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St. Luke's Hospital is applying the lessons they've learned reducing readmissions and providing optimal care for patients with complex needs to their work as an ACO.
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Tips for Reducing Avoidable Readmissions in the Era of Value-Based Care

By Kimberly Mitchell | Friday, August 21, 2015

“It’s easy to become very hospital-centric,” says Peg Bradke, Vice President of Post-Acute Care Services at UnityPoint Health–St. Luke's Hospital, “but today you can’t provide everything a patient needs within the hospital.” In this interview with IHI Content Development Manager Jo Ann Endo, Bradke describes why it’s an exciting time in health care, despite the many challenges. Bradke is faculty for the IHI Expedition: Improving Care Transitions to Reduce Readmissions.


Having worked on reducing readmissions for a number of years, what has been the biggest change in the last five years or so?

The biggest change for me has been accountable care. We started our readmissions work back in 2008. Since then, as we’ve gotten into more ACO work, we don’t just focus on readmissions anymore. We now look at any hospitalization more closely. [Preventing avoidable] readmissions is still very important, but now we have to consider the bigger picture. We need to coordinate the care and provide for safe transitions between levels of care. Instead of just focusing on high-risk patients, we’re taking a broader view and looking at how we can best impact care for all patients.

UnityPoint–St. Luke’s Hospital has reduced all-cause readmissions to an average of 10 percent. What are the keys to your organization’s success?

What made the difference for us was creating a cross-continuum readmissions team prior to becoming an ACO. We call it Transitions to Home. The team meets once a month and has broad representation, including from patients, inpatient settings, the emergency department, inpatient and outpatient social services, skilled nursing, home care, physician inpatient and outpatient clinics, palliative care, and hospice. We get a good look at the big picture at those meetings, talk about the root causes of what’s bringing patients back into the hospital, and look for opportunities to improve care coordination efforts.

The key to the success of this team has been building cross-continuum relationships and partnerships. To really understand the factors that influence readmissions, you’ve got to talk with people from across the care continuum because you can miss things if you just look within your own scope. By getting a bigger perspective, we get a clearer view of patients’ needs, and we see what everybody can contribute to put together a program that makes the care work for patients.

What else have you learned from these team meetings that helped you address the issues that lead to preventable readmissions?

It’s important to use data. We look at the general information on the root causes for readmissions. Also, we find it especially helpful to interview patients, to ask what they think caused them to come back to the hospital. We ask, “What was your greatest concern when you left the hospital? Did you try to contact a health care provider? If so, what happened?” Sometimes patients tell you they called their physician’s office two times and they didn’t get a call back, so they just went to the emergency room. Interviewing patients is how you can get to the crux of the matter, and find out how you could have done things differently. It’s key to hear directly from patients because it helps you see things through their eyes.

When we looked at our readmissions data more closely, we noted some patients who may have benefited from going to a post-acute service after discharge, but they went home instead. Or maybe it would have been helpful to get home care services. The patients declined these options and ended up back in the hospital. Maybe they underestimated how hard it would be once they were home. Maybe they didn’t like the idea of strangers coming to their house. Maybe we could have done a better job of explaining why these were good ideas.

We’ve been working on some scripted language to help prepare patients from day one. The care team will say something like, “It’s not unusual for a patient who’s been in a situation like yours to go to a skilled nursing facility for two weeks for additional strength building after their hospital discharge, to make sure they can go home safely.” Or, “When you go home, it’s not uncommon to need some extra help, and home care is a great option.” We’re trying to make sure the medical staff are saying the same thing as the therapists, nurses, and nurse’s assistants so patients hear a consistent message with every encounter, have opportunities to learn more, and may be more open to these options.

How has use of Teach Back as a way to confirm understanding of care instructions helped your patients?

We have put a big emphasis on Teach Back since around 2009. I’m a big advocate for using it because it makes a difference when you’re working with patients and families. I don’t think you really know for sure how the patient is going to self-manage [their post-discharge care] unless you have them operationalize what you’ve been working on together.

It’s important to use Teach Back. Too often, the tendency is to give patients their paperwork, go through the discharge instructions quickly, and then ask if they have any questions. But usually they don’t ask many questions because they just want to go home, and they might be overwhelmed and having difficulty paying attention to what you said. We discovered the importance of getting patients engaged in their discharge instructions, so now, after reviewing the instructions, nurses ask patients some scripted questions:

  • Will you show me [on the discharge instructions] where your next appointment is?
  • Will you show me what warning signs you’re going to be looking for?
  • Did we leave anything out?
  • Do you have questions about anything we didn’t discuss?
  • Is there anything on these instructions you don’t think you’ll be able to do when you go home?

We’re also encouraging the use of Teach Back across the care continuum, so we’re helping patients build [self-management] skills after they go home.

How does being an ACO influence your organization’s efforts to reduce readmissions?

The ACO’s focus is not only reducing readmissions, but reducing hospitalizations in general. The bottom line is you want patients to have seamless care and get the outcomes they want. When you’re at risk for someone’s whole continuum of care, as an ACO is, you need to look at what’s most important for patients and how to best meet their needs — which is what health care organizations should be doing anyway, whether they are ACOs or not. We need to put the patient at the center of care.

How do you apply what you’ve learned about reducing readmissions to improving care for patients with complex needs?

Patients with complex needs get a lot of attention and rightfully so, but there’s a difference between complex patients and vulnerable patients. I see complex patients as chronically ill with multiple co-morbidities. You’re trying to link services and support together for them, and there are lots of specialists involved. It takes a unique skillset to guide that patient through the continuum of care. On the other hand, some patients are not chronically ill, but they are highly vulnerable for about the first two to six months after they leave the hospital. Maybe they’ve had major surgery or experienced some major trauma. They need intensive support, but it’s temporary. You can’t lose sight of caring for the vulnerable patients because you’re putting all your efforts into helping the complex patients.

The key to coordination and achieving the right outcomes is a very thorough assessment of where a patient is and where they want to go. Then you build the plan based on the patient’s needs. You can’t make assumptions. You can’t just build a plan based on one diagnosis or five diagnoses. You have to understand what the patient really needs. For example, some patients may have multiple co-morbidities, but they have good self-management skills and lots of social support. Maybe they don’t need as much from the health care team. Other people might initially seem like they won’t need much, but then you do an assessment in their home and learn they don’t have the support they told you they have or thought they had. 
How have you applied your experience in the acute care setting in your current role to improve care in post-acute services?

I try to make sure people understand each other’s worlds, and that we aren’t operating in silos. It goes back to building those [interprofessional, cross-continuum] relationships. When you’re working with a patient throughout the continuum of care, those relationships make communication and the handover process easier.

When we started the cross-continuum team and made the patient our focus, it changed our work. It was transformational for me because I suddenly had a whole new perspective of — and appreciation for — the role of home care and skilled nursing facilities, and they in turn had a new perspective of the hospital. We learned things about each other that really improved our ability to work together.

It’s easy to become very hospital-centric, but today you can’t provide everything a patient needs within the hospital. Often, you have to focus on stabilizing patients and getting them ready for the transition to the next level of care. A lot of what the patient really needs comes from the community. That’s where the patient is more able to absorb the information, develop their self-management skills, and get the social support they need.

It’s an exciting time overall for health care. I think we’re getting better at looking at the big picture. We still have silos, but not like before. We are trying to improve care from the patient’s perspective and make it better for them.

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