MARCH 2013
Reform in Action:
How the U.S. Health Care System Can
Reduce Avoidable Readmissions
Insights from the Robert Wood Johnson Foundation and Aligning Forces for Quality
Patients discharged from U.S. hospitals return far too often. Almost one in five elderly patients
In 2010, the Robert Wood
Johnson Foundation (RWJF)
released from a hospital is back within 30 days, and more than one in three are back within 90
launched the Hospital
Quality Network, a learning
days.1 Although some readmissions are part of a patient’s treatment plan, many are avoidable.
network of 120 hospitals
They are the result of a fragmented system of care that too often leaves discharged patients
to develop and exchange
quality improvement tools,
confused about how to care for themselves at home, unable to follow instructions they didn’t
strategies, and lessons
understand, not taking medications properly or getting the necessary follow-up care, and
learned on three core focus
ultimately leading them to return to the hospital. These unnecessary readmissions negatively
areas: improving language
affect patients’ health, place a burden on their families and caregivers, and cost our country
services, increasing
throughput, and reducing
billions of dollars.
avoidable readmissions.
The initiative was part of
Facing the Readmissions Crisis in America
effort to lift the overall quality
of health care in 16 targeted
Te issue of preventable readmissions has recently come to the forefront in our health care system
communities. Lessons
due to the Medicare penalties imposed on hospitals with excessive rehospitalizations. Under the
from AF4Q and its Hospital
Quality Network demonstrate
Affordable Care Act, more than 2,000 hospitals faced penalties in October 2012 because of high
how health care providers
readmission rates for heart attack, heart failure and pneumonia, and these penalties will become more
can work together and
severe over time.2
with patients to help them
transition out of the hospital.
RWJF has supported a wide range of programs to improve care transitions and reduce avoidable
readmissions. Most recently, hospitals participating in the AF4Q Hospital Quality Network
developed and implemented replicable quality improvement strategies for reducing avoidable
readmissions for heart failure patients, resulting in approximately 500 avoided readmissions over an
18-month period.
RWJF’S PERSPECTIVE
Tis brief highlights how the local alliances that lead the AF4Q effort in each community and
hospitals participating in the Hospital Quality Network are trying new approaches to help patients
MD, MPH, senior vice
get the care they need without returning to the hospital. Tey are starting conversations in their local
president and director of
communities, targeting patients at high risk for being readmitted, spurring changes within hospitals
the Health Care Group at
the Robert Wood Johnson
to streamline processes, and improving coordination between hospitals and outpatient care facilities
Foundation, on steps
to help patients receive continuous care.
patients and caregivers can
take to improve transitions
from hospital to home.
Additional Resources from RWJF:
1
Convening the Health Care Community on Reducing Readmissions
Reducing avoidable readmissions is not the sole province of hospitals—patients, caregivers, doctors,
nurses and other stakeholders play an important role in addressing this problem. AF4Q alliances are
working to engage those who give care, receive care, and pay for care in their communities to help
patients transition from hospital to home.
Te AF4Q alliance in Cleveland, Better Health Greater Cleveland, has convened a quality improvement
network of 11 local and regional hospitals that has identified reducing avoidable readmissions for heart
failure patients as a primary goal. As part of the collaborative, nurses, hospital quality improvement
staff members and heart failure clinic staff members from different provider groups in the increasingly
competitive health care marketplace found common ground to discuss strategies, challenges and
successes to address the larger problem of reducing avoidable readmissions. Trough its participation in
the Hospital Quality Network, Better Health Greater Cleveland has offered new resources, strategies,
performance metrics and definitions for benchmarking to participating providers.
Te Cleveland alliance also measures potentially avoidable hospitalizations to better inform the
community about the need for change. Te alliance’s 2013 public report analyzed hospitalizations
in Cuyahoga County, Ohio, finding that 2,854 fewer patients were hospitalized for cardiovascular
conditions from 2009 through 2011, saving $20.1 million.3 For the cardiovascular conditions that
Better Health Greater Cleveland’s initiatives target, the report found that hospitalizations decreased
10.7 percent in 2011, after declining steadily in 2009 and 2010.4
report showing that timely and appropriate care could have prevented 12,722 hospitalizations in Shelby
County, Tenn., saving approximately $87 million.5 Te report examined disparities in preventable
hospitalizations based on race, sex, access to primary care, and whether a patient had a chronic illness.6
Tough reports on reducing potentially avoidable hospitalizations do not focus solely on patients
returning to the hospital, they help providers identify ways to support patients managing chronic
conditions and ensure patients get the care they need outside the hospital—whether they have been
hospitalized yet or not.
LEARNING BY EXAMPLE
how Healthy Memphis
awareness about this issue in the community by hosting a conference where nearly 100 local health
Common Table is
care stakeholders shared lessons on reducing avoidable readmissions. Quality Corp assessed the local
working to prevent
potentially avoidable
landscape by cataloguing local initiatives that are working to reduce avoidable readmissions. Based on
hospitalizations.
this work, the state of Oregon is relying on Quality Corp to identify pilot projects and new strategies
that it will test to develop best practice guidelines.
