Reducing Hospital Readmissions: Lessons from Top-Performing Hospitals
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Reducing Hospital Readmissions:
Lessons from Top-Performing Hospitals
Synthesis Report • April 2011
By S haron S ilow-C arroll, J ennifer N. E dwards,
and A imee L ashbrook
H ealth M anagement A ssociates
SUMMARY
Significant variability in 30-day readmission rates across U.S. hospitals suggests
that some are more successful than others at providing safe, high-quality inpa-
tient care and promoting smooth transitions to follow-up care. This report offers
The mission of The Commonwealth
a synthesis of findings from four case studies of hospitals with exceptionally low
Fund is to promote a high performance
health care system. The Fund carries readmission rates.
out this mandate by supporting Hospitals’ environments contribute to their capacity to reduce read-
independent research on health care
missions. The four hospitals studied—McKay-Dee Hospital in Ogden, Utah;
issues and making grants to improve
health care practice and policy. Support Memorial Hermann Memorial City Medical Center in Houston, Texas; Mercy
for this research was provided by Medical Center in Cedar Rapids, Iowa; and St. John’s Regional Health Center
The Commonwealth Fund. The views
in Springfield, Missouri—are influenced by the policy environment, their local
presented here are those of the authors
and not necessarily those of The health care markets, their membership in integrated systems that offer a contin-
Commonwealth Fund or its directors, uum of care, and the priorities set by their leaders.
officers, or staff.
These hospitals do not focus on readmissions per se, but instead seek to
achieve clinical excellence and invest in quality improvement strategies. They
follow many of the same improvement strategies of hospitals that were profiled
in a case study series of top performers on the Hospital Quality Alliance process-
For more information about this study,
please contact:
of-care, or core, measures. For example, the hospitals incorporate evidence-based
Sharon Silow-Carroll, M.B.A., M.S.W. practices into daily protocols, standardize procedures, and use electronic informa-
Health Management Associates tion systems as tools to gather information, provide feedback, and support clinical
ssilowcarroll@healthmanagement.com
decisions.
But hospitals with low readmission rates also seek to ensure smooth care
transitions as their patients are discharged—helping to avoid the deterioration in
To download this publication and health status that often brings patients back to the hospital. The hospitals identify
learn about others as they become and target patients at the highest risk for readmissions, particularly heart failure
available, visit us online at
www.commonwealthfund.org and patients, the very elderly, patients with complex medical and social needs, and
register to receive Fund e-Alerts. those without the financial resources to obtain post-hospital care. For example,
Commonwealth Fund pub. 1473 they help the uninsured and underinsured obtain primary care and other needed
Vol. 5
services through free clinics and prescription drug assistance programs.2 T he C ommonwealth F und
By providing individualized education and med- measures improves, and savings are realized as
ication reconciliation, emphasizing warning signs, and byproducts.
scheduling follow-up appointments with community • Use health information technology (e.g., electronic
physicians, the case study hospitals seek to ensure that health records, patient registries, and risk stratifica-
patients and their families not only receive post-dis- tion software) to improve quality and integrate care
charge instructions, but that they understand them, fol- across settings.
low them, obtain appropriate care, and know when to
• Begin care management and discharge planning
seek additional help. Some of these strategies involve
early, target high-risk patients, and ensure frequent
workforce innovations by creating new roles for nurses
communication across the care team.
and pharmacists and by promoting use of hospitalists
and care coordinators to manage patients’ needs. • Educate patients and their families in managing
The hospitals also check in with high-risk conditions. Teach at a level appropriate to patients
patients after discharge by having nurses call patients and ensure they understand and can teach back key
and by using telemonitoring devices that relay critical instructions.
information (e.g., blood pressure and weight) to pro-
• Maintain a “lifeline” with high-risk patients after
viders.
discharge through telephone calls, telemonitoring,
Integrating hospital and outpatient care is key to
or other practices.
reducing readmissions. Formal or strong informal rela-
tionships between hospitals and local primary care pro- • Align hospitals’ efforts with those of community
viders, heart clinics, nursing homes, home health care providers to provide a continuum of care. While
agencies, and health plans appear to improve outcomes this may be best achieved in integrated systems,
for patients at the four case study hospitals. Close such cooperation can be facilitated through col-
coordination between the hospitals and palliative care laborative relationships among hospital and com-
and hospice programs—and efforts to understand and munity providers.
honor patients’ preferences for end-of-life care—seem Payment reforms across the U.S. health care
to reduce unwarranted and unwanted readmissions system are needed to reinforce hospital providers’
as well. desire to “do the right thing” for patients. Financial
Hospitals’ membership in integrated health sys- incentives that reward or hold providers accountable
tems can contribute to lower admissions and avoidable for patient outcomes across inpatient and outpatient
readmissions through the systems’ emphasis on pri- settings are emerging with the piloting of new deliv-
mary and preventive care, community-based education ery methods such as bundled payments and account-
and health promotion, and enhanced communication able care organizations. Refining and expanding such
and flow of information (e.g., through shared electronic reforms could help reduce avoidable readmissions and
health records) among inpatient and outpatient provid- improve the effectiveness and efficiency of the health
ers. Systems can promote sharing of best practices, and care system.
a continuum whereby patient care can be coordinated
across settings. INTRODUCTION
The experiences of the four case study hospitals At a time when health care leaders are driven to
offer the following lessons for hospitals seeking to reduce waste and inefficiency, eliminating unnecessary
reduce avoidable readmissions: readmissions has been identified as a desirable and
achievable goal by both practitioners and policymak-
• Invest in quality first: care for patients correctly ers. A readmission is defined as a hospitalization that
and readmission rates fall, performance on quality occurs shortly after a discharge; “shortly” is most oftenR educing H ospital R eadmissions : S ynthesis R eport 3
measured as 30 days but it could be shorter or longer. hospital readmissions deemed “potentially prevent-
Such readmissions are often but not always related to a able.”4 Until recently, the cost of readmissions was
problem inadequately resolved in the prior hospitaliza- borne entirely by those who paid the bills: health plans,
tion, such as a hospital-acquired infection or unstable employers, consumers, and government agencies.
