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Dome - A Push to Reduce Readmissions

May 2010

A Push to Reduce Readmissions

Date: May 7, 2010

Physicians developed a process that tries to prevent early readmissions through better communication and coordination.


Eric Howell, Bayview’s chief of hospital medicine
Eric Howell, Bayview’s chief of hospital medicine, led a study showing ways to prevent early readmissions among elderly patients.

Maybe it’s because they get confused about the medications they need to take after leaving the hospital. Perhaps it’s because they’re sent back to a home environment that’s rife with fall risks.

Whatever the reason, roughly one of every five elderly patients wind up back in the hospital within a month of discharge. And these early readmissions—many of them preventable—cost the Medicare program $15 billion a year.

But a group of physicians at Johns Hopkins Bayview Medical Center say they have arrived at one solution to the problem. They’ve developed a process that tries to prevent early readmissions through more thorough communication and coordination surrounding discharge.

In a paper published late last year, they report how Safe and Successful Transition of Elderly Patients (Safe STEP) reduced readmission rates at 30 days from 22 percent to 14 percent. In the pilot, emergency department visits within three days of discharge also dropped, from 10 percent to 3 percent.

“We really wanted to prove that the intervention could work and we wanted to see in very basic terms that there were outcomes that could lead to cost savings” to the health care system, says Steven Kravet, president of Johns Hopkins Community Physicians and a study investigator.

The Safe STEP process begins upon admission, as physicians fill out specialized history and physical forms that prompt them to consider geriatric issues, such as the wherewithal of the patient’s caregiver; case managers fax admission details to the patient’s primary care physician; and pharmacists consult with hospitalists on medication reconciliation.

Additionally, professionals from physical therapy, social work and other disciplines use an interdisciplinary summary sheet to share their perspectives on the barriers to the patient’s safe return home. This form serves as the basis for the discharge plan, which the patient goes over with a nurse and the physician before leaving.

Most discharge protocols already employ elements similar to Safe STEP, but more as an “afterthought” than as components integrated into a patient’s treatment plan, says Eric Howell, Bayview’s chief of hospital medicine and a Safe STEP study investigator.
Howell’s group published its study at a time when more attention is going to readmission costs. Last year, CMS began posting hospital 30-day readmission rates for heart failure, heart attacks and pneumonia on the Web. This year, Maryland’s Health Services Cost Review Commission expects to launch its own pay-for-performance system based on readmission rates.

The question, now, is how to make the time-consuming, paper-heavy process affordable to use on a large scale.

The pilot was conducted in 2006 and 2007. Continuing it full time on the hospitalist unit would require hiring a pharmacist and case worker. Kravet argues that a greater reliance on technology could help make the process less costly. For example, risk assessment tools could target the most vulnerable patients and allow providers to make the best use of limited resources.

While Safe STEP is on hold, its promising results helped spawn a sequel called Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), an ongoing initiative of the Society of Hospital Medicine to improve the discharge process at 30 hospitals. Project BOOST was funded with $1.4 million from the Hartford Foundation, which also funded the $99,000 Bayview study.

Safe STEP is among several strategies for reducing readmissions across the Hopkins health system. Under the leadership of Amy Deutschendorf, senior director of utilization and clinical resource management, a task force is developing a new transition of care process. She hopes that it will include a discharge summary for better communication with primary care physicians.

“We need to find a way to hand off care to primary physicians so that they own part of this and become responsible for ensuring that the patient follows up,” Deutschendorf says.                                                                     —Stephanie Shapiro

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