Reduce readmissions with a simple discharge communication tool for care teams
By Laurie Robinson, RN, Director of Louisiana CMS Care Transitions Project
It’s a daunting number that is a poor reflection of health care quality; 64%. This is the percentage of Medicare beneficiaries who return to the hospital within 30 days without having received any post-acute care following their discharge. A large number of these patients are “high risk,” with complex, acute conditions and end stage diseases. Yet, they were not referred to home health or hospice care. Why aren’t we sending these patients home with the necessary resources?
One reason is the medical record does not include an easy-to-read summary of the patient’s crucial needs, both clinical and social. Without this, it is unrealistic to expect a good outcome when the individual is discharged to home.
Case managers need to understand the challenges facing the patient in the home environment as well as clinical data. For example, knowing that a patient has co-morbidities such as diabetes and COPD is important in the after-care plan, but understanding their lack of family support in the home would also create a trigger for considering a home health referral.
eQHealth Solutions collaborated with case managers and nurses to develop a simple tool that helps discharge planners better understand the complete needs of the patient and prevent a readmission even before the patient is discharged.
• Providing your discharge planning teams with clear guidance for when to refer patients to home health or hospice care. Case managers use the simple risk factor checklist to calculate a patient’s risk score and make recommendations to home health or hospice services based on the patient’s score and the eligibility criteria listed on the tool.
The tool works by:
• Creating a common process for evaluating patients’ risk and determining the appropriate post-discharge care. Discharge planning teams make an accurate assessment of a patient’s health status and post-discharge needs using the tool because it creates a complete information source to identify all of the patient’s risk factors and the appropriate resources.
• Improving proactive communication of post-discharge recommendations to the physician. Case managers use the tool to determine the patient’s risk level two days before discharge. This enables the discharge planning team to make care recommendations before the physician has already decided on the patient’s post-discharge plan.
Reduce readmissions by closing knowledge gaps in discharge planning
Hospitals across the country have prevented readmissions by filling patient knowledge gaps with education and health coaches. But patients aren’t the only ones lacking critical information. Case managers and treatment teams today are forced to use inadequate information about patient risks and available resources to make care decisions that result in readmissions.
This new discharge tool tackles causes of readmissions from the hospital perspective. Hospitals using this tool as part of a CMS project saw a statistically significant increase in their referrals to home health and hospice, as well as reduced readmissions.
Laurie Robinson, RN, Care Transitions Project Director, explains how to use this tool:
Additional resources and tools for reducing readmissions:
Download the free discharge risk assessment tool here.
Use this patient discharge checklist to reduce readmissions in your hospital.
Hear from one hospital physician who used buzz-words to reduce readmissions.