heart functioning. They also can be caused by deterio- However, payers have begun to limit the amount they
ration in a patient’s health after discharge due to inad- will pay by denying payment for readmissions deemed
equate management of their condition, misunderstand- preventable. Medicare, for example, contracts with
ing of how to manage it, or lack of access to appropri- quality reviewers to investigate readmissions and may
ate services or medications. Therefore, interventions to deny payments if discharge planning was deemed to
reduce readmissions target both inpatient care, through be inadequate.5
efforts to improve the quality and safety of care, and Section 3025 of the Affordable Care Act
the transition to outpatient care, through efforts to includes a provision for CMS to reduce its payments
ensure continuity and coordination between providers to hospitals with high readmission rates (the details are
and timely access to needed follow-up services. forthcoming as CMS promulgates health reform regu-
Hospital-specific readmission rates for three lations). One health system raised the bar on providers’
common diagnoses—heart attack, heart failure, and responsibility for reducing readmissions when they
pneumonia—are available on the Centers for Medicare announced they would waive charges for any heart
and Medicaid Services (CMS) Web site, Hospital patients who were readmitted within 90 days.6
Compare.1 The Commonwealth Fund’s Web site, A small but growing number of payers and pro-
WhyNotTheBest.org, includes this information from viders are experimenting with bundling payments in
CMS as well as data from other sources, composite a manner that encourages accountability for use of all
scores, and state and national benchmarks. A recent health services related to an episode of care, including
study suggests that public reporting may be associated multiple hospitalizations. Pilots in New Hampshire,
with hospital process improvement and better patient Massachusetts, and elsewhere are exploring how a
and quality outcomes, including readmissions.2 single payment for both inpatient and outpatient care
might encourage better care coordination and quality,
Reducing Readmissions Through as well as efforts to reduce avoidable admissions and
Payment Reforms readmissions.7 National health reform legislation calls
The predominant fee-for-service payment system for additional testing of this model, which is intended
means that, in many cases, any hospital admission to create opportunities for providers to retain savings if
results in additional revenue for hospitals—creating lit- they provide care in ways that reduce costs and reach
tle incentive for hospitals to seek to reduce readmission quality standards.
rates. Yet both public and private health care purchas-
ers have begun to look critically at readmission rates Reducing Readmissions Through Process
and introduce payment policies designed to discourage Redesign
them. A review of studies published from 1998 to 2008
Data on the costs of readmissions are not avail- revealed that a variety of quality improvement and
able across the entire health system, but the largest process redesign approaches have lowered readmis-
payer, Medicare, spent $17 billion (20 percent of all sion rates, including: “close coordination of care in the
Medicare payments) for unplanned readmissions in the post-acute period, early post-discharge follow-up care,
fee-for-service segment of its program in one year.3 enhanced patient education and self-management train-
The Medicare Payment Advisory Commission esti- ing, proactive end-of-life counseling, and extending the
mated that Medicare spends $12 billion per year for resources and clinical expertise available to patients4 T he C ommonwealth F und
over time via multidisciplinary team management.”8 Goal of Synthesis Report
The California HealthCare Foundation profiled nine To learn what leading hospitals have done that may
efforts in the state that sought to coordinate post-hospi- contribute to their low readmission rates and to inspire
tal care across settings, reconcile patients’ medications, improvement in other hospitals, The Commonwealth
schedule follow-up appointments, and engage patients Fund supported the development of case studies of top
and families in managing health needs.9 Now it is performers. This report summarizes findings, best prac-
working with a set of hospitals to implement changes tices, and lessons learned at four U.S. hospitals that
that may reduce readmissions.10 had readmission rates in the lowest 3 percent among
Recognizing that reducing readmissions may all U.S. hospitals in at least two of three clinical areas
require changes across the health care system, the (heart attack, heart failure, and pneumonia) during the
Institute for Healthcare Improvement with support Q4 2007 through Q3 2008 period.
from The Commonwealth Fund has embarked on a The four hospitals examined for this case study
three-state effort called State Action on Avoidable series are:
Rehospitalizations, or STAAR. STAAR seeks to • McKay-Dee Hospital is a 352-bed, private,
improve coordination across the health care continuum, nonprofit hospital in Ogden, Utah. A member
reduce shortcomings of the current system such as vol- of Intermountain Healthcare, McKay-Dee was
ume-based incentives, and create new public and pro- selected because it was among the best 3 percent
fessional norms that support improvements in care.11 in terms of low readmission rates for heart attack,
Despite a growing knowledge base about how heart failure, and pneumonia patients among more
to reduce readmissions, there remains a great deal of than 2,800 hospitals eligible for the analysis.
variability in readmission rates. Some hospitals have
reduced readmissions below 18 percent (heart attack), • Memorial Hermann Memorial City Medical
21 percent (heart failure), and 15 percent (pneumonia), Center is a 427-bed, private, nonprofit hospital in
but these are the positive outliers. At the other extreme, Houston, Texas, belonging to Memorial Hermann
hospitals with the highest readmission rates are read- Health System. It was among the best 3 percent in
mitting more than one of five heart attack and pneu- low readmission rates for heart attack and pneumo-
monia patients and more than one of four heart failure nia patients among more than 2,800 hospitals.
patients.12
Exhibit 1. 30-Day Readmission Rates Among Case Study Hospitals
Heart Attack Heart Failure Pneumonia
(2,427 hospitals (3,935 hospitals (4,095 hospitals
reporting) reporting) reporting)
McKay-Dee Hospital Center 17.70% 19.30% 13.70%
Memorial Hermann Memorial City Medical Center 18.00% 24.60% 14.30%
Mercy Medical Center—Cedar Rapids 17.20% 20.10% 14.90%
St. John’s Regional Health Center 17.10% 21.30% 15.60%
Top 10% 18.40% 22.40% 16.50%
National Average 19.97% 24.73% 18.34%
Notes: All-cause 30-day readmission rates for patients discharged alive to a non–acute care setting with principal diagnosis. These data are based on the most recently
available, from reporting period Q3 2006 through Q2 2009.
