By Mary Beth Schweigert
Most patients are ready to see even the easiest hospital stay come to an end.
Reducing readmissions after a hospital stay is a major area of focus for clinicians throughout Penn Medicine.
Paul M. Conslato, MD, medical director at Lancaster General Health Physicians, said readmissions are emotionally and physically taxing for patients, their families and clinicians, as well as costly for all. From a national perspective, readmissions also place patients at greater risk for hospital-acquired infections.
“After a hospital stay, patients are at their sickest and most vulnerable, and families are overwhelmed,” he said. “There is nothing more emotionally draining to a patient and their family than getting discharged from the hospital only to then be readmitted within a few weeks.”
At LG Health, geriatricians and hospitalists collaborate with local skilled nursing facilities to reduce readmissions, using strategies that include on-site medical directors, advanced practice providers, standardized processes, and improved transitions of care. Those efforts have led to a 30-day readmission rate of about half the national rate.
Elsewhere in the Penn Medicine system, the Hospital of the University of Pennsylvania’s SOAR (Supporting Older Adults at Risk) program improves care coordination during the transition from hospital to home. And an innovative contract between the University of Pennsylvania Health System and Independence Blue Cross has reduced readmissions by 25 percent.
LG Health works closely with a network of nine Lancaster County skilled nursing facilities. Dale K. Hursh, MD, managing physician at LG Health Physicians Geriatrics, said that in fiscal year 2018, those facilities reported a 30-day readmission rate of 10.3 percent, compared to about 20 percent nationally.
Hursh said that in many skilled nursing facilities, visiting physicians do rounds. However, most of the facilities in LG Health’s network follow a different model, with an LG Health geriatrician serving as on-site medical director.
“When a patient is discharged to one of our PPN facilities, we are there every day to manage the patient’s care,” he said. “That close supervision and care continuity have been significant factors in reducing readmissions.”
Philip J. Billoni, MD, a physician with LG Health Physicians Hospitalists, said because Medicare considers readmissions a quality metric for both hospitals and skilled nursing facilities, it is in their best interest to work together. In fact, some readmissions are not reimbursed.
“Readmissions place patients at increased risk for death or further loss of function,” he said. “Ultimately our work to reduce readmissions is about improving patient safety and overall quality of care.”
Billoni is part of a team that reviews charts for readmissions involving patients of Preferred Provider Network facilities, which is typically 12 to 20 per month. The review identifies possible areas of opportunity, many of which involve transitions of care.
“We came up with ideas to address systematic issues that contribute to readmissions,” he said. “Over time this has led to changes at the facilities that have standardized processes and improved communication and coordination of care, ultimately reducing readmission numbers.”
Improving communication between skilled nursing facilities, hospital staff, patients and families is a special area of focus. For example, when a facility sends a patient to the Emergency Department, the ED staff might assume that the facility is requesting an admission. However, in some cases, the facility can manage the patient’s care but is simply requesting expedited access to X-ray or lab testing.
The LG Health team’s efforts also have improved end-of-life care planning. A clear plan for comfort care that has the knowledge and support of the patient’s family is the key to avoiding confusion, Billoni said.
“Now the facilities engage with patients and their families on their preferences in advance, so that if the patient’s health begins to decline, there are no surprises,” he said. “In many cases, the patient can be kept comfortable at the facility and avoid the need for a hospital stay.”
Hursh said the LG Health team also developed evidence-based treatment pathways for common conditions, including congestive heart failure, pneumonia, hip fracture and sepsis, helping to ensure a standard approach to care and ultimately decreasing the length of a patient’s stay at a facility.
A recently revised discharge summary highlights key items for the patient’s care providers to address following a hospital stay. The facility’s care team is immediately directed to that section of the discharge summary. At discharge, patients receive a “LACE” score, which assesses risk for readmission based on length of stay, comorbidities and other factors, he said. A higher LACE score alerts the facility’s staff that the patient warrants closer attention.
Nurse practitioners play an important role in the patient’s care at a skilled nursing facility, Hursh said. A physician sees the patient initially and develops a plan of care, which then is implemented with the assistance of a nurse practitioner.
“This collaborative approach enables us to increase access for our patients,” he said. “By working together and monitoring the patient closely, we can identify changes in condition that we can treat on-site and avoid the need for a readmission.”