Additional Resources from RWJF:
2
Identifying and Working With At-Risk Populations
Since reducing preventable readmissions is a formidable task, many organizations and hospitals begin to
tackle the problem by identifying patients who are most likely to return.
As part of its work with the Hospital Quality Network, the staff at Redington-Fairview General
Hospital in Skowhegan, Maine, examined trends across its heart failure patients to determine how
to recognize those at higher risk for readmission. Te hospital chose to incorporate the hospital
“LACE” assessment, which calculates a risk score based on length of stay, acute admission through
the emergency department, comorbidities, and emergency department visits in the last six months.
For 18 months, Redington-Fairview tested the system by assigning LACE scores to each patient upon
admission. If a patient had a high score, care transition nurses closely monitored the patient and
provided more comprehensive education. During the 18-month trial, 30-day readmission rates for
heart failure patients decreased from 6.9 percent to zero percent.
Health System-Humboldt County to identify and target patients who are frequently hospitalized and
provide them with intensive social services. Te alliance estimates that these hard-to-reach patients fill
10-30 percent of hospital beds at St. Joseph, and that physicians often keep them hospitalized longer
because socioeconomic challenges prevent them from continuing to get healthier after leaving the
hospital. To address this, St. Joseph implemented the “Intensive Transitional Services Program,” which
tasks a nurse team and social worker with developing customized plans to help patients overcome
barriers for getting care and complying with treatment plans. Te team works with community
resources to meet patients’ basic needs, such as food, housing and transportation, so patients can better
follow their treatment plans and get continuous outpatient care. By providing tailored, one-on-one
support, the Intensive Transitional Services Program helps patients, many of whom are homeless, get
and maintain jobs and long-term living arrangements. St. Joseph has seen a decrease in readmissions
and length of stay, as well as significant cost savings.
Six AF4Q alliances are also leading initiatives to provide support services to patients who receive
repeated care in emergency departments and hospitals, known as “super-utilizers.” Tese patients
often have multiple chronic medical problems and social complexities that prevent them from
managing their health, leading them to frequently receive care at the hospital, which is an expensive
and inefficient way to treat these patients. As part of the program, the alliances review hospital
records to identify super-utilizers in their communities, work with care teams to coordinate social
and medical services that patients need to stay healthy outside the hospital, and provide coaching
and support for primary care practices to help them provide targeted care and case management for
super-utilizer patients. Te program aims to reduce unnecessary hospitalizations by engaging care
teams and primary care practices to work closely with patients to recognize and address barriers
for maintaining their health, and coach them on better ways to manage their conditions with their
doctors and caregivers.
Additional Resources from RWJF:
3
LEARNING BY EXAMPLE
Refining Processes in Hospitals for Smoother Transitions
how the P2 Collaborative
AF4Q alliances are working alongside local hospitals to identify processes that can be improved to
of Western New York
help patients transition home. Aligning Forces Humboldt has supported St. Joseph Health System-
is implementing a care
transitions program to
Humboldt County in changing its discharge processes to ensure patients identified as high risk for
give patients one-on-one
readmission get needed follow-up care with primary care physicians and specialists. St. Joseph’s Care
support after leaving the
Transitions Program engages nurses to serve as transition coaches, assisting patients with medication
hospital.
self-management, educating them on their conditions and the importance of keeping a personal health
record, and linking them with primary care providers. Te transition coaches work with patients
several times before they leave the hospital. Since patients in the program are not receiving follow-up
care through home health, hospice, or a nursing home, transition coaches follow up by calling patients
within 24 hours of discharge and making a home visit shortly thereafter. Since 2009, St. Joseph’s has
cut its readmission rate by 20 percent.
Additional hospitals that participated in the Hospital Quality Network employed similar quality
improvement strategies to improve care transitions. Marymount Hospital in the Cleveland Clinic
network in Garfield, Ohio, implemented “Heart Failure Care Advocates” to help patients manage
their conditions after leaving the hospital. Care advocates acted as intermediaries between patients,
physicians, hospital staff, and caregivers to ensure that patients received recommended care while in the
hospital and were given comprehensive discharge plans, including medication and dietary instructions.
Care advocates also confirmed that a family member or caregiver would assist the patient at home
and made follow-up calls to check on patients soon after discharge. During the program, Marymount
reduced its 30-day all-cause readmission rate by 13 percent and maintained 100 percent compliance
with core measures for heart failure care.
Samaritan Albany General Hospital in Albany, N.Y., focused on reducing preventable readmissions
for heart failure patients by implementing a comprehensive patient education program. Te hospital
standardized its congestive heart failure education materials, distributed “Heart Failure Care Kits” to
patients soon after being admitted, and implemented the teach-back method, which asks patients to
repeat instructions in their own words. Samaritan Albany General also began making follow-up calls
after discharge, and engaged different providers, such as pharmacists and nutritionists, to meet with
patients and answer questions during their initial hospital stay. Trough the program, the hospital
reduced heart failure readmissions from 23.6 percent to 11 percent.
