Barton Associates: Readmission reduction primer for locum tenens providers

The Hospital Readmission Reduction Program is set to take effect in October and will penalize hospitals that have a higher-than-average rate of 30-day readmissions for select conditions. The Centers for Medicare & Medicaid Services (CMS) will reduce the total Medicare payment made to under-performing hospitals by 1% in 2013. The reduction percentage will increase each year until eventually topping out at 3%. Hospitals across the country are beginning to implement readmission reduction strategies in order to avoid payment reductions and improve patient care. The following are a collection of popular readmission reduction strategies that locum tenens physicians and nurse practitioners (NP) may encounter on their assignments. Having a basic understanding of these readmission reduction strategies will prepare locums so they can have a successful assignment and help hospitals meet their readmission goals. Project BOOST Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a national initiative created by members of the Society of Hospital Medicine (SHM). The goal of project BOOST is to reduce 30-day readmission rates and length of stay. To accomplish that, the program promotes a patient-centered approach, encouraging patients to play an active role in developing their care plan. As of February 2012, the project BOOST toolkit had been downloaded by approximately 3,895 sites. The toolkit includes materials that help facilities implement industry best practices such providing comprehensive discharge records to outpatient providers using the teach-back process during discharge education. Physicians or NPs who are expected to provide patient education should be aware of the teach-back process. Using this method, patients are asked to demonstrate their understanding of the information that is provided. Instead of asking a yes-or-no question, such as “Do you understand how to check your blood sugar?”, the provider asks open-ended questions such as, “Please explain to me how you will check your blood sugar?” Because SHM is a hospitalist association it makes sense that hospitalists are at the core of the program; however, other care providers (e.g., nurses, social workers, case managers, residents) are part of the initiative’s care transition improvement team. Locum tenens physicians or NPs who take an assignment at a hospital that uses project BOOST must be prepared to collaborate with these team members. Project RED Project RED (Re-Engineering Discharges) is a research group at Boston University Medical Center dedicated to improving the hospital discharge process and reducing preventable readmissions. The program is based on 11 components:

Educate the patient about his or her diagnosis throughout the hospital stay
Make appointments for clinician follow-up and post-discharge testing
Discuss with the patient any tests or studies that have been completed in the hospital and discuss who will be responsible for following up on results
Organize post-discharge services
Confirm the medication plan
Reconcile the discharge plan with national guidelines and critical pathways
Review the appropriate steps for what to do if a problem arises
Expedite transmission of the discharge summary to the providers accepting responsibility for the patient’s care after discharge
Assess the patients’ degree of understanding by asking them to explain in their own words the details of the plan
Give the patient a written discharge plan at the time of discharge
Provide telephone reinforcement of the discharge plan and problem-solving two-three days after discharge

Project RED does not rely on hospitalist participation as much as project BOOST. A discharge educator (DE) is in charge of educating and advocating for the patient. However, physicians are expected to coordinate with the DE and provide information, such as potential barriers to discharge. Physicians who can help identify patients who would benefit from RED intervention and are open to communicate with the DE will guarantee success of the program. Transitional Care Model and Care Transitions Intervention The Transitional Care Model (TCM) is designed for older adults with certain risk factors, including history of recent hospitalizations, multiple chronic conditions or medications, and poor ratings of self-health. Patients that meet the criteria are assigned a transitional care nurse (TCN) who works with the patient and medical team to coordinate patient care. When hospital inpatients are enrolled in the TCM program, the TCN conducts an assessment and defines the patient’s needs and required services. The TCN then collaborates with the physicians and other care team members to create a care plan. The TCN continues to work with the patient after discharge and will accompany patients on follow-up appointments with primary care physicians or specialists. Similarly, the Care Transitions Intervention (CTI) is a four-week program for patients with complex care needs. A care transitions coach, typically an advanced practice nurse (APN), works with patients who are identified as requiring assistance meeting the goals of the four coaching pillars:

Medication self-management
Dynamic personal health record
Timely physician follow-up
Promotion of patient understanding of “Red Flags” and how to respond

Hospitals have successfully used the CTI model to improve transitions from acute care hospital to home and reduce unnecessary emergency department visits. Some facilities have also made intervention from the care transitions coach the standard of care for patients with select conditions (e.g., dementia, congestive heart failure, chronic obstructive (CHF), pulmonary disease (COPD)). Locum tenens physicians and NPs must be prepared to collaborate with these patient advocates when treating patients that require special assistance. Although physicians or NPs may not currently encounter these initiatives on their assignments, readmission reduction strategies will become more common as hospital payments continue to be affected by readmission rates.