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Managed Care Partners - Collaborating to Reduce Hospital Readmissions

Managed Care Partners Winter 2013

Collaborating to Reduce Hospital Readmissions

Date: February 25, 2013


Kim Beddow and Tara Sohrabi with Louis Haven
Suburban Hospital nurse Kim Beddow and Hebrew Home clinical educator Tara Sohrabi discuss with Louis Haven the condition of his foot wound.

Once a week, Jonathan Zenilman, chief of infectious disease at Johns Hopkins Bayview Medical Center, and Karen Daniels, a nurse practitioner who runs the Outpatient Parenteral Antibiotic Therapy program, spend an afternoon at Sava Senior Care, a nursing home in Glen Burnie. Their work is part of a collaboration designed to spot problems at long-term care facilities after patients discharged from hospitals arrive needing intravenous antibiotic treatments.

The two review microbiology data, lab results, antibiotic doses and the patients’ response to therapy, and also provide consultations and feedback to the nursing home staff. “We noticed that the vast majority of missed appointments at the antibiotic clinic were from nursing home discharges,” Zenilman says. “And since appointments are key to making sure discharged patients are getting the right care, we decided to come to them.”

The collaboration is one of several projects Johns Hopkins is undertaking to meet the Centers for Medicare and Medicaid Services’ mandate to lower readmissions rates. CMS estimates that costs associated with preventable readmissions exceed $17 billion a year nationwide.

Carol Sylvester, Johns Hopkins Bayview’s senior director of care management, leads the Johns Hopkins task force developing collaborations with skilled nursing facilities. “Patients sent to nursing homes for rehabilitation and recovery return to hospitals at rates far higher than those who were discharged to their homes,” she says.

Compounding the problem is that long-term care facilities have far fewer physicians and registered nurses than a hospital, “yet patients coming to them from here are frail,” Sylvester says, “and their cases are complex.”

She adds that in today’s world of shorter hospital stays, “we discharge patients to nursing homes when they are stable, not when they are completely well. There’s a belief that someone at the nursing home will monitor them as closely as in the hospital, which is not necessarily the case. We want to improve handoffs and communication.”

The task force also wants to implement best medical practices at nursing facilities, centering on the most common ailments, including heart failure, chronic obstructive pulmonary disease, antibiotic therapy and delirium. The group has developed an evaluation form for nursing home staff to use when a patient is readmitted to the hospital “so we can understand contributing factors,” Sylvester says.

Another initiative, spearheaded by Michele Bellantoni, clinical director of the Division of Geriatric Medicine and Gerontology, is partnering with the five skilled nursing facilities that have the highest number of patients discharged from Johns Hopkins Bayview and The Johns Hopkins Hospital. The initiative with these facilities and Johns Hopkins Bayview Care Center, where Bellantoni is the medical director, is one of several projects funded by the Center for Medicare and Medicaid Services to improve patient care and lower costs. To that end, administrators, nursing directors and medical directors of the skilled nursing facilities and the Care Center are working together to disseminate best practices.

“We are learning not only from the experiences of the Care Center but also from the other facilities’ successes,” Bellantoni says. One facility, for example, has protocols for educating patients and families about managing congestive heart failure.

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