Applying Project BOOST
Sherman Health System in Elgin, Ill., also takes a multipronged, multidisciplinary approach. The hospital is one of the mentored-implementation sites for Project BOOST, a Society of Hospital Medicine initiative to improve the hospital-to-home transition while reducing readmission rates and length of stay.
At Sherman Health, nurses employ "teach back" techniques, in which they teach patients about their discharge instructions and ask them open-ended questions to make sure the patients understand.
"Patients will tell us anything to get out the door," said Kelly Tarpey, R.N., director of clinical excellence at Sherman Health. "What teach back does is make sure that the key points really are validated and understood."
After using the teach-back approach on one unit, Sherman Health saw its H-CAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores increase for patient perception of the quality of the discharge instruction, from 84% in 2011 to 92% in 2012, according to the hospital.
Through BOOST, they have also taken a more aggressive approach to postdischarge follow-up. Although the hospital staff has always called patients 24-48 hours after discharge, they are now focusing the calls on clinical concerns. Nurses have the patients’ charts in hand when they call and ask about medications and follow-up appointments. And the nurses continue to use the teach back method they employed in the hospital.
So far, the BOOST work and other care-coordination efforts seem to be paying off. In the first half of 2009, Sherman Health’s 30-day readmission rates for heart failure were 26%. But by the second half of 2011, that figure had fallen to 11%, according to the hospital.
But the improvements came too late to shield the health system from Medicare penalties that are based on performance data. Sherman Health will face a 0.61% cut to its Medicare payments starting in October.
Paying Attention to the Stick
Although hospitals are at various stages of readiness, experts say it is the penalty that has made readmissions a top priority for many hospitalist programs.
Dr. Luke Hansen of Northwestern University in Chicago and the lead analyst for Project BOOST said that there has been a steady increase in the attention that hospitals have paid to readmissions in just the last 3 years. Now when he first meets with the staff at a BOOST site, they are much more likely to have already undertaken some type of effort to reduce readmissions. They also frequently have funded positions such as a transitions nurse who can help identify patients at high risk for rehospitalization.
"Those are things that in the beginning were really uncommon," he said.
Many hospitalist programs are leading the readmission reduction efforts in their institutions, said Dr. Greg Maynard of the University of California, San Diego, and a coinvestigator for Project BOOST. Hospitalists are leading system redesigns by improving interdisciplinary rounds, setting up communication protocols, and reaching out to providers outside the hospital.
"For the first time in my memory, there’s a lot of work being done with the hospital and hospitalists’ groups working with outside groups of skilled nursing facilities, for example," Dr. Maynard said. "I am seeing an incredible amount of dynamism around better partnership, better communication, [and] better tools, and I think hospitalists are playing a big role in that."
In contrast, Dr. Maynard said that there are also hospitalist programs in which the business model allows time only for seeing patients, not for quality improvement.
"To them, it feels like something is being done to them," he said. "They may be feeling like they’re victims instead of leaders."