Generally we think of hospital readmissions as being in one of two categories – planned and unplanned. Some patients need rehabilitation in the SNF between procedures, for example. This would be a planned readmission to the hospital. Unplanned readmissions are readmissions that we do not expect. They can further be subdivided into avoidable or unavoidable readmissions.
We all know what happens when we get the call at night and a patient has had a change in condition, perhaps with shortness of breath, