39 Among Medicare beneficiaries readmitted within 30 days of discharge, the proportion readmitted for the same condition was just 35% after hospitalization for heart failure, 10% after hospitalization for acute myocardial infarction, and 22% after hospitalization for pneumonia.40
Lack of community support
Multiple social and environmental factors contribute to adverse postdischarge events.41–43 For socioeconomically disadvantaged patients, care-transition issues are compounded by insufficient access to outpatient care, lack of social support, and lack of transportation. Some studies indicate that between 40% to 50% of readmissions are linked to social problems and inadequate access to community resources.44–47 Psychosocial issues such as limited health literacy, poor self-management skills, inadequate social support, and living alone are associated with adverse outcomes, including readmission and death.48,49 Such factors may help explain high levels of “no-shows” to outpatient follow-up visits.
NATIONAL MODELS OF BEST PRACTICES
Efforts to reduce readmissions have traditionally focused on hospitals, but experts now recognize that multiple factors influence readmissions and must be comprehensively addressed. Several evidence-based models seek to improve patient outcomes with interventions aimed at care transitions:
Project BOOST
Project BOOST (Better Outcomes by Optimizing Safe Transitions)50 is a national initiative developed by the Society of Hospital Medicine to standardize and optimize the care of patients discharged from hospital to home. The program includes evidence-based clinical interventions that can easily be adopted by any hospital. Interventions are aimed at:
- Identifying patients at high risk on admission
- Targeting risk-specific situations
- Improving information flow between inpatient and outpatient providers
- Improving patient and caregiver education by using the teach-back method
- Achieving timely follow-up after discharge.
The program includes a year of technical support provided by a physician mentor.
Preliminary results from pilot sites showed a 14% reduction in 30-day readmission rates in units using BOOST compared with control units in the same hospital.51 Mentored implementation was recognized by the Joint Commission and the National Quality Forum with the 2011 John M. Eisenberg Award for Innovation in Patient Safety and Quality.52
Project RED
Project RED (Re-Engineered Discharge)53 evolved from efforts by Dr. Brian Jack and colleagues to re-engineer the hospital workflow process to improve patient safety and reduce rehospitalization rates at Boston Medical Center. The intervention has 12 mutually reinforcing components aimed at improving the discharge process.
In a randomized controlled trial, Project RED led to a 30% decrease in emergency department visits and readmissions within 30 days of discharge from a general medical service of an urban academic medical center.54 This study excluded patients admitted from a skilled nursing facility or discharged to one, but a recent study demonstrated that Project RED also led to a lower rate of hospital admission within 30 days of discharge from a skilled nursing facility.55