Source: WhyNotTheBest.org, accessed Dec. 14, 2010.R educing H ospital R eadmissions : S ynthesis R eport 5
• Mercy Medical Center is a 305-bed, private,
nonprofit hospital in Cedar Rapids, Iowa. Mercy To think simply within our own silo as an acute
Medical Center owns a physician network, hos- care facility, we won’t be effective in managing the
pice, and home health service. It was among the [readmission] issue.
top 3 percent in low readmission rates for heart Tim Charles, CEO, Mercy Medical Center
attack, heart failure, and pneumonia patients
among more than 2,800 hospitals. Healthcare Improvement (IHI) as a high-performing
• St. John’s Regional Health Center is an 866-bed, health care community for its high quality of care
private, nonprofit hospital in Springfield, Missouri. and low cost of health care services—Mercy Medical
St. John’s is a member of St. John’s Health System, Center has engaged with a competitor hospital and
and scored in the best 3 percent in low readmis- other local providers to establish common processes
sion rates for heart attack and heart failure patients for improving patient care. Mercy also has joined
among more than 2,800 hospitals. with its competitor and other providers to support a
safety-net clinic serving over 200 patients a day. The
Exhibit 1 illustrates the four hospital’s read- availability of free care to the uninsured likely reduces
mission rates, which are significantly lower than the the risk that the uninsured will be rehospitalized. Tim
national average and nearly all better than the top 10 Charles, CEO, says that if a hospital continues “to
percent of hospitals reporting to CMS (these are in think simply within our own silo as an acute care facil-
bold). ity, we won’t be effective in managing the [readmis-
sion] issue.”
DRIVERS OF READMISSIONS: INTERNAL Though the state of Texas is generally resource-
AND EXTERNAL ENVIRONMENTS poor and Texas hospitals as a group have worse than
One of the lessons gleaned from the four case studies is average readmission rates, discharge planners at
that hospitals’ environments contribute to their capac- Memorial Hermann Memorial City Medical Center
ity to reduce readmissions. Hospitals are influenced by in Houston, Texas, take advantage of the practices of
the policy environment, the local health care market, local home health agencies to arrange post-discharge
whether they belong to an integrated health system, care for all of their patients, even the uninsured. Local
and the priorities set by their leaders. home health companies provide free care in their first
few months of operation in order to gain experience
State Capacity and Local Market for the Medicare certification process.13 Also, all home
Dynamics health companies in the Houston area—including
A study by Jencks et al. vividly illustrates the enor- Memorial City’s agency and start-up companies—
mous variation in readmission rates across states, employ home health liaisons, who follow discharged
ranging from a low in Idaho of 13.3 percent to a high patients to ensure they receive ordered services and
in Maryland of 22 percent (Exhibit 2). The authors answer their questions, which likely helps to avoid
discussed the potential for higher numbers of available readmissions.
hospital beds to correlate with higher rates of rehospi-
talization, while areas with greater access to primary Membership in an Integrated Health
care and better continuity of care could be expected to System
have lower readmissions. However, data limitations Being part of an integrated health system gives
prevented explicit study of these questions. hospitals access to data and support that indepen-
In our case studies, the local environment dent hospitals may not have. McKay-Dee Hospital
appears to play an important role in readmissions. In Center in Ogden, Utah, is a member of Intermountain
Cedar Rapids, Iowa—recognized by the Institute for Healthcare, a system that invests heavily in6 T he C ommonwealth F und
Exhibit 2. State-by-State Variation in Readmission Rates
Source: S. F. Jencks, M. V. Williams, and E. A. Coleman, “Rehospitalizations Among Patients in the Medicare Fee-for-Service Program,” New England Journal of Medicine,
April 2, 2009 360(14):1418–28.
developing, testing, and sharing best practices among policy and payment reforms discussed above. Leaders
its members. Members work together to provide the of hospitals that are part of health systems may care
right care the first time, under a conviction that this less about the number of admissions overall and more
leads to better care, fewer readmissions, and lower about serving patients in the most appropriate and least
costs in the long term. The health system established costly setting.
an institute devoted to this work, the Intermountain
Institute for Health Care Delivery Research. Clinical Excellence and
Also, being part of an integrated system helps Quality Improvement
bring all parties to the table and enhances communi- The four case study hospitals do not focus on reduc-
cation and flow of information among inpatient and ing readmissions per se, but on improving clinical
outpatient providers. It promotes a continuum whereby quality and patient care in the belief that readmissions
patient care can be coordinated across settings. will decline as a byproduct of their broader improve-
“Don’t undersell the importance of being an ment efforts. Like other high-performing hospitals, St.
integrated delivery system. We have the luxury of hav- John’s Regional Health Center pays close attention to
ing hospital officials, clinic physicians, and our health its performance on the core measures and implement-
plan at the table always,” said Ann Cave, vice presi- ing evidence-based care; these indicators are viewed by
dent of health plans medical management at St. John’s hospital leaders as major contributors to its low read-
Regional Health Center in Springfield, Missouri. mission rates.
