MARIN GENERAL: Reducing Hospital Readmissions

Terry Winter, RN, MPH

Marin General Hospital (MGH) has launched a major initiative to improve the experience of patients and their families through better communication, earlier planning, and clearer guidance on what to expect after hospitalization. Any patient leaving the hospital deserves a safe, low-stress transition, but that hasn’t always happened in the past. In fact, patients often haven’t been given all the tools necessary for a safe discharge--a discharge that makes the need for future readmission less likely.

Our aim is to encourage better health outcomes and fewer readmissions. Although our readmission rates are similar to the national average, they’re still too high. At MGH, 12% of our seniors are readmitted within 30 days, and 15% within 90 days. These figures don’t even include the 10% who return to the emergency department for care.

While our technical care is thorough, we sometimes inadequately prepare patients for a healthy transition out of the hospital. Through interviews and focus groups with elderly patients recently hospitalized at MGH, we’ve learned that 75% were unable to verbalize important information about their diagnoses, medications, plan of care, or ways to prevent exacerbation or recurrence of their conditions. Nearly two-thirds were unclear about their follow-up appointments. Although patients often said they were given too little information in the hospital, they also admitted that they rarely asked for clarification. Whether or not we shared all this information with them during their hospitalizations, little was communicated in a manner that stuck. We need to change that.

To reduce readmissions, MGH has adopted two national, evidence-based models that address these communication gaps and have been shown to significantly reduce the risk of readmission.

The first is Project RED (Re-Engineering Discharge), a program developed by researchers at Boston Medical Center that focuses on changes in hospital practice to provide better tools for patients and caregivers. The essence of Project RED is creating more defined interdisciplinary teams for providing care; more effective, timely communication between all members of the team; more thorough engagement of patients and caregivers in their illness and treatments; and a better understanding of what to expect after discharge.

Project RED starts by setting a plan for discharge and outpatient follow-up as soon as the patient is hospitalized. The next step is to reconcile inpatient medications with home meds immediately. The outpatient follow-up is scheduled before discharge, including having a clear, executable plan worked out with the patient for tests and post-discharge treatment. The hospital also makes sure the patient knows which tests are still pending at discharge and with whom to follow up.

At all points in this process, the hospital focuses on improving how we communicate with patients and caregivers, from their diagnoses to what medications we are prescribing and why. We make sure patients and caregivers understand what symptoms are signs of complications that require immediate follow-up (“red flags”) by requiring them to “teach back” what we’ve told them. The goal is to ensure comprehension.

An important element of Project RED is eliminating surprises. Patients need to know what to expect after discharge, and they need to know when and who to call if problems arise--including evenings or weekends. We hope to achieve this goal by providing clear, patient-friendly discharge instructions (due to be rolled out in May), and by initiating follow-up calls to patients a few days after discharge. During these calls, we check on their condition, review medications, reinforce the discharge plan and eliminate any barriers to its implementation.

The second model for reducing readmissions is Care Transitions Coaching--a program for seniors at higher risk because of age, limited support or their overall medical condition. This program replaces the follow-up phone call with the intervention of a specially trained, community-based Care Transitions Coach who meets with the patient or caregiver in both the hospital and the home and makes at least three follow-up calls within one month of discharge. These coaches engage patients to help improve their self-management skills, measure their understanding of their situation and needs, reinforce hospital discharge instructions, identify medication discrepancies, and solve problems.

Coaches also help patients create a Personal Health Record for articulating their needs and questions and keeping a running log of their health conditions, including “red flags” and medications. Patients are encouraged to use the record to write questions for their physicians, and to bring the record to all medical appointments as a reminder.

How are these improvements being implemented at MGH?

We have created a new seven-days-a-week pharmacy tech position dedicated to compiling an accurate home medication history that the physician can reconcile with the regimen ordered upon admission. Any potential confusion is clarified by calls to medical offices, outpatient pharmacies, and families or caregivers.

We’re also debuting a mobile application called CareBook that allows the entire care team to communicate individually or collaborate in groups in real time during the hospitalization. MGH is the first hospital in the world to employ this innovative, cutting-edge tool.

All of the key communication elements of CareBook are now built into the hospital protocol, from immediate anticipation of a discharge date (this can be changed later if necessary); to development of a care plan; to working with the patient and caregiver to ensure they fully comprehend their diagnosis, treatment, medications, and post-hospitalization plan. Throughout hospitalization, nurses will assess the patients’ level of comprehension in each of these areas to improve their understanding and ability to follow through after discharge. This continuous assessment eliminates a last-minute scramble at discharge, which can be confusing and incomplete for the patient.

Finally, we make sure that patients discharged from the medical or surgical units at MGH are followed-up by a supervising nurse (phone call 2-3 days after discharge) or a Care Transitions coach (hospital visit, home visit and phone calls).

As CareBook is more fully implemented, specialists and primary care physicians who choose to participate will be notified electronically of admissions or discharges of their patients. We’re also working to make discharge instructions more comprehensive, patient-friendly and readable, and to allow all members of the care team to incorporate their recommendations into this document. These instructions will be accessible on the Web to patients and outpatient providers involved with CareBook. To allow for continual improvement, MGH will engage in extensive measurement to monitor the strengths and weaknesses of our interventions.

If you care for patients at MGH and would like to go live with CareBook, contact Terry Winter, director of the Care Transitions Program, at wintert@maringeneral.org, or Dr. Susan Cumming, medical director, at cumminss@maringeneral.org. You can also encourage your staff to provide priority access for your hospitalized patients when they call from the hospital for follow-up appointments. Scheduling follow-up appointments before the patient is discharged is critical to implementing a safe and successful transition.

Finally, you can reinforce the work done by Care Transitions coaches by addressing questions articulated by your patient in their Personal Health Record. It’s important for them to see that their concerns are being heard. We can all provide safer transitions for patients by making strong communication and patient engagement a true priority.

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Mr. Winter directs the Care Transitions Program at Marin General Hospital.

Email: wintert@maringeneral.org

Special thanks to the following funders and community partners for their support of Care Transitions coaching: Gordon and Betty Moore Foundation; Marin Community Foundation; Marin General Hospital Foundation; County of Marin Division of Aging and Adult Services; Meritage Medical Network; Seniors at Home/Jewish Family and Children’s Services; Sutter Care at Home; West Marin Senior Services.