As hospitals face penalties for readmissions, they are implementing programs to enhance care coordination to keep patients from returning to the hospital.
Using a grant-funded program to reduce hospital readmissions for elderly patients with heart failure, the University of California, San Francisco (UCSF) Medical Center was able to reduce rates of heart failure readmissions over a two-year period by 46 percent within 30 days of hospital discharge and by 35 percent within 90 days.
According to The Commonwealth Fund's recent case study on the UCSF Medical Center program, the hospital initiated the program in late 2008 in collaboration with the Institute for Healthcare Improvement (IHI).
Program coordinators were hired to provide enhanced patient education and follow-up care connections to promote the elderly patient's successful transition to home or to skilled nursing care.
The program started out with a target population of Medicare patients age 65 and older (average was age 80) hospitalized with a primary or secondary diagnosis of heart failure (representing approximately 700 admissions during the year the program began).
"They worked systematically over time to build a program with several key components," said Douglas McCarthy, senior research advisor at The Commonwealth Fund. Those components included testing their patients' knowledge about their conditions and tailoring education to them, follow up phone calls and home visits and team-based care.
Another IHI program, called the STate Action on Avoidable Rehospitalizations (STAAR) initiative, has been working with a number of hospitals in Michigan, Massachusetts and Washington to reduce avoidable rehospitalizations and improve transitions in care by providing strategic guidance, support and technical assistance to hospitals and cross-continuum teams.
According to Peggy Segura, a nurse practitioner who formerly led the STAAR team at Sinai-Grace Hospital in Detroit, Sinai-Grace started working with the STAAR initiative after deciding that their readmission levels for heart failure patients were too high.
Segura said after initiating the program in 2009 with a heart failure readmission rate of around 40 percent, the rates dropped to 12 percent for heart failure patients being readmitted for heart failure and 18 percent for all-cause readmissions for heart failure patients.
"We kept costs down this way, but most important are the patients and not sending them out the door without the right information," she said. "It's just the right thing to do. If we don't hear our patients' stories and their concerns, how can we facilitate and provide the best care for them? We also had heart failure support groups and clinics for the uninsured."
Peg Bradke director of Heart Care Services at St. Luke's Hospital in Cedar Rapids, Iowa, has been working with the STAAR initiative at her organization since 2009 and said that her organization has become more comfortable over time with having transparent dialogue between departments and across the continuum of care.
"Sometimes you don't want to share the difficult issues you are having, but for us it's about being transparent and making improvements for a better outcome for the patient," she said. "Our home care services, physician clinics and hospital - we're really looking at care from a big viewpoint - not in silos."
Bradke added that part of the reason the STAAR initiative has been so successful at St. Luke's when it comes to cross-continuum participation and alignment is the amount of top-level administration support she and her co-workers received for implementing the program.
She said they've also learned from things that don't work. "It's a learning environment and it takes a lot of interventions to get your coordination where you want it," she said.