Zanderville Healthcare Systems, a regional acute care facility in the foothills of the Appalachians, is committed to delivering quality healthcare to its local and neighboring communities. The population it serves is diverse by gender and ethnicity. The primary payer for healthcare services is CMS. Over the past six months, the acute care facility has experienced a 25 % increase in readmissions from this payer group within the first 30 days of discharge. The economic impact on the health system has been negative, and patients' satisfaction with their hospital experience has declined. Senior leadership has charged you, the nurse executive, to convene an ad-hoc task force to perform an outcomes audit and propose an intervention. Currently, patients receive a follow-up telephone call about 7 days following discharge. You decide to use an evidence-based practice approach and have the following information for the "working" PICOT:
P: CMS patients readmitted within 30 days of discharge
I: What will we do differently to impact the improved outcome
(State what this is)
C: Follow-up phone call 7 days after discharge
O: Reduce readmission rate of CMS patients from _ to _…..
T: Over next six months
If this were happening in your organization, discuss:
Whom will you include in your task force?
What outcomes measures will you audit?
Where will you obtain the data to determine your baseline and goal regarding the percentage of readmissions within 30 days of discharge?
What specific outcome do you want to achieve?
What standard or benchmark will you use for the outcome? What does your organization use as a benchmark for readmissions within 30 days of discharge?
Describe the intervention you will use to achieve your goal.
Then, restate the completed PICOT using the information you have collected related to the intervention and outcomes.
Full Answer Section
- Pharmacist: To review medication reconciliation processes, patient education on medications, and identify potential drug-related issues contributing to readmissions.
- Social Worker/Case Manager: To address social determinants of health, assess patients' post-discharge support systems, and facilitate access to community resources.
- Quality Improvement Specialist/Data Analyst: To lead the data collection, analysis, and tracking of outcome measures. Their expertise in audit methodology is crucial.
- Patient Representative/Advocate: To provide the patient's perspective on the hospital experience and identify areas where communication and support could be improved.
- Home Health/Visiting Nurse Representative (if significantly utilized): To provide insights into challenges patients face in the immediate post-discharge period at home.
What Outcome Measures Will You Audit?
The primary outcome measure will be:
- 30-day Readmission Rate for CMS Patients: This directly aligns with the identified problem and the payer's focus.
Secondary outcome measures to provide a more comprehensive understanding of the issue will include:
- Reasons for Readmission: Categorizing the primary causes of readmission to identify specific areas for intervention.
- Patient Satisfaction Scores (e.g., HCAHPS): Tracking trends in patient satisfaction, particularly related to discharge information, care transition, and understanding of their condition and medications.
- Length of Stay (Index Admission): Monitoring if changes in discharge planning are prematurely discharging patients.
- Emergency Department Visits Post-Discharge (within 30 days): Identifying patients who are seeking care in the ED but not necessarily being readmitted, indicating potential issues with outpatient management.
- Adherence to Discharge Plan (qualitative data where possible): Understanding if patients are following medication regimens, attending follow-up appointments, and implementing recommended lifestyle changes.
Where Will You Obtain the Data to Determine Your Baseline and Goal Regarding the Percentage of Readmissions Within 30 Days of Discharge?
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Baseline Data:
- Hospital Electronic Health Record (EHR): The EHR system will be the primary source for identifying all CMS patients discharged over the past six months and tracking their readmission status within 30 days. The data analyst will be crucial in extracting this information.
- Billing Records: Cross-referencing with billing data can ensure accurate identification of CMS patients and readmission dates.
- Quality Department Records: The hospital's quality department likely already tracks readmission rates and may have existing reports that can serve as a starting point.
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Goal Setting Data:
- Internal Historical Data: Reviewing readmission rates for CMS patients over a longer period (e.g., the past year or two) can provide context and identify any pre-existing trends.
- Benchmarking Data (see below): Comparing the organization's current readmission rate to national or regional benchmarks for similar patient populations.
What Specific Outcome Do You Want to Achieve?
The specific outcome is to reduce the 30-day readmission rate for CMS patients by a significant and measurable percentage over the next six months. The exact target reduction will be informed by the baseline data and the chosen benchmark. For example, if the current 30-day readmission rate for CMS patients is 25%, a realistic initial goal might be to reduce it by 15-20% of that rate, aiming for a rate of 20-21.25% by the end of the six-month period. This represents a concrete and achievable target.
What Standard or Benchmark Will You Use for the Outcome? What Does Your Organization Use as a Benchmark for Readmissions Within 30 Days of Discharge?
I would investigate the following benchmarks:
- National Hospital Readmission Reduction Program (HRRP) Data: CMS publishes national average readmission rates for specific conditions. This is a critical benchmark as it directly relates to the primary payer. We need to identify the national average readmission rates for the primary conditions contributing to our readmissions.
- Regional Hospital Association Data: Our regional hospital association may collect and share benchmark data among member facilities, providing a more localized comparison.
- Internal Historical Best Performance: Reviewing past periods where the readmission rate was lower can provide an internal benchmark of what is potentially achievable within our system.
It is crucial to determine what benchmark Zanderville Healthcare Systems currently uses for 30-day readmissions. This existing benchmark will provide context for understanding the organization's prior expectations and performance goals. If no specific benchmark is in place, adopting the national HRRP average for our key patient populations would be a logical and evidence-based starting point.
Describe the Intervention You Will Use to Achieve Your Goal.
Based on evidence-based practices for reducing readmissions, the task force would likely implement a multi-faceted intervention focusing on improving the quality of discharge planning and the transition of care:
- Enhanced Discharge Planning Process:
- Early Identification of High-Risk Patients: Implement a standardized risk assessment tool (e.g., HOSPITAL score, LACE index) upon admission to identify patients at higher risk for readmission.
- Multidisciplinary Discharge Planning Rounds: Conduct daily or regular rounds involving the physician, nurse, case manager, pharmacist, and potentially other team members to proactively plan for discharge.
- Personalized Discharge Plans: Develop individualized, written discharge plans that are clear, concise, and tailored to the patient's needs, including medication reconciliation, follow-up appointments (scheduling before discharge), dietary instructions, activity restrictions, and potential complications to watch for.
- Teach-Back Method for Patient Education: Utilize the teach-back method to ensure patients and caregivers understand their discharge instructions, medication regimen, and warning signs.
- Medication Reconciliation at Discharge: Conduct a thorough review of all medications with the patient and provide a clear, updated medication list.
- Improved Post-Discharge Communication and Support:
- Proactive Post-Discharge Phone Call (within 48-72 hours): Instead of 7 days post-discharge, implement a follow-up phone call within 48-72 hours by a trained nurse or case manager to:
- Assess the patient's current condition.
- Reinforce discharge instructions.
- Answer any questions.
- Address any emerging issues or concerns.
- Verify medication adherence and understanding.
- Confirm follow-up appointments.
- Transitional Care Services (for high-risk patients): Explore and implement more intensive transitional care services for high-risk patients, such as:
- Home Visits: For patients with complex needs or limited support.
- Telehealth Monitoring: For remote monitoring of vital signs and symptoms.
- Early Follow-Up Appointments: Scheduling appointments with primary care physicians or specialists within a few days of discharge.
- Improved Communication with Outpatient Providers: Develop a streamlined process for sharing relevant discharge information with the patient's primary care physician and any specialists involved in their care.
- Addressing Social Determinants of Health:
- Screening for Social Needs: Implement a standardized screening process to identify patients with social needs that may impact their recovery and risk of readmission (e.g., food insecurity, housing instability, lack of transportation).
- Referral to Community Resources: Establish partnerships with local community organizations to provide support and resources to address identified social needs.