Oregon Health & Science University (OHSU) in Portland, Ore., also worked to help patients
understand their discharge plans better. After learning that patients were overwhelmed with
paperwork after leaving the hospital, OHSU staff members engaged a health literacy expert to
simplify and minimize discharge instructions to make them patient-friendly. Discharge instructions
were consolidated from an eight-page document written at a 12th-grade reading level to a more
easily understood one-page document written at a 6th-grade reading level. Te hospital also
asked nurse practitioners to use the teach-back method during discharge, and offered a disease-
specific education booklet to heart failure patients. Over the 18-month program, OHSU reduced
readmissions for heart failure patients by 11 percent.
Additional Resources from RWJF:
4
LEARNING BY EXAMPLE
Improving How Health Care Providers Work Together
how St. Joseph’s Health
Changes driven solely by the hospital are not silver bullets for preventing avoidable hospitalizations—
System in Humboldt
doctors, nurses and staff across all settings of care must work together for lasting change. For instance,
County, Calif., improved
care transitions for
Central Maine Medical Center (CMMC) in Lewiston, Maine, a participant in the Hospital Quality
patients.
Network, began working with Androscoggin Home Care & Hospice to provide needed, individualized
follow-up care. Nurses made home visits to every heart failure patient discharged from CMMC within
a week of leaving the hospital. After implementing this tactic, the hospital’s 30-day all-cause heart
failure readmission rate dropped from 22.8 percent to 17 percent.
Regions Hospital in St. Paul, Minn., also worked with care providers to ensure patients get necessary
follow-up care as part of its work in the Hospital Quality Network. After examining its discharge
practices, the hospital found that not only were heart attack patients responsible for scheduling their
own cardiac rehabilitation appointments, but also that the hospital did not have a consistent system
in place to recommend and track these follow-up appointments. Regions Hospital worked with its IT
staff to include a recommendation for cardiac rehab in discharge orders for heart attack patients. Te
hospital used posters to engage nurses to notify the rehab staff of a discharge order recommending
cardiac rehab so they can then visit the patient’s bedside to schedule their first appointment. After
making these changes, referral rates to cardiac rehab at Regions Hospital rose to 60 percent higher than
the national average.
Del Sol Medical Center in El Paso, Texas, also faced the issue of heart failure patients not receiving
recommended care and returning to the hospital too often. Since heart failure was a common diagnosis
in the mostly Latino community, the hospital established a heart failure center to bridge inpatient
LEARNING BY EXAMPLE
Androscoggin Home
identified and visited heart failure patients in the hospital to educate them about tracking symptoms,
Care & Hospice in Maine
maintaining a healthy diet, monitoring weight and blood pressure, and taking medications consistently.
worked with patients to
Tey provided diagnosis information in the patient’s preferred language, referred patients to the heart
help them transition out
of the hospital.
failure center, and made follow-up calls after discharge to schedule a visit. At the heart failure center,
patients and caregivers could attend nutrition and health education classes and receive helpful tools,
such as a heart healthy cookbook, a scale, and bilingual calendars and diaries for monitoring blood
pressure, weight, and symptoms. After establishing the clinic, Del Sol’s 30-day readmissions for heart
failure decreased from 16 percent to 7 percent over two years.
Additional Resources from AF4Q:
Te initiatives in this brief prove that no one agent—not a health care organization or hospital—can
reduce avoidable readmissions on its own. Hospitals, primary care providers, local organizations,
patients and caregivers must all work together to coordinate care across entire communities to help
patients leave the hospital better informed and in a better position to get continuous care outside of the
hospital, so they do not need to return.
5
The Robert Wood Johnson Foundation focuses on the pressing health and health care
issues facing our country. As the nation’s largest philanthropy devoted exclusively to health and
health care, the Foundation works with a diverse group of organizations and individuals to identify
solutions and achieve comprehensive, measurable, and timely change. For 40 years the Foundation
has brought experience, commitment, and a rigorous, balanced approach to the problems that affect
the health and health care of those it serves. When it comes to helping Americans lead healthier lives
and get the care they need, the Foundation expects to make a difference in your lifetime. For more
1
Jencks SF, Williams MV and Coleman EA.
“Rehospitalizations Among Patients in the Medicare
Fee-for-Service Program.” New England Journal of
Medicine, 360(14): 1418-1428, 2009.
2
Burton R. “Health Policy Brief: Care Transitions,”
3
Better Care, Better Health, Lower Cost: It Takes
a Community. Cleveland: Better Health Greater
4
Ibid.
5
Status Report on Efforts to Understand
and Create Awareness of Potentially Avoidable
Hospitalizations in Memphis and Shelby County,
Tennessee. Memphis, Tenn.: Healthy Memphis
6
Ibid.
6
