Reducing Readmissions Through Value-Based Care

By Amanda Griffith, Contributing Writer

To comply with the Readmissions Reduction Program, Nash Healthcare had to reduce time clinicians spent with traditional chart audit methods and allow them to spend more time with patients.

Many healthcare organizations are turning their attention to reducing readmissions, in large part due to the CMS’s Hospital Readmissions Reduction Program and the significant financial penalties associated with higher-than-expected ratios. To wit, only 799 out of more than 3,400 hospitals subject to the Hospital Readmissions Reduction Program performed well enough on the CMS’ 30-day readmission program to face no penalty, and 38 hospitals will be subject to the maximum three percent reduction, according to an analysis of newly posted CMS data.

This increasing pressure on hospital margins, and an uptick in the number of hospitals losing money on readmissions, has motivated health systems like Nash Healthcare, a 403-bed non-profit hospital authority affiliated with the UNC Healthcare System, to find ways to cut their readmission rates. Nash Healthcare serves five neighboring counties in North Carolina and draws patients from beyond those areas as well. This makes it critical to foster collaborative relationships and enhance care coordination among providers across care settings. What’s more, while cost savings are important for the organization, reducing readmissions is also important for patient- and family-centered care.

That’s why Shakeerah McCoy, Clinical Nurse Specialist and Transitional Care Program Coordinator for Nash Healthcare, believes patients and families should be involved in the development of the plan of care. She also feels clinicians should work closely with patients and families to foster an understanding of their barriers and goals for quality of life within the financial and resource constraints of the system and the surrounding community. All of these efforts contribute significantly to readmission rates.

From the beginning, McCoy and her colleagues knew that in order to comply with the Readmissions Reduction Program, Nash Healthcare would need a new method to track readmissions in a way that reduces time spent in the traditional chart audit methods. In most cases, the process was so time-consuming it took away from valuable minutes clinicians should have been spending helping patients. McCoy wanted to identify a more rapid process, one that would bring the entire team of stakeholders together so everyone involved had a vested interest in its success.

Too Little Data, Too Late
“There was a time when our healthcare system’s readmissions data was based almost solely on patients who were previously identified as at-risk through time-consuming, labor-intensive manual chart reviews that checked for contributing factors,” explained McCoy. “What’s more, we found the readmissions data we received was always old. Information was received three to six months after the fact, because it was based on claims data that we’d have access to only after it was submitted and validated.”

With such dated information, how could Nash Healthcare eliminate readmission rates when some of the patients it was trying to help had already been readmitted before clinical staff could review their initial discharge records? In addition, it quickly became apparent the organization needed to better understand the issues that led to patient readmissions. The organization found that even slight variations in paperwork or the recording of individual stories could affect the success or failure of care transitions.

“What does it mean when a patient is flagged as high risk, and what happens after a psychosocial or chronic illness assessment?” McCoy remembers asking. “It became quickly apparent we needed to help our staff refine a patient-centered care approach. At the same time, we needed to nurture a better understanding of different disease states and what life was truly like for some of our patients once they stepped outside the hospital’s four walls.”

Nash Healthcare needed access to more robust, timely data. After participating in a number of hospital collaboratives, McCoy and her colleagues knew what they liked and didn’t like. After reviewing paper-based tools and evidence-based literature, they realized that an automated process — one that focused on people processes while automating assessments without extra steps in workflow — would work best for the organization. The challenge, however, lay in helping staff understand that readmissions prevention is more about an organization-wide process review than an analysis of individual work. The goal would be to figure out how to band together to ensure the safest transition processes were in place.

Helping Providers Avoid Readmission For Patients
A Cerner client since 2011, Nash Healthcare knew it could trust the company’s readmissions solution to help cull through patient interviews as it worked to audit documentation within medical charts, interviews with providers, and notes from patients’ families.

Nash Healthcare began implementation of Cerner’s Readmission Prevention solution (a feature within the Cerner EHR) in October 2014, officially launching the endeavor in late March the following year. The technology quickly identified patients across the hospital system who had a high or moderate readmission risk and allowed providers to take appropriate action to avoid readmission. Any patient admitted to the hospital could be automatically assessed through a standardized process that avoided adding to the workload of the nursing or care management staff.

“The solution we implemented provides hospital systems like ours with tools to monitor care processes and provides real time data updates, evidence-based content, reporting, and training materials to identify and manage patients who are at a high risk of 30-day readmissions,” explains McCoy. “What’s more, the Readmission Prevention process continues post discharge through the monitoring of high-risk patients through a number of transitional care services and partnership meetings with community care partners.”

Proven Success Through Evidence-Based Strategies
The readmission prevention process at Nash Healthcare has succeeded so far because it focuses on proven evidence-based strategies to address readmissions. Initiatives include an emphasis on stakeholder identification, medication reconciliation, understanding red-flag symptoms, enhanced care management assessment, patient/family engagement, effective hand-off communication, and early/ongoing followup in the early post discharge period.

Because the care management process is now hardwired, clinicians have readily embraced the technology as it provides a more structured approach to patient and family interviews and takes discussions beyond the surface level to truly anticipate patient discharge needs.

“In addition to using the technology to improve many of our processes, we like being able to monitor, track, and trend where failures occur in our care processes so we can prevent repeat readmission patients from returning,” notes McCoy. “The solution has also impacted the discharge process by prompting review of care management assessment forms, communication among the entire care team, and discussion with patients and their caregivers about the potential risk of readmission.”

Nash Healthcare has also integrated its work with readmission tools with its Curaspan electronic referral system to allow better readmission tracking by individual providers post discharge. In the future, McCoy says the staff also hopes to use the automated readmissions process to track ER utilization.

“It’s hard to impact inpatient outcomes if we can’t capture that patient-level data the moment they walk through the front door,” says McCoy. “By restructuring some of our current processes — initially developed solely for our care managers — we can better home in on transitional care management while patients and their families are still in the hospital.”

Preventing readmissions is an evolving process that requires the dedication of the entire organization. With a changing regulatory environment and a multitude of competing priorities within the care setting, readmissions can be daunting. The good news is that by better understanding one’s patient population, it becomes easier to track patients in myriad ways.

From risk stratification and disease processes to comparing outcomes and data metrics, readmissions prevention solutions offer organizations like Nash Healthcare a way to further develop and build a better way of treating their care communities today and well into the future. With a greater understanding of the population being cared for come safer treatment methods and a higher level of patient-centered medicine.