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Reducing Hospital Readmissions Toolkit
Reducing Hospital Readmissions Toolkit
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The Reducing Hospital Readmissions Toolkit is a comprehensive four-volume set that illustrates innovative strategies to reduce unnecessary hospital readmissions.

Like the convenience of receiving a PDF the same business day, but still want a hard copy of this book? Order both versions and save 35 percent!

Retooling Care Transitions to Reduce Hospitalizations in Medicare Patients

The federal government's mandate to reduce costly hospital readmissions of Medicare patients, pending legislation such as the Medicare Care Transitions Act of 2009 and adoption of the care coordination-focused medical home model are forcing a closer look at the transitioning of patients between care sites — hospital to home, hospital to skilled nursing facility (SNF), SNF to home, and from one hospital department to another — and the opportunities they present to close gaps in care, eliminate medical errors and reduce healthcare costs.

Retooling Care Transitions to Reduce Hospitalizations in Medicare Patients is an essential resource for healthcare organizations wishing to evaluate their care transition efforts against best practices in the industry. This 40-page resource delivers current trends in care transition programs as well as advice and guidance from industry thought leaders on key elements of care transition programs — from enhancements to the hospital discharge process to medication reconciliation ideas to better utilization of home visits during care transitions.

Poor communication, conflicting information and medication errors during transitions in care contribute to rehospitalizations for Medicare beneficiaries, which accounted for $17.4 billion of the $102.6 billion Medicare paid hospitals in 2004, according to one estimate. Additionally, in an AARP study, one in five Americans 50 and older with at least one chronic condition and one hospitalization in the last three years said their transitional care was not well- coordinated.

This exclusive 40-page report analyzes the responses of nearly 100 organizations to HIN's April 2009 Industry Survey on Managing Care Transitions Across Sites, presenting the data in dozens of easy-to-follow graphs and tables. This industry snapshot is enhanced by recommendations and advice from thought leaders in care coordination as well as detailed case studies of successful care transitions programs:

  • Geisinger Health Plan's embedded case managers manage every Medicare patient through transitions in care — from hospital to home or from hospital to nursing home — as part of its lauded patient-centered medical home PCMH pilot program.
  • McLeod Regional Medical Center's use of a Universal Medication Form clarifies communication of medication information among patients, providers and pharmacists during patient transfers and discharges at the 453-bed flagship hospital.
  • Commander's Premier Consulting Organization recommends case manager adherence guidelines and a host of health literacy tools that can help bring about the behavior change necessary to improve medication adherence and self-management among elderly patients.
  • St. Peter's Hospital CHOICES program collaborates with community organizations to reduce readmissions, reduce avoidable hospitalizations and divert unnecessary ER care for its older patients.

Whether your organization is just beginning to examine transitions in care or is already getting results from care transition planning, the key to success is access to reliable program and performance data.

Get answers to the most common questions surrounding care transitions ó from suggested training for the transition team to program challenges and benefits to measuring the success of care transition efforts.

Data highlights include:

  • Top three care transitions addressed by responding organizations;
  • Sector-specific analysis of care transition efforts by hospitals, nursing homes, long-term care facilities and more;
  • The number one component of a care transition program in use by more than four-fifths of respondents;
  • Ideas to improve hospital discharge planning;
  • Seven top tasks that take place during home visits, as well as the frequency, duration and impact of home visits;
  • Optimal training programs for staff members charged with transition programs;
  • The impact of care transition programs on healthcare costs, health utilization, avoidable hospital admissions, health outcomes and caregivers and other benchmarks;
and much more.

Discharge Planning Primer: Community Collaborations to Decrease Hospital Readmissions Risk

Coordinated planning of a patient's care following a hospital or nursing home stay can greatly affect health outcomes, likelihood of readmission and/or emergency room visits, as well as cost to patients, providers and insurers. A discharge management plan that integrates community resources and programs can further ease the transition from hospital to home and improve continuity of care.

Discharge Planning Primer: Community Collaborations to Decrease Hospital Readmissions Risk profiles two aptly named discharge management efforts that access and maximize partner resources for their populations. CHOICES is a hospital-based case management program for older adults in Albany, N.Y., while CASA (Community Alternative Systems Agency) in Broome County, N.Y. is a community-based initiative that collaborates with hospitals and nursing homes to help frail elders and young disabled adults. Both are client-centered models in discharge planning designed to meet the physical and psycho-social needs of their respective populations.

In this 32-page special report, "Discharge Planning Primer: Community Collaborations to Decrease Hospital Readmissions Risk," Nora Baratto, manager of the case management department at St. Peter's Hospital's CHOICES program, and Michelle M. Berry, CASA director, describe the coordinated approaches central to their hospital discharge processes and the impact their programs have had on patients' outcomes and satisfaction, hospital readmission rates and healthcare costs. The CHOICES program has been so well-received that St. Peterís Hospital now makes it available to its own employees as an elder care benefit.

