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July / August 2011
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New Efforts Focus on Avoidable Readmissions

Northwest Community Hospital's Care Improvement and Patient Outcomes (CIPO) committee is taking aim at reducing 30-day readmission rates. Strategies are being formed by the committee in an effort to curb avoidable readmissions within the Medicare patient population, which will not only lower Hospital costs but also prepare the organization for Medicare reimbursement changes in 2012.

"Health reform is moving toward a pay-for-performance model," says Kathy Ferket, executive director of Patient Services. She explains that hospitals are looking at ways to reduce readmission rates, specifically for Acute Myocardial Infarction (AMI), heart failure (HF) and pneumonia patients, in order to avoid financial penalties issued by the Centers for Medicare and Medicaid beginning in October 2012.

The CIPO team will serve as the steering committee that oversees care improvement initiatives that include length of stay and readmissions. Teams previously pulled together for length of stay initiatives under CIPO are now expanding their focus to evaluate potentially avoidable readmissions.

"It will be a combination of many small things that allow us, as an organization, to move readmissions," Ferket adds. These teams will examine the types of readmissions occurring within their clinical areas, observe measurable trends and implement change as appropriate.

A key area of focus is the Hospital's HF patient population, which currently has a high rate of 30-day hospital readmissions. A pilot program is underway at NCH that provides post-discharge support for HF patients recovering at home without home care services.

Called the Link to Home Program, this new initiative creates an opportunity for clinicians to maintain a connection with the patient even after discharge. "The purpose is to ensure patients are able to adhere to their treatment plan, which will reduce their likelihood for a rehospitalization," says NCH Social Worker Stacy Abben, LSW.

Within 72 hours of discharge, Abben will contact patients to identify unanticipated needs, answer questions and evaluate their compliance with the treatment plan (e.g. taking medications and scheduling appointments). Should barriers hinder a patient's ability to follow the care plan, as a social worker, Abben can link the patient to community resources that can help meet their practical needs or provide psychological support.

The signature objective of the Program is to ensure these patients are staying healthy once they are home, and it's anticipated that avoidable interventions like rehospitalizations or trips to the Emergency Room will decrease. As a result, patients will find greater satisfaction in the care they receive and the Hospital will move toward its goal to meet – and exceed – the national readmission rate for heart failure patients.

Efforts are underway to extend the Link to Home Program to also include high-risk diagnoses such as AMI, pneumonia and COPD. Meanwhile, the CIPO committee will continue to work with clinical teams to develop programs that decrease the occurrence of avoidable rehospitaliztions, ultimately raising the level of care and service patients receive at NCH.

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Last Updated 04/10/2009