Date: 01/04/2016

Johns Hopkins Bayview Medical Center has launched an ambitious strategy to lower its 30-day hospital readmissions rate. And the effort is already showing results: According to the latest data from the Maryland Health Services Cost Review Commission, Johns Hopkins Bayview’s rate in the period January to July 2015 was 14.73 percent, down 8.63 percent compared with the same period in the baseline year, 2013.

Johns Hopkins Bayview’s rate, like that of other urban hospitals serving vulnerable populations, is higher than the statewide average, 12.94 percent.

Carol Sylvester, vice president of care management services for the medical center, says that the significant reduction was accomplished largely through implementing a comprehensive care coordination bundle that is applied to all patients regardless of diagnosis.

“The better you are at helping patients transition out of the hospital and find outpatient care, the less likely it is that they will come back,” says Charles Reuland, Johns Hopkins Bayview’s executive vice president and chief operating officer.

One focus of transition planning is patient and caregiver education. A technique called teach-back asks the patient or caregiver to repeat care instructions in his or her own words. “When you ask patients what they heard you say, you get a better understanding of what they understand,” says Sylvester.

Other educational outreach includes providing instructions on managing one’s health — making and preparing for an appointment, refilling prescriptions, avoiding falls. New inpatients are also shown the “Bridge to Home” video to help prepare them for taking care of their health post-discharge.

Specially trained pharmacists educate patients and their caregivers as part of an interdisciplinary care team that includes a physician, nurse, dietician, social worker and case manager. The pharmacist talks with the patient about medications, explaining dosage, timing and interactions with other medications, over the counter as well as prescribed. These instructions are particularly important for high-risk medications, such as anticoagulants and insulin, says Sylvester.

The care planning team ensures that the patient has medications in hand before leaving the hospital and, if appropriate, has a follow-up appointment within 14 days of discharge.

Sylvester says a new goal is to have all discharge summaries completed within 48 hours of discharge so that the next physician patients see will have necessary information about the hospitalization and aftercare. Until recently, the expectation was the discharge summaries were to be completed within 30 days of discharge. “Now we know that time frame is inadequate to support the transition of care from hospital to community,” she says. Although completion within 48 hours is a challenging goal, the medical center’s physicians are making progress toward it. Most Johns Hopkins Bayview physicians complete their summaries within 14 days, and many are getting them done within seven, she says.

For patients at high risk for readmission — a group that includes those hospitalized in the previous six months and those with functional impairments — a nurse called a transition guide visits the home, performs medicine reconciliation, and helps schedule appointments and access community resources.

Lower-risk patients receive a phone call from a nurse to check on their progress at home.

“Our goal is to give patients the services and support they need to be healthier and remain in the community,” says Sylvester.