And with readmission rates affecting quality and profitability, the healthcare industry is taking notice. In this special report, you'll also get a summary of more than 200 responses to a non-scientific e-survey conducted in 2007 by the Healthcare Intelligence Network on how healthcare organizations are working to reduce hospital readmissions.

Ms. Baratto and Ms. Berry share details on the comprehensive assessments, home visits, transition planning, and collaborative partnerships that are integral to their discharge management processes. They provide details on:

  • Overcoming barriers between the health system and community;
  • Successfully transitioning patients from one care setting to another;
  • Identifying patients at risk for readmission;
  • Forging collaborations with emergency room staff, inpatient staff, community physicians, and community agencies during discharge planning;
  • Educating clients, family and caregivers on care access and appropriate use of health resources;
  • Developing a home visit checklist for comprehensive assessments of patient condition;
  • Benefits gained and lessons learned in the discharge planning process;
  • and much more.
PLUS, this report contains:
  • Details on new practices in hospital discharge instructions and in-person, print and telephonic initiatives underway industry-wide to pare hospital readmission rates;
  • 14 pages of Q&A that offer practical strategies for coping with non-compliant patients, culturally diverse populations and breakdowns in the discharge process.

This report is based on a 2007 audio conference on best practices in hospital discharges to reduce preventable readmissions.

Table of Contents

  • St. Peterís CHOICES Program Breaks Down Barriers to Care
    • CHOICES Provides Collaborative Approach
    • Services Provided by CHOICES
    • Significant Referral Sources
    • CHOICES Program Outcomes
  • Broome County CASA: Discharge Planning via Community Collaboration
    • The Importance of Community Collaboration
    • Getting the Frail and Disabled Home
    • Lessons Learned in Discharge Planning
  • 2007 HIN Survey Results: How Health Plans and Hospitals Are Preventing Readmissions
  • Q&A: Ask the Experts
    • Case Managers as Educators
    • CHOICES Program Outcomes
    • Data Supports the CHOICES Program
    • Addressing Breakdowns in the Discharge Process
    • Education & Effective Questioning Reduces Readmissions
    • Walking Through a Home Visit
    • Physician Feedback on Program Extremely Positive
    • Home Visits by Practitioners
    • Handling Young Disabled Adults
    • Discontinuing Care for Non-Compliant Behavior
    • Measuring Outcomes & Utilizing Trend Data
    • Community Partnering Critical
    • Meeting the Needs of Immigrants & the Homeless
    • Translators for Cultural Issues
    • Helping the Homeless Access Medicaid
    • A Guest Book for the Homebound
    • Working with Managed Care
    • Reviewing Cases to Avoid Readmissions
  • Glossary
  • For More Information
  • About the Authors

Reducing Readmissions for Heart Failure Patients: A Multidisciplinary Approach for the Medicare Population

Approximately 5 million people in the United States have heart failure, with 550,000 new cases diagnosed annually. The condition is the number one cause for hospitalization among the elderly; one fifth of all hospitalizations have a primary or secondary diagnosis of heart failure.

In response, magnet hospital Hackensack University Medical Center (HUMC) has launched a dedicated inpatient heart failure unit that is dramatically reducing readmission rates in this population. This special report, "Reducing Readmissions for Heart Failure Patients: A Multidisciplinary Approach for the Medicare Population," chronicles the evolution and operation of the three-year-old unit and its foundation in continuous care and patient education and self-management.

In this 23-page report, the team's education coordinator and administrative manager — both cardiac nurses — describe how the team is overcoming barriers to effective heart failure management.

Contributing authors Michele Gilbert, education coordinator of the heart failure team, and Lenore Blank, administrative manager, share some of the workings of the team, including:

  • Addressing comorbidities, medication reconciliation, diet, psychosocial concerns and financial and physical limitations often faced by heart failure patients;
  • Applying continuous care strategies to improve the quality of emergency room, inpatient, outpatient and home care of heart failure patients;
  • Fostering patient education and self-management through improved discharge instructions, home visits, telephone follow-up and support groups;
  • Developing admission and exclusion criteria for the heart failure unit;
  • Educating and training multidisciplinary team members;
  • Building partnerships with other heart failure nurses and subacute facilities to improve care for heart failure patients;
and much more.

The HUMC dedicated heart failure unit received a grant from Pursuing Perfection: Raising the Bar for Health Care Performance, a $21 million initiative sponsored by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI), an internationally recognized leader in healthcare quality.

This report is based on a 2007 audio conference on pursuing perfect care for the chronically ill by focusing on the whole patient.

