Hospital readmissions have become an important focal point for everyone at UM Shore Regional Health. Under the umbrella “Readmission Matters,” several initiatives are now in progress to reduce the number of 30-day readmissions at UM Shore Medical Centers at Chestertown, Dorchester and Easton. The engagement of all team members in Readmission Matters initiatives is key to helping patients maintain their best health outside the walls of our hospitals.
There are three arenas in which strategic interventions can reduce readmissions:
- at discharge from the hospital
- post-discharge (as patients heal in their home settings), and
- upon the patient’s return to the hospital for possible readmission.
Enabling patients to successfully transition back home is the goal of every discharge. In the case of patients readmitted within the first week after discharge, the precipitating factors have been issues with medication and/or the discharge plan. UM SRH interventions in this arena are as follows:
- Medication Reconciliation – New strategies are in place to ensure that patients are discharged with the right medications and that they fully understand their new medication orders. Other medication reconciliation issues now under review are:
- 1) barriers patients may face in affording or accessing their medications, and
- 2) possible partnership with local pharmacies to ensure that certain high risk patients leave the hospital with their medications in hand.
- Discharge Planning – The scope of the discharge planning process has been expanded to include the broader, holistic needs of patients. Caseworkers and transitional nurse navigators help patients anticipate their care needs will be in their home environment, connect with the patient’s primary care provider to ensure proper follow-up, and provide links to needed community resources offering services such as transportation, home care, meals, home technologies and social support.
HEALING AT HOME
Comprehensive discharge planning extends Shore Regional Health’s involvement with patients well beyond their discharge. The Transitional Nurse Navigator (TNN) Program, inaugurated last fall, provides continued care coordination for high-risk patients from the beginning of their hospital stay through up to 30-days after discharge. Two TNNs at Easton and one each at Chestertown and Dorchester work not only with patients but also with family members and caregivers to provide education and support, resolve insurance issues, order needed medical equipment and supplies, provide referrals to specialists, and much more.
Another key initiative is the expansion of the UM SRH Palliative Care Program to provide patients with relief from the symptoms and stress of serious illness and improve the quality of life for them and for their families. The Palliative Care team is training hospital providers to identify patients for whom a palliative care consult is appropriate prior to discharge; as of mid July, the newly-launched Outpatient Palliative Care program enables patients to receive treatment in the UM Community Medical Group – Primary Care office in UM Shore Medical Pavilion at Easton.
Working more directly with the community providers is another important strategy for reducing hospital readmissions. Primary care providers are being empowered to take a more active role in their patients’ post-discharge care and two-way communication between hospital personnel and community providers is being improved. In the process of development is a strategy for high-risk patients to obtain “Golden Tickets” for prompt appointments with certain specialists (e.g. cardiology, pulmonology) to avoid delays in their follow-up care.
AT THE PATIENT’S READMISSION VISIT
In line with UM Shore Regional Health’s goal of providing “the right care, at the right place, at the right time,” there are two strategies in development for patients presenting in the Emergency Departments for readmission:
- The establishment of Observation Units in the hospitals – dedicated areas for patients who are placed under observation so that providers, nurse and ancillary service staff can focus on ensuring timely discharge. The first Observation Unit is now in operation on the 2nd floor of UM Shore Medical Center at Easton; similar units at Chestertown and Dorchester are in the works.
- Because hospitalists are usually the physicians most familiar with patients returning to the hospital, there is new process for Readmission Consults that empowers them to assess patients presenting in the Emergency Department to determine where the patient can receive appropriate care.
As these measures continue and coalesce, UM Shore Regional Health will achieve the goal of reducing 30-day readmissions rates in allt hree hospitals.