As the Centers for Medicare & Medicaid Services sharpens the sticks and sweetens the carrots to encourage health care providers to reduce avoidable readmissions, better discharge planning has become a priority for hospitals. A number of strategies have shown promise already:

  • Integrating discharge planning into care management.
  • Addressing nonmedical needs such as transportation to the doctor’s office or a pharmacy.
  • Building teamwork between acute and post-acute care settings.
  • Actively engaging family or other caregivers in the process.

Critics have raised questions about the design of the Medicare Hospital Readmissions Reduction Program, included in the Affordable Care Act, which penalizes selected hospitals for exceeding certain readmission measures. Still, a recent report in the Annals of Internal Medicine concluded that the readmissions reduction program has helped to speed reductions in risk-standardized readmission rates for heart attack, heart failure and pneumonia.

Trustee talking points

  • Patient discharge planning is increasingly important for hospitals and health systems as value-based reimbursement models and population health management become more prevalent.
  • When discharge planning is made a part of the overall care plan, readmission rates can decrease.
  • Good discharge plans involve not only post-acute care providers but patients, their family and other caregivers.
  • The social determinants of health need to be considered when discharging patients.

Another criticism of the HRRP was that it did not adjust for the “social determinants of health” — those factors that make that make a patient’s ZIP code a strong predictor of health and longevity. While a legislative fix has been passed to address that, more changes to the program are still needed, according to the American Hospital Association.

“America’s hospitals and health systems are focused on reducing unnecessary readmissions to improve quality and lower health care spending,” says Akin Demehin, the AHA’s director of policy. “While we appreciate that the lack of socio-demographic adjustment in the Hospital Readmissions Reduction Program will begin to be addressed in FY 2019 due to passage of the 21st Century Cures Act, further reforms to this flawed program must be made. An example of a needed reform to the program is to exclude admissions that are unrelated to the initial admission. The payment penalty formula also should be modified to ensure that it does not penalize the field for making progress in reducing readmissions.”

Meanwhile, however, the drive to reduce readmissions continues, and planning for discharge and care transitions have been major focuses of this effort. One thing that has been learned is that there is not a one-size-fits-all solution.

“It’s a complex topic, and a lot of people need to get involved,” says Charisse Coulombe, vice president of clinical quality for the Health Research & Educational Trust, the AHA’s research arm. “In the experience I’ve had, working with 1,600 hospitals, there have been a lot of different ideas, different cultures, different patients and communities facing different challenges.”

Discharge planning has become a “continuous process” rather an “event,” according to Brent Feorene, vice president of integrative delivery models for Health Dimensions Group, a Minneapolis-based health care management consultant. As an event, it was not high on the priority list and was done quickly. But CMS “unleashed a whole host of incentives,” including bundled payment, to change that, Feorene says.

Coulombe says discharge planning has also been an important strategy for reducing readmissions, but financial penalties have made it “more top of mind,” which has contributed to more discussion and more sharing of tools and best practices.

As a continuous process, discharge planning starts earlier and continues later and involves reaching out to both health care professionals and family caregivers along the entire continuum of a patient’s care.

“We’re thinking about discharge and planning for what things a patient needs in the transition of care as early as possible,” says Marie Cleary-Fishman, also an HRET vice president of clinical quality. “We’re not waiting until after the physician says it’s OK to go.”

Trissa Torres, M.D., who is now chief operations and North America programs officer for the Institute for Healthcare Improvement, previously led population health initiatives at Genesys Health System in Grand Blanc, Mich. “At Genesys, they told me, ‘Discharge starts at admission.’ That means getting to know patients, what their social support is, and building trust with the patient and their family.”

And hospitals are now incentivized to strengthen links with post-acute providers through accountable care organizations and other mechanisms for sharing savings or reimbursement. Hospitals are becoming more selective about the other providers they work with, looking at CMS star ratings, geography, bed availability and openness to innovation. They are asking potential partners, “Is there energy there for reducing lengths of stay, and do you want to work with us to change the way care is delivered?” Feorene says.

In this new environment, Health Dimensions recommends that hospitals hold monthly meetings with their post-acute partners in which they share data and “learn each other’s language.” The hospital should appoint a specific individual to ensure that the process is implemented successfully. “There has to be a hospital person whose job it is to do this — it won’t just happen,” Feorene says. “The data sharing, the problem solving, the communicating — someone has to own this.”

