Starting in October, hospitals will have added incentive to reduce their readmission rates. Thats when Medicare will start reducing reimbursements for hospitals with high percentages of readmissions within 30 days for three diagnoses: acute myocardial infarction, heart failure and pneumonia. The list of diagnoses gradually will expand.
Hospitals with the highest readmission rates could lose up to 3% of their Medicare payments. But nurses and physicians at Mountainside Hospital in Montclair, N.J., have a plan to make sure that doesnt happen. They have been working for a year on a system that will identify those most at risk for readmission and trigger a care and exit plan that lessens that risk.
Mountainside voluntarily added chronic obstructive pulmonary disease to the three initial diagnoses it is targeting for readmission, said Sabina Fallon, RN, EdD, director for case management. Although the hospitals percentage rates for all four diagnoses are below the state average, she said — in the low 20s for AMI, HF and COPD and 15.5% for pneumonia — the goal is to cut readmissions for each diagnosis by 20% by the end of 2013.
Part of the plan involves updating the electronic nursing assessment templates with risk-assessment factors from Project BOOST (Better Outcomes for Older Adults through Safe Transitions), developed by the Society of Hospital Medicine.Sabina Fallon, RN
The initiative assigns numerical risk values for eight Ps:
• Problem meds: Insulin, Coumadin, Digoxin and Plavix are among medications that raise readmission risk.
• Psychological: Cognitive slowing and appetite or sleep disturbances may interfere with treatment.
• Principal diagnosis: Certain diagnoses naturally put patients at higher risk for readmission.
• Polypharmacy: More than five medications is a trigger.
• Poor health literacy: Patients may not understand what a nurse is telling them or may be offended by certain questions.
• Patient support lacking: Caregivers after discharge may lack education, good communication.
• Prior hospitalizations: Readmissions go up with the number of prior hospitalizations.
• Palliative care: Establishing goals of care could prevent avoidable readmissions.
These categories are reviewed upon admission and each category receives a score, said Mountainside informatics nurse Katherine OSullivan, RN-BC, MCIS. If scores are high enough, they will trigger a consult, she said, and all disciplines will be alerted.
That score could change daily. A patient may not trigger a risk when admitted, but a nurse may realize in subsequent discussions that the patient has little understanding of a diagnosis and is, therefore, at risk. Or patients may come in with high-risk ratings, but nurses may find they are managing so well their risk status is downgraded.
“It truly still requires the critical thinking by both the bedside nurse and all the ancillary departments,” OSullivan said.
Nurses also will develop “refrigerator sheets.” Instead of getting a stack of papers at discharge, patients will get a one-page sheet that spells out when they need to call the physician or seek emergency care.
A transition nurse will follow up with the patients and caregivers after discharge and test them on what they know. The transition nurse will be the liaison with other agencies, such as home care, to coordinate care after discharge.
A new electronic system, called ExitCare, interfaces with Mountainsides EHR and provides exit information at a fourth- to fifth-grade reading level with enlarged font, OSullivan said. Using the teach-back method, nurses at all levels will be trained to ask patients what they understand from what theyve just heard from care providers.
The biggest changes for nurses will be in new ways of educating patients and identifying the family member who will be the primary caretaker. Nurses will make sure everyone on the medical team knows that person and directs extensive education to her or him.
Nurse managers, with input from staff, meet regularly as they work toward going live by Oct. 1, the date the penalty phase starts.
“[The penalties are] the push for hospitals to change,” Fallon said. “But it is really something we need to be doing for the good of the patient.”
Marcia Frellick is a freelance writer.