Many hospital leaders face perverse financial incen- McKay-Dee is shaped by a leadership team
tives, in that readmitting patients can lead to additional and culture that promote patient-focused care.
revenue—though this is changing as part of ongoing Administrators and providers seek to “do theR educing H ospital R eadmissions : S ynthesis R eport 7
right thing” for patients, believing this will have a
positive impact on their finances in the long term. Don’t undersell the importance of being an integrated
Administrators at two of the case study hospitals, delivery system. We have the luxury of having
McKay-Dee and Memorial Hermann, report that lower hospital officials, clinic physicians, and our health
readmission rates and other efficiencies help them plan at the table always.
negotiate better rates from health plans and other pay- Ann Cave, vice president of health plans medical
ers, enabling them to recoup some of the revenue lost management, St. John’s Regional Health Center
through lower numbers of admissions.
The four hospitals emphasize standardization of
described by Kathy Kipper-Johnson, director of case
care and use of best practices, use of information sys-
management at Memorial City, “We pay close atten-
tems to support performance reporting and decision-
tion to the comorbidities and knowledge base of each
making, and review of data in real time while problems
patient to form a community plan of care.”
can still be fixed. Some use workforce innovation,
The hospitals also target patients who are likely
extending the role of nurses, pharmacists, and hospital-
to have problems following discharge for enhanced
ists to help educate patients and coordinate their care.
care coordination and/or case management. For exam-
These strategies are discussed further below.
ple, at Mercy, social workers visit all patients over 80
years old to address their needs.
CARE TRANSITION STRATEGIES
The hospitals use technology to assist them in
As noted above, research shows a strong link between
assessing, tracking, or referring patients. At Memorial
attention to care transitions and lower readmission
City, risk-assessment software helps case manag-
rates. When patients move from the hospital to the
ers establish the appropriate level of care and assess
next site of care—be it their home or a nursing home,
patients’ readiness for discharge. This tool also helps
rehabilitation facility, or hospice—they benefit from
the hospital make the case with patients’ insurance
having a clear treatment plan they can understand and
plans about needed care.
follow, providers who are aware of and able to carry
While all hospitals coordinate with home health
out the plan, access to the right medications, and sup-
agencies and connect patients to available community
port services. The case study hospitals used several
resources, McKay-Dee and Mercy take an extra step
strategies to help ensure smooth care transitions and
by scheduling follow-up appointments for most of their
well-coordinated care.
patients prior to discharge. The two other hospitals are
The four hospitals focused on patients at the
only able to make appointments on an ad hoc basis
highest risk for readmissions, including heart failure
for the neediest patients, because of limited staff and
patients, the very elderly, and those with complex
resources. Scheduling appointments for patients can
medical and social needs. They also sought to help
ensure they receive follow-up care and comply with
uninsured or underinsured patients make connections
recommended treatment.
with needed services in their communities.
Like other top-performing hospitals profiled
for case studies on WhyNotTheBest.org, these four
Care Coordination and Discharge Planning
hospitals commit to regular communication across
While all hospitals plan for patients’ discharge, the
care teams and with patients and their families. Daily,
four case study hospitals paid particular attention to
interdisciplinary care coordination meetings, or rounds,
discharge planning from the first day of patients’ stay.
are common, providing an opportunity to raise issues
Staff assess patients’ risk factors, needs, available
or concerns about patients, adjust the discharge date
resources, knowledge of disease, and family support
based on progress, and arrange for equipment or
shortly after admission, typically within eight hours. As8 T he C ommonwealth F und
services that may be needed in the community. In some patients’ understanding and identifies for nurses areas
of the hospitals, whiteboards are located in patients’ that may be confusing and require additional attention.
rooms to keep families apprised of the target discharge At McKay-Dee, nurses and case managers receive
date and other important milestones. training to assess patients’ literacy level and adjust
Despite their successes, the hospitals noted materials and teaching methods to ensure they are
some aspects of discharge planning are beyond their understood.
current capacity or could be improved, such as univer- Medication compliance is critical for discharged
sal scheduling of follow-up appointments or develop- patients to remain stable at home, and hospitals
ing a care plan with every patient. have been working hard to improve their medication
education and reconciliation approaches. Memorial
Patient Engagement and Patient-Centered City places pharmacists in high-risk units to educate
Education patients and try to minimize the number of prescrip-
The hospitals try to help patients understand their tions a patient takes home. McKay-Dee uses a check-
conditions—and empower them to manage their diet, list to ensure heart disease patients are discharged with
activities, medications, and care regimens and know the right medications and provides each patient with a
when to seek care—through educational activities customized list that describes, in simple language, the
throughout the stay. This can reduce patients’ fear and purpose and timing of each medication (Exhibit 3).
uncertainty, which are factors that contribute to read- Lack of access to affordable medication is a risk
missions. factor for readmission, too. To ensure access to needed
The hospitals employ various methods to engage medications, McKay-Dee, St. John’s, and Mercy refer
patients. For example, Memorial City nurses review patients who cannot afford prescription drugs to medi-
discharge instructions thoroughly with patients and cation assistance programs or a clinic with free medi-
their families, who are then asked to demonstrate or cations.
“teach back” the instructions. This method strengthens
Exhibit 3. Sample Personalized Medication List:
McKay-Dee Hospital Center
Date:
February
19,
2010
Please
keep
this
record
of
your
current
medications
in
your
wallet
or
purse.
Update
it
when
medications
are
added
or
stopped.
This
will
help
others
to
better
assist
you
in
the
future.
