All Aboard

The Hospitalist. 2011 February;2011(02):

February 1, 2011 | The Hospitalist

Eric Siegal, MD, SFHM, an SHM board member, past chair of SHM’s Public Policy Committee, and a clinical assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health, says BOOST has benefited from being solidly in place at the right time, gaining momentum and garnering significant national attention as the focus on better care transitions has intensified.

Dr. Halasyamani

“If BOOST demonstrates substantial and reproducible decreases in rehospitalizations, improvements in quality, and presumed projected cost reductions, I think that it’s going to go off like a bomb,” he says, “in a good way.”

Lakshmi Halasyamani, MD, SFHM, vice president for medical affairs for the Saint Joseph Mercy Health System in Michigan and an SHM board member, says BOOST encourages hospitalists to think about ways in which a discharge might fail. “And then we need to actively mitigate those risks,” she says.

National Collaborations

CMS has tapped a network of technical assistance and QI contractors in all 50 states, known as quality-improvement organizations (QIOs), for its own project addressing rehospitalizations. In 2008, these QIOs began working with communities in 14 states to implement what’s known as the Care Transitions Program.

The program has helped community leaders highlight three root causes of high readmission rates: patients’ lack of knowledge and understanding about their chronic conditions, lack of communication among providers, and the healthcare system’s lack of known standards.

Figure 1: State-by-State Breakdown of 30-Day Rehospitalizations of Medicare Beneficiaries

The 14 communities, 70 hospitals, and 1.25 million Medicare beneficiaries being followed to date suggest that 30-day readmission rates can be significantly decreased, says Paul McGann, MD, CMS deputy chief medical officer. Preliminary data based on the number of readmissions per 1,000 Medicare beneficiaries, he says, show that participating communities have improved by an average of 4.7% over the first two years of the project, with the top performer improving 14% (for more information, visit www.cfmc.org/caretransitions).

Dr. Halasyamani says no single program has necessarily found the “secret sauce” to improve readmission rates across the board. “And we definitely haven’t figured out how to implement that in as cost-effective a way as possible,” she says.

But optimism is clearly building. With the initial focus on coaching low-performing institutions to improve their rates, Medicare could tap programs that demonstrate early promise as the main go-to teaching aids.

More importantly, hospitals around the country are finding what it takes to help their own patients.

“The question isn’t, ‘Is our number better than St. Elsewhere’s down the street?’ ” Dr. Jencks concludes. “The real question is, ‘Are there things we could reasonably have done for this patient and could do for the next patient that will keep this from happening to them?’ ” TH

Bryn Nelson is a freelance medical writer based in Seattle.

Reference

Jencks SJ, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.

What To Do, and When To Do It

Today

Understand your current performance. One tool is Medicare’s Hospital Compare website (www.hospitalcompare.hhs.gov), which lists readmission rates for heart attack, heart failure and pneumonia patients. “If you don’t know how you’re doing, there’s no way to improve it,” Dr. Halasyamani says.
Consider which patient populations are getting readmitted and the factors that might be involved, such as medications, follow-up, or lack of understanding. Ask whether you’re really doing what you think you’re doing for patients during the discharge process.
Approach your effort as a learning opportunity rather than a guilt trip or an attempt to assign responsibility. That way, you, your colleagues, and readmitted patients all will be less defensive and more inclined to help each other improve the process.

This Week

Talk to a readmitted patient about what went well and what didn’t work. Also try it for a patient who had a good handoff. Pay special attention to whether they felt actively engaged in the process.
Find partners on your healthcare team, and ask them about discharge challenges from their perspective.
Strengthen your ties and communication channels to other community care providers. Sometimes, a simple phone call can do wonders to prevent an avoidable lapse in patient care.
Use the teach-back method to ensure patients are clear on their discharge instructions. SHM’s new teach-back curriculum is available at www.hospitalmedicine.org/boost.

This Month

Work with your hospital to ensure that you or another colleague can assume the responsibility of medication reconciliation and simplification. “I would put that at the top of the list. Medications just cause so much damage to 85- and 90-year-old people. I think we need to be constantly aware of that,” says Dr. McGann.
Use feedback from patients and colleagues and online resources to begin formulating a team approach to patient care, including both inpatient and outpatient settings.
Get funding. Consider applying for a grant or fellowship to help your institution implement its plan. One available source is the Community-Based Care Transitions Program, administered by CMS, and scheduled to be available in early 2011.

This Year

Start small. Aim your initial interventions at a specific unit or patient population so you can learn from that experience before expanding your reach. “You don’t need to try to get the whole elephant,” the NTOCC’s White says.
Look for more opportunities to learn. Project BOOST (www.hospitalmedicine.org/BOOST) offers its own online toolkit, and is hosting a free informational webinar Feb. 8 (it’s also available on-demand). Case studies and toolkits are available through NTOCC (www.ntocc.org).
Help your medical institution develop a more patient-centric approach to care so that records travel with the patient from setting to setting and ease their transitions of care. “Hospitalists can have a very important role in this,” Dr. Sherman says.

—Bryn Nelson