It takes only one gap in care for a patient to be readmitted to the hospital:
Failing to fill a prescription places newly discharged patients at risk for a return trip to the hospital.
Patients who don’t understand discharge instructions are more likely to be readmitted as well.
Those without a primary care provider also stand a better chance for rehospitalization.
Since 2011, a Johns Hopkins task force has sought to reduce costly and preventable readmissions across the health system by closing potential gaps in the transition from inpatient to outpatient care. An array of strategies devised by teams of physicians, nurses, pharmacists, physical therapists and others center on addressing patients with complex needs and aligning them with post-acute services. These services are designed to support discharged patients as they manage their own care.Interventions may include visits by a registered nurse, called a transition guide; enhanced patient and family education; medication management; and other services.
Johns Hopkins is on the right path, according to targets for reasmission reduction established by the Maryland Health Services Cost Review Commission (HSCRC). The organization, which regulates hospital rates in the state, ties the amount of reimbursement to readmission rates as part of its Maryland Quality Based Reimbursement initiative. For calendar year 2016, Maryland hospitals must achieve a 9.5 percent reduction in readmission rates compared to 2013 readmisson rates to avoid hefty penalties. According to the most current numbers, readmissions have dropped at The Johns Hopkins Hospital by 14.91 percent. (In fiscal year 2015, The Johns Hopkins Hospital was able to achieve only a 6.02 percent improvement against a target of 9.3 percent.)
Other initiatives have also contributed to the decrease in readmission rates, says Amy Deutschendorf, vice president of care coordination and clinical resource management for the Johns Hopkins Health System. Researchers at Johns Hopkins, for example, are working to inform the science of readmission measurement and are exploring whether current calculations should apply to academic medical centers providing complex, high-risk services.
“We’ve found that there are complexities related to certain illnesses—like cancer—that contribute to overall readmission rates and should not be viewed as a failure in care coordination,” says Deutschendorf. These findings and others led the HSCRC to remove medical and surgical oncology from the readmission metric, an adjustment that benefited Johns Hopkins as well as other hospitals in the state.
“We do really serious things like brain surgery and major pancreas surgery, and there’s an expectation that a certain number of patients will be readmitted. We want to make sure that our patients do come back if they need to,” says Deutschendorf.
Other Johns Hopkins hospitals are seeing improvements as well. Johns Hopkins Bayview Medical Center, Howard County General Hospital, Sibley Memorial Hospital and Suburban Hospital are all on track to meet their readmission prevention goals this year.
But it’s not just about the numbers, says Deutschendorf. “Everything we are doing is keeping patient and family needs in mind. When you provide quality care, it results in good measures, which means the patient didn’t fail when they went home. That’s our real goal.”