Medication
Reason
Dose
How
to
Take
AM
Lunch
PM
Diltiazem
Heart
Rate
180
mg
Once
daily
X
Potassium
Electrolytes
10
meq
Twice
daily
X
X
Lasix
(furosemide)
Water
Pill
40
mg
Twice
daily
80
80
22-‐Feb
Spironolactone
Water
Pill
50
mg
Twice
daily
X
X
Synthroid
(levothyroxine)
Thyroid
150
mcg
Once
daily
X
Colace
Stool
Softener
100
mg
Twice
daily
X
X
Pravachol
Cholesterol
20
mg
One
pill
once
daily
X
Aspirin
(ASA)
Clot
Prevention
81
mg
Once
daily
X
Prevacid
Stomach
Acid
15
mg
Once
daily
Dilantin
Seizures
100
mg
3
pills
once
daily
X
Coumadin
Clot
Prevention
5
mg
Once
daily
as
X
prescribed
per
CAC
Allopurinol
Gout
300
mg
Once
daily
X
Ambien
Sleep
10
mg
Once
daily
X
Metolazone
Water
Pill
2.5
mg
See
below
X
Other
instructions:
1. Metolazone
2.5mg
Mon
&
Thurs
only
as
of
2/25
Source: McKay-Dee Hospital, 2010.R educing H ospital R eadmissions : S ynthesis R eport 9
Cardiovascular patients receive special consider- This method was employed to some degree by all four
ation at all four of the case study hospitals. For exam- hospitals. Some indicated that the process is not stan-
ple, St. John’s cardiac rehabilitation educators work dardized or it is available only to a subset of patients,
with heart failure patients to prepare them for transition such as heart failure patients or the uninsured. Patients
into the community and refer them to the hospital’s at St. John’s who are members of the hospital’s affili-
cardiac rehabilitation program for post-discharge care. ated health plan also receive follow-up calls from the
At McKay-Dee, the computer system flags any patient health plan’s care manager, illustrating a benefit of
with a history of heart failure, triggering tailored edu- integrated health systems.
cation, including use of the MAWDS (Medications, At Memorial City, home health liaisons fol-
Activity, Weight, Diet, Symptoms) teaching approach low up with patients referred for home health care to
and a referral to the hospital’s outpatient heart failure confirm that ordered services have been received and
clinic for ongoing management of the disease answer questions. Even uninsured patients are referred
(Exhibit 4). to local home health care agencies, and some uninsured
patients with chronic illness are referred to Memorial
Post-Discharge Follow-Up City’s community-based disease management program.
A common concern that emerged from interviews with The hospital targets emergency department “frequent
staff at the four hospitals is the need to ensure patients flyers” and those with certain chronic conditions for
do not “fall off a cliff” after returning home. The hos- telephone-based disease management education and
pitals provide support after discharge, even if it results help finding a medical home. It has seen a drop in
in higher costs in the short term. One of the simplest emergency visits and inpatient admissions among those
ways they do this is through telephone calls one week receiving this support.
after discharge to answer patients’ questions, reinforce Two hospitals use telemonitoring devices that
disease-specific education, and confirm patients are make it possible to monitor patients remotely so that
receiving the recommended follow-up care—including clinicians can intervene early if there is evidence of
reminding them to see their primary care physician. clinical deterioration. At Mercy, all cardiac patients
Exhibit 4. The MAWDS Heart Failure Patient Education Mnemonic
SELF-MANAGEMENT WITH MAWDS qquui icckk r
r ee ffeerreenncce ef of ro r
Self-management is key to heart failure treatment. Teach Intermountain’s MAWDS
mnemonic to help promote compliance with these important self-care steps:
Heart Failure
MAWDS Self-Care MAnAgEMEnT AnD
HEART FAILURE PREVENTION
& TREATMENT PROGRAM (HFPTP) M EDICATIONS: “Take your MEDICATIONS”
Make sure your patients understand the importance of medications in their heart
Diary: Encourage your
patients to use the MAWDS
self-care diary to record their
D R u g R E C o M M E n D AT I o n s
PROVIdER sUPPORT HOTLINE and cONsULTATION cLINIc: failure management. Tell them which medications they are taking and why. Most daily weight and symptoms,
PHONE: (801) 507-4000 importantly, make sure they understand the necessity of taking their medications and keep track of their
every day, even when they are feeling well. medications and appointments.
FAx: (801) 507-4811
Reviewing the diary at
WEb: intermountainhealthcare.org/heartfailure
or use the referral form in clinical Workstation (cW) hot text
A CTIVITY: “Stay ACTIVE each day”
Many patients with heart failure are afraid to be active. For others, it just seems like
every office visit promotes
a partnership between you and
too much of an effort. Encourage your patients to participate in some form of physical your patient, and may help
activity every day. Participation in a supervised cardiac rehabilitation program is a you better coordinate with
good way to help patients overcome their fears and understand their limits. other physicians involved in
FOR MORE INFORMATION: the patient’s care — thereby
Intermountain heart failure patient education
materials:
W EIGHT: “WEIGH yourself each day”
It is critical that your patients understand the importance of weighing themselves
improving treatment outcomes
and quality of life.
??
daily. Patients will be more likely to comply with daily weighing if they understand
n Clinicians can view and order materials from
intermountainphysician.org/PEN or call (801) 442-2963.
4
that you are concerned about fluid retention as it relates to heart failure. Patients
4
If your patient smokes,
provide resources to help
2 0 0 9 Up dAT E
should notify their provider when they gain more than 2 pounds in one day or 5
Send patients to intermountainhealthcare.org/health pounds from their usual/target weight. them quit. Intermountain
?
n
provides a smoking cessation
D 4
?
Other helpful websites: IET: “Follow your DIET” booklet for this purpose.
n
n
Heart Failure Society of America (HFSA):
provider: www.hfsa.org patient: abouthf.org
American College of Cardiology: www.acc.org
4
4 ?
A good diet—especially sodium restriction—is critical to heart failure management.
Helping patients understand how to restrict their sodium and learn other
important diet elements can be time consuming. A referral to a registered
dietitian is recommended for most patients.
Other patient education
4 Intermountain
resources:
?
n American Heart Association: www.americanheart.org also provides a Living with
S YMPTOMS: “Recognize your SYMPTOMS”
Make sure your patients know how to recognize the signs and symptoms of heart
Heart Failure booklet and a
heart failure DVD for patients.
View and order these and
failure, and tell them what you want them to do when they experience them. other resources from inter-
The MAWDS Self-Care Diary and Living with Heart Failure booklets described mountainphysician.org/PEN.