Representing the patient

Integrating caregivers into the discharge process resulted in a 25 percent reduction in the risk of elderly patients being readmitted to the hospital within 90 days of discharge and a 24 percent reduction in the risk of readmission within 180 days, according to a study published in April in the Journal of the American Geriatrics Society.

Hospitals have been agreeable to this, according to one of the researchers, but it can’t be another mandated task added to a to-do list.

“The main thing that hospitals want is that this is integrated into existing workflow and not further delay the patient’s discharge,” says A. Everette James, director of the University of Pittsburgh Health Policy Institute and a co-author of the study.

This caregiver involvement reflects the overall transformation taking place in the nation’s health care system, according to Torres, of IHI. “We’re shifting from doing it to and doing it for, to doing it with the patient,” she says.

A BOOST and beyond

Torres says most successful discharge planning programs evolved out of early initiatives such as Project BOOST, which was launched by the Society of Hospital Medicine with input from the IHI, the Joint Commission and others. In a 2013 study, 11 hospitals that adopted Project BOOST, which stands for Better Outomes by Optimizing Safe Transitions, saw 30-day readmission rates fall to 12.7 percent from 14.7 percent in 12 months.

The project’s toolkit consists of a bundle of activities that include identifying patients at high risk for readmission, improving communication and optimizing discharge processes. By early 2014, it had been implemented at 180 sites.

“If we focus more on listening and less on telling, it builds trust, and people will share their barriers to health, and we can come up with solutions,” Torres says. “Ask them, ‘Now that you’re heading home, what are you most worried about?’ And, ‘How can we best support you to stay healthy?’ ”

Beth Carlson, R.N., director of consulting services at Health Dimensions, says the discharge team should be multidisciplinary and include nurses, care navigators and social workers, among others. If there's an ACO, it should embed discharge planning into the clinical process for all providers to utilize rather than maintaining it in a hospital-based silo.

The patients’ primary care physicians should be contacted at discharge, Carlson says, to let the doctors know their patients “knocked on a different door” of the health care system and have received treatment at an urgent care center, visited an emergency department or seen an out-of-network provider.

Teamwork is integral to the discharge process at Northwest Community Hospital in Arlington Heights, Ill. Doctors or nurses provide information about medications and follow-up care. Case managers help with setting up home care or admission to post-acute care facilities. Social workers help patients and their families or caregivers to navigate financial, social and emotional needs related to the patient’s illness or recent hospital stay.

Coulombe and Cleary-Fishman note that, for hospitals seeking resources, success stories and best practices are being shared by HRET’s Hospital Improvement Innovation Network and Huddle for Care programs. Among their favorites is the Sunday Shoes program initiated by Preston Memorial Hospital, a 25-bed critical access hospital in Kingwood, W.Va.

For a variety of reasons, including patients' poor health literacy or poor eyesight that made reading a scale difficult, care teams were struggling to reduce heart-failure readmissions.

By listening to patients, Cleary-Fishman says, Preston Memorial staff knew that attending Sunday church services was important to patients and that most owned a pair of dress shoes that were reserved for the occasion.

At discharge, patients were typically at an ideal “dry weight,” with their fluid retention under control. So, at this time, they would test to see how well their “Sunday shoes” fit. Patients were then instructed to do the same each morning. If they struggled to put on their shoes, it suggested that their feet were swelling, a sign of fluid retention, and that they needed to call their primary care physician or visit an urgent care center. Preston Memorial reported that its heart-failure readmission rate fell from 22.6 percent in 2012 to zero in 2013.

Nonmedical issues matter, too

In addition to the obvious medical issues, hospitals are looking at the social determinants of health before discharging a patient. This includes investigating whether the patient will have safe housing after discharge or finding resources for diabetic patients who visit the emergency department at the end of every month because they run out of money to buy food.

“Often, it’s more than just lining up the next health care component, it’s lining them up with resources,” Carlson says. In fact, she recommends taking an inventory of available community resources as a first step.

The first question to ask might be, “Who are your downstream partners?” Carlson says. That’s particularly important to help patients manage their conditions. They may need reinforcement of the education they received in a hospital but did not fully understand or retain.

Cleary-Fishman notes that food insecurity, unsafe housing and limited access to transportation “all can impact how many times a patient is readmitted.”

Success stories

Discharge planning programs can produce quick and measurable results.

Winston-Salem, N.C.-based Novant Health had success in 2016 piloting a “targeted outreach” and “high-touch health care” initiative for patients at highest risk for readmission. Novant care teams worked with patients’ family caregivers along with 40 post-acute skilled nursing facilities and 40 home health agencies to ensure that care continues after the acute-care episode.