Table of Contents

  • Magnet Hospital Aims for Perfect Care of Heart Failure Patients
    • Barriers to Effective Heart Failure Management
    • Types of Heart Failure and Evolution of Treatments
    • Inpatient Care, Outpatient Management Affect Outcomes
  • Creating a Dedicated Heart Failure Inpatient Unit
    • Effective Home and Subacute Care Reduces Readmissions
    • Multidisciplinary Heart Failure Team
    • Meeting Core and Quality Measures
    • Medication Reconciliation
  • Q&A: Ask the Experts
    • How-toís of Home Visits
    • Opening a Heart Failure Clinic
    • Daily BNP Notifications
    • Sharing Knowledge with Other Facilities
    • Strategies to Engage Physicians
    • Empowering the Primary Care Nurse
    • The Effect of Quality on Recruiting and Patient Admissions
  • Glossary
  • For More Information
  • About the Authors

Reducing Readmission Risk for the Elderly through Care Transition Coaching

With the healthcare industry focused on reducing the high numbers of Medicare patients readmitted to the hospital within 30 days of discharge, landmark studies of transitions in older adults at high risk for readmission upon discharge are transforming care management approaches across the country.

Reducing Readmission Risk for the Elderly through Care Transition Coaching presents new models of care coordination for the elderly, including an Oxford Health Plan care transition coach program. This book also reports on Inspiris's care team approach to managing care transitions for the frail elderly — adults 65 and older who comprise 40 percent of elderly hospitalizations and who are particularly vulnerable during transitions from one care site to another.

This report examines four coaching-based approaches to coordinating care across healthcare settings from Oxford Health and the impact that these programs are having on healthcare utilization:

  • Transition coach program for Medicare beneficiaries that includes patient education and empowerment, health record creation, medication management, communication with physicians, and home visits and follow-up;
  • Advanced illness and coordinated care program for seriously ill patients who do not yet meet hospice criteria but require assistance with medical symptom management as it impacts end-of-life comfort care and proactive decisions about end-of-life healthcare services;
  • Health coaching and pharmacy outreach for Medicare members designed to break down barriers to medication adherence — drug and food interactions, functional issues and socioeconomic factors; and
  • Options for Living self-management classes for Medicare members living with diabetes, lung conditions and chronic pain.

Beyond Oxford Health's coaching-based approaches, this 30-page special report presents an analysis of vulnerabilities in care transitions for the frail elderly — a population whose numbers are expected to more than double by 2023 — from Inspiris, Inc. Since self-care, self-management or behavior modification is not an option for the majority of the frail elderly due to some degree of cognitive impairment, Inspiris proposes a care team-centered approach: identifying the at-risk population, developing the care plan and providing ongoing health maintenance and acute problem management.

In this special report, these respected thought leaders share their unique approaches to care transition management that positively impact cost and engage the patient and support team in their care decisions:

  • Danielle Butin, former director of Northeast Health Services for Secure Horizons, United Healthcare;
  • Gregg Lehman, Ph.D, president and CEO of Health Fitness Corp., who contributed to this report in his former position as president and chief executive officer of INSPIRIS.

Table of Contents

  • Integrating Health Coaching Into a Comprehensive Health Management Effort
    • Using Health Coaching to Better Manage Transitions and Improve Empowerment
    • Implementing Health Coaching Programs
    • Results of Health Coaching in Managed Care
    • Transition Coach Program
    • Advanced Illness and Coordinated Care Program (AICC)
    • Polypharmacy Transitions
    • Options for Living Self-Management Programs
    • Results of Living Self-Management Programs
  • Managing Transitions for Medicare Patients to Avoid Costly Inpatient Admissions
    • The Frail Elderly: Growing Need, Growing Problem
    • The Changing Role of Family Caregivers
    • Ten Most Common Reasons for Hospitalizations Among the Elderly
    • How and When Breakdowns Occur
    • Acute Problem Management
    • Physician Relationship Management
    • Utilization and Cost Outcomes
  • Q&A: Ask the Experts
    • Predicting Inpatient Acute Utilization
    • Managing Fractures on an Outpatient Basis
    • Criteria for Identifying Pre-Hospice Patients
    • Acute Problem Management
    • Geriatric Depression Scale and Mini Mental Status Exams
    • Funding & Reimbursement
    • Interventions for Self-Management Disease Programs
    • Health Coaching in Pharmacy Outreach Programs
    • Determining the Frequency of Maintenance Visits
    • Components of the Home Visit
    • Training Transition Coaches
    • Training Nurse Practitioners
  • Glossary
  • For More Information
  • About the Authors
Publication Date: October 2009
Number of Pages: 125
ISBN 10: 1-936186-87-X (Print version); 1-936186-88-8 (PDF version)
ISBN 13: 978-1-936186-87-7 (Print version); 978-1-936186-88-4 (PDF version)
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