©2002-2009 Intermountain Healthcare. All rights reserved at right provide an action plan to guide patients.
Patient and Provider Publications. 801.442.2963
IHCEDHFPKTCARD – 01/09
Source: Intermountain Healthcare, 2009.10 T he C ommonwealth F und
are discharged with a telemonitoring device. The
devices, which are provided free of charge to patients We can find a [medical] home for almost anyone.
who cannot afford to pay for them, monitor blood Without this system alignment, some patients could
pressure, pulse, oxygen saturation, weight, and blood be difficult to place.
sugar and transmit this information through a phone Charlotte Foy, quality and
line to the hospital, where a registered nurse reviews it case management director, McKay-Dee
and initiates appropriate follow-up steps if results are
not within the physician-approved parameters for the an affiliated home health network, which provides
patient. Since implementing the devices in February coordination and support to help patients stay out of
2008, the hospital has experienced a 47 percent the hospital. If a patient does not have a medical home,
decrease in readmissions and a 57 percent decrease in hospital staff will help the patient secure one—either
average length of stay among participating patients. within the Intermountain network or with one of the
At St. John’s, an interactive voice response community clinics with which the hospital partners.
(IVR) system—referred to as the Teleheart Program— St. John’s efforts to coordinate inpatient and
provides a mechanism for the hospital to monitor outpatient care include engagement of local primary
cardiac patients after discharge. Cardiac patients are care physicians. For example, the hospital sponsored
given a scale and blood pressure cuff at discharge, a “heart failure summit” to bring physicians up to date
and instructed to call in every day with their current on current guidelines for heart failure treatment—
weight and blood pressure. When abnormal results are a step that could help reduce admissions as well as
reported, the IVR system automatically notifies the readmissions. The hospital also provides electronic
nurse on duty, who calls the patient and coordinates notification to community physicians via its electronic
appropriate follow-up care. medical record system when one of their patients is
discharged from the hospital with heart failure.
Collaborating with Community Providers McKay-Dee, Mercy, and St. John’s provide all
to Promote a Continuum of Care community physicians with access to their patients’
Collaboration and close communication between inpa- electronic medical records. At McKay-Dee and St.
tient and outpatient providers can enhance care transi- John’s, physicians are asked or required to have fol-
tions and reduce readmissions. For example, McKay- low-up phone calls or appointments with their patients
Dee takes advantage of Intermountain’s network of within one week of discharge. At St. John’s, this
physician practices and clinics. One leader there noted, applies to heart failure patients only; community physi-
“We can find a [medical] home for almost anyone. cians are asked to give them priority access through a
Without this system alignment, some patients could be “call in, get in” standard of care. Although the standard
difficult to place.” is not mandatory, it appears to be capturing physicians’
McKay-Dee and St. John’s engage community attention.
providers and support patients after discharge with out- Both McKay-Dee and St. John’s also run out-
patient clinics for ongoing management of the patient’s patient cardiac clinics and other services that provide
condition. education, rehabilitation, and ongoing management to
At McKay-Dee, many doctors—both those help patients stay out of the hospital. St. John’s makes
employed by the system and independent physicians— resource centers available to support patients with
have offices on site in the hospital’s physician office heart failure, asthma, and diabetes. McKay-Dee has
wing, adjacent to the related inpatient floor. The prox- an outpatient heart clinic on site to which it refers at-
imity of physicians’ offices to the hospital promotes risk cardiac patients at discharge. Having such clinics
follow-up care. Hospital patients also have access to and resource centers on site provides clear advantages;R educing H ospital R eadmissions : S ynthesis R eport 11
clinicians can for example send a heart failure patient Telemonitoring and interactive voice response
with high fluid levels, or “overload,” directly to systems, as discussed above, also help these hospitals
McKay-Dee’s intravenous clinic, where successful monitor high-risk patients and provide early interven-
fluid reduction can avoid an admission to the hospital. tions that can avoid readmissions.
For more serious situations, patients can be admitted
immediately. Strong End-of-Life Care
Mercy Medical Center links its strong end-of-life
Use of Information Technologies care—including palliative care teams, portable advance
All four case study hospitals use health information directives, and a hospice program—to its low read-
technology (HIT) to improve quality and reduce avoid- mission rates. Mercy provides a palliative care con-
able readmissions. The hospitals have implemented sultation to patients with complex illnesses or serious
electronic medical records (EMRs) that provide access health conditions, as identified by frequent visits to
to patient medical histories, facilitate computerized the emergency department, frequent admissions, poor
ordering, and standardize care with automatic patient prognoses, or prolonged hospital stays. A palliative
alerts and electronic order sets. The EMRs also track care team helps clarify patients’ goals, leads discus-
and report outcomes in real time, enabling hospitals to sions about advanced directives, and guides care transi-
benchmark their performance against others and com- tions so patients can receive the right level of care at
pile physician report cards. The records also enhance the right time. The team also works closely with the
communication across care settings through fast and hospital’s hospice program, which provides an alterna-
accurate sharing of patient information among hospi- tive to inpatient care for patients who are unable to stay
tals, physician offices, and even affiliated insurance in their home.
plans. Mercy and other area health care providers
HIT also can be used to support coordinated dis- developed a pilot program called IPOST to improve
charge planning and improvements in chronic care. For communication and honor a patient’s end-of-life deci-
example, St. John’s uses a sophisticated patient registry sions across care settings.14 The IPOST tool, signed
to notify community physicians about their patient’s by a physician, captures a patient’s advance directives
condition and recent hospitalizations. The registry is and creates a set of orders that follows the patient
populated based on diagnosis codes, laboratory codes, from facility to facility or home setting. The program
and manual entries and linked to the hospital’s EMR. helps the hospital maintain its low readmission rate by
The patient registry generates a Visit Planner Tool and enabling it to honor patients’ wishes, for example to
Exception List to inform physicians of needed tests or spend their final days at home or avoid extraordinary
interventions and highlight any gaps in care. interventions.