The system credits bundled payment models with allowing a care delivery redesign that includes using care coordinators to educate patients on infection prevention, monitor and evaluate their progress, and make sure they’re taking their medications as prescribed. The effort resulted in a drop in 30-day readmission rates from 13.6 percent in January 2015 to 4.5 percent in December 2016, the system reported.

The Hospital to Home discharge program for heart-failure patients was launched at the University of Virginia Health System in Charlottesville in July 2010 with success. “We focus on teaching and education,” says Craig Thomas, a UVA nurse practitioner involved in the program. 

Torres says she’d like to reframe the process. She’d prefer to call it “care-transition planning” to engage everyone. CMS adopted that concept in its five-year Community-based Care Transitions demonstration program, launched in 2012. It featured the Sun Health Care Transitions program, which lowered the readmission rate to 7.8 percent at Sun Health in Arizona. Comparing that figure with the national average of 17.8 percent (for targeted conditions), Sun Health says its program avoided some 12,000 readmissions and saved Medicare $14.8 million.

The program educated patients about their conditions, medications and to be watchful for warning signs. Social workers meet with elderly patients and their caregivers and family in the hospital to connect them with community resources. Nurses visit patients in their home to help manage medications, among other things.

Andis Robeznieks is based in Chicago.

Beyond the traditional discharge model

Wilmington, Del.-based Christiana Care Health System received the John M. Eisenberg Patient Safety and Quality Award in April for its Carelink CareNow program. The information technology-enabled network of care coordination support services coordinates care for almost 75,000 Medicare beneficiaries. It is credited with helping the system achieve a 30 percent reduction in 90-day readmissions.

In February, Carelink CareNow and its medical director, Tabassum Salam, M.D., were recognized by the American Board of Quality Assurance and Utilization Review, which cited the program for its “robust interprofessional care coordination and discharge planning.”

Patty Resnik, vice president of care management at Christiana Care, says the system did have a discharge planning program before it implemented Carelink CareNow, and it included educating patients and families on medications and other issues before handing the patient off to the next provider.

“But that’s where it would end,” Resnik says. Carelink CareNow goes “beyond the traditional discharge model.”

Delaware’s Legislature passed its AARP-championed Caregiver Advise, Record and Enable Act last year, but the procedures it mandated were already in place at Christiana Care. 

“It truly didn’t impact us because we were doing it ahead of that,” Resnik says. “We’re not waiting for regulations to drive what we do.”

Support services Christiana Care provides include making sure patients can get to their appointments and that their primary care providers know in real time about any health care encounters they may have.

“If any of them have a visit to a hospital or emergency department in the state, we know that they’re there,” says Salam, Christiana Care’s senior physician adviser for population health.

Information technology makes this possible, and the Center for Medicare & Medicaid Innovation provided $10 million in 2012 to build Carelink CareNow’s IT system.

Every patient receives outreach, she says. The highest-scoring patients receive the highest level of attention, which extends the reach of the system outside the hospital, Salam says, including to the 17 skilled nursing facilities with which Christiana Care works.

No matter how much organizations prepare patients and families at discharge, Salam says, things can unravel once they get home and cope with issues such as behavioral health problems, lack of transportation and “the realization that the family lacks the financial ability to pay for medications or devices.”

Salam recalls one case in which a patient was the guardian of her three grandchildren, and the health system had to arrange for the family’s transportation and signing the children — including one with special-education needs — up for school.

“We realized that had to be in place before we could engage the patient herself,” Salam says. “So we are that glue — that continuity for our patients.” — Andis Robeznieks

Trustee takeaways

Don’t confuse a discharge planning tool with a patient assessment tool, an American Hospital Association report advises.

Hospital discharge planning tools:

  • Inform the planning process for the transition from acute care to home or a post-acute care setting.
  • Assess patient demographic and clinical characteristics, risk of readmission, expected post-acute care needs and level of resource use.
  • Once the patient is discharged, generally are not used.

Patient assessment tools:

  • Used across settings to assess the level of care needed and to ensure appropriate care is provided.
  • Can aid in tracking patient rehabilitation progress over an episode of care and in various settings.
  • Some are distinct tools mandated for Medicare beneficiaries in different care settings and are used to determine reimbursement. 

Source: “Private-Sector Hospital Discharge Tools,” American Hospital Association, 2015