Some hospitals leverage HIT in the patient McKay-Dee also has palliative care and hospice
assessment and discharge planning process. Branching programs, both of which work closely with the hospi-
logic can be been built into nursing assessment tools to tal’s heart failure clinic to help patients make decisions
trigger automatic referrals for case management, social about end-of-life care. This can provide great comfort
work consults, or other services based on a patient’s to patients’ and their families, and may also reduce
answers to an assessment. As noted above, case man- readmissions.
agers at Memorial City use risk stratification software
to assess a patient’s readiness for discharge and ensure Testing Payment Incentives
they receive the appropriate level of care according to Two of the hospitals, McKay-Dee and St. John’s,
evidence-based practices. are testing ways to better align incentives to pro-
mote high-quality, efficient care and discourage12 T he C ommonwealth F und
avoidable readmissions. McKay-Dee’s health sys- RESULTS
tem, Intermountain, is piloting three elements of a The four case study hospitals had exceptionally low
“shared accountability organization.” In one pilot, 30-day readmission rates (among the best 3 percent of
Intermountain and a large payer are working on an U.S. hospitals) for at least two of the three conditions
agreement whereby hospitals will receive a single reported by CMS (heart attack, heart failure, and pneu-
bundled payment for pregnancy, labor, and delivery monia).
services. A second pilot involves bundled payments for These hospitals attribute their success at reduc-
hip, knee, and heart services. In the third pilot, patient- ing readmissions to their commitment to clinical excel-
centered medical homes will be expanded to include lence—commitment that has resulted in high scores
patients insured through Intermountain’s health plan, on other performance measures as well. For example,
with the “coordination fee” to participating clinics cov- Memorial City has achieved high adherence to recom-
ering preventive services, certain acute conditions, and mended process-of-care measures for heart attack and
eventually chronic disease management. pneumonia care during the initial inpatient stay, which
St. John’s physician group has been participat- they believe has helped reduce readmissions (Exhibit 5).
ing in the Medicare Physician Practice Group dem- The results of Mercy Medical Center’s targeted
onstration, a pay-for-performance program that offers initiatives are striking. Mercy attributes a 47 percent
financial rewards or shared savings for improving decrease in readmission rates for its heart failure and
patient outcomes and achieving efficiencies.15 The chronic obstructive pulmonary disease patients to the
physicians’ participation reflects their leadership’s installation of home monitoring devices (Exhibit 6).
belief in aligning incentives to promote health out- McKay-Dee has had success in reducing readmissions
comes and efficiency, and encouraging actions that bet- through efforts to target, educate, and follow up with
ter integrate inpatient and outpatient care. heart failure patients.
Exhibit 5. Memorial Hermann Memorial City Medical Center
Heart Attack and Pneumonia Care Performance, 2006–09
Clinical Measures 2006 2007 2008 2009
Heart Attack Care
Aspirin administered within 24 hours 99% 99% 97% 98%
Aspirin prescribed at discharge 98% 96% 95% 99%
ACEI or ARB prescribed at discharge 96% 93% 89% 100%
Counseling for adult smokers 99% 100% 100% 100%
Beta blockers prescribed upon arrival 99% 96% 95% 95%
Beta blockers prescribed at discharge 98% 99% 98% 99%
Pneumonia Care
Antibiotic within six hours of arrival 78% 86% 100% 98%
Oxygenation assessment 100% 100% 100% 100%
Note: other pneumonia measures were not tracked in the same way during this entire time period.
Source: Memorial Hermann Healthcare System, 2006–08; CMS, 2009.R educing H ospital R eadmissions : S ynthesis R eport 13
However, the hospitals acknowledge they do LESSONS
not excel in all areas and need to continuously measure The four hospitals’ experiences offer several lessons
several aspects of performance to target areas in need for hospitals seeking to reduce their readmission rates.
of improvement. For example, Memorial City’s inter-
ventions to prevent readmissions contributed to very Care for patients correctly and
low rates, compared with national averages, for pneu- readmission rates fall, performance on
monia and heart attack, but just average rates for heart quality measures improves, and savings
failure. This suggests that conditions such as heart are realized as byproducts.
failure require focused interventions. While St. John’s The case study hospitals have found that dedication
performance is above average on most quality mea- to clinical excellence and patient safety can result in
sures reported by CMS, it has a surprisingly low score declines in readmissions and costs over the long term.
for documentation of heart failure discharge instruc- Hospital leaders should focus on the performance
tions. Although the problem may be more a failure to measures they believe are most strongly connected to
document the delivery of discharge instructions than a meaningful improvements. This requires investments
failure to deliver them, it nevertheless indicates an area in dedicated quality improvement staff, tools such as
for improvement. electronic monitoring of key performance measures,
While McKay-Dee has low readmission rates development of care standards and protocols, finan-
in all three clinical areas, hospital leaders say that their cial incentives, and other strategies described in the
performance on surgical process-of-care measures is Summary Table of Improvement Strategies of Top-
not as good as it should be; according to the leaders, Performing Hospitals.
they are working to convince surgeons to follow rec- Hospitals that do not have a major improve-
ommended care guidelines but are “still fighting that ment infrastructure or a long history of performance
battle.” measurement can still make progress. They could begin
Exhibit 6. Hospitalizations Among COPD Patients Receiving Telemonitor
Hospitalizations
during 6 months
prior to receipt 221
of monitor
Hospitalizations
during 6 months after 118 47% decrease
monitor installed P-value =14 T he C ommonwealth F und
by selecting a few priorities, building data systems to Begin case management and discharge
measure outcomes, testing new care processes, and planning early, target high-risk patients,
then incorporating them into daily protocols. A key is and ensure frequent communication
to standardize and simplify processes, so they are easy across the whole care team.
to follow and reflect evidenced-based care. Planning for patients’ discharge should begin on the
A hospital committed to providing the best care day of admission and involve social workers in the
must be prepared to make decisions that may result in case of elderly and high-risk patients. Strong case man-
higher costs over the short term. For example, among agement and discharge planning—by qualified staff
the case study hospitals such decisions included: with manageable caseloads—can reduce patients’ con-
ceasing to perform elective preterm births, creating a fusion and ensure they receive appropriate care.
research institute dedicated to improving care delivery, Ingredients for successful case management and
and founding a home health network. discharge planning include: daily team meetings during
A successful improvement program must obtain which floor nurses, care coordinators, social workers,
commitment from providers. To encourage this, hospi- and hospitalists discuss each patient, their expected
tals should monitor adherence to evidence-based care discharge date, and issues that need to be addressed;
standards and identify and address causes of nonadher- whiteboards in patient rooms that alert the patient and
ence, including those that lead to readmissions. family to the anticipated discharge date so they can
Hospital leaders must demonstrate their com- plan accordingly; scheduling of follow-up appoint-
mitment to quality and safety. For example, leader- ments before the patient is discharged; home health
ship rounds can encourage communication between liaisons rounding with case managers; and effective
administrators and frontline staff about how to improve education.
quality. Hospitals and hospital systems must establish
accountability for meeting performance benchmarks— Teach patients and families how to
with rewards and penalties—up and down the ladder, manage their conditions.
from individual physicians to managers to CEOs. By helping patients understand and manage their disease,
hospitals can reduce patients’ fear and uncertainty and
Use information technologies as tools to avoid the medication mistakes and missed warning
improve quality, integrate care, and ease signs that can result in readmissions. Staff at the case
patient transitions. study hospitals credit educational methods such as
While information technologies are not solutions, they teach-back—not merely read-back—with giving patients
can be used to support clinical, financial, and opera- greater confidence when they leave the hospital.
tional decisions that can improve quality and outcomes Staff must engage patients at their level by
and potentially reduce readmissions. Various software assessing their literacy skills and adjusting their verbal
systems track performance at the system, hospital, and written materials accordingly. Some hospitals have
department, and provider levels, enabling creation of had success using pharmacists to teach patients about
dashboards that benchmark performance; identify outli- their medication regimens.
ers; and facilitate targets and incentives for improvement. Targeted education to heart failure patients—
Patient registries, clinical risk assessments, and deci- whether or not heart failure is their primary diagno-
sion support software provide evidence-based proto- sis—can help reduce avoidable readmissions among
cols, warnings, and reminders. Telemonitoring devices this high-risk group. But education is important for
enable hospitals to obtain critical information about all patients. By teaching patients how to recover from
discharged patients and address problems before they acute episodes and control even minor chronic condi-
lead to complications that may require hospitalization. tions, hospitals can slow or prevent further deteriora-
tion and reduce readmissions.R educing H ospital R eadmissions : S ynthesis R eport 15
Maintain a “lifeline” with high-risk Improving health requires a community-wide
patients after discharge. effort. Hospitals and hospital systems must reach out
Taking care of patients after discharge helps keep them to colleagues in their communities in order to manage
from coming back to the hospital. Two strategies that readmissions and improve overall health. Such collabo-
the case study hospitals have found to be effective ration is likely to have benefits for the participating
are: 1) post-discharge phone calls for all patients with organizations as well as for the local population.
certain conditions or characteristics (e.g., heart failure,
diabetes, post-catheter, elderly); and 2) use of tele- Incentives are needed to encourage
monitoring devices that transmit vital information to a hospitals to “do the right thing.”
trained clinician who can determine whether follow-up Traditional fee-for-service reimbursement by public
care is needed. and private payers, and even discharge-based payments
In addition, hospitals can help uninsured based on individual hospital stays, create incentives
patients find a medical home for follow-up care and for hospitals to increase the volume of hospital admis-
provide or refer patients to community-based telephone sions. New payment mechanisms that alter these incen-
case management when needed. tives are emerging as public and private payers are
looking for ways to reduce costs and waste. Medicare
Align the efforts of hospital and has announced it will no longer pay for readmissions
community providers to ease transitions within 30 days of discharge for the same diagnosis. In
across care settings. addition, it is supporting efforts to expand primary care
Access to a continuum of care facilitates smooth tran- medical homes, testing bundled payments that cover a
sitions across settings and helps ensure delivery of total episode of care, and promoting accountable care
appropriate care. Vertically integrated systems may organizations—all of which should create incentives to
have an advantage in providing continuous and coor- reward quality and outcomes, such as fewer readmis-
dinated care. For example, their members—including sions, instead of volume.
hospitals, primary care networks, rehabilitation centers, Although low readmission rates may in the short
home care agencies, nursing homes, and other provid- term result in lost revenue, two hospital leaders noted
ers—may share electronic health records that give that lower readmission rates and other efficiencies
them easy access to comprehensive patient informa- help them when negotiating rates with health plans and
tion. Still, there are ways to create effective partner- other payers. They also say that—while they are moti-
ships between hospital and community providers apart vated to achieve clinical excellence—incentives are
from formal ownership arrangements. needed to motivate inpatient and outpatient providers
The case study hospitals nurtured partner- to work together to integrate patient care and take other
ships and collaborations with nonaffiliated clinics in steps to reduce avoidable readmissions.
low-income neighborhoods as well as with special- With new opportunities presented by national
ists and even competitor hospitals that resulted in health reform and other changes in the health care sys-
smoother patient transitions and higher-quality care. tem, hospitals stand to benefit from being pioneers in
For example, a health system could extend access to providing high-quality, coordinated care and avoiding
its electronic health records to nonaffiliated physicians readmissions.
through Web portals (for a fee or no fee), permitting
timely access to a patient’s history, medications, test
results, and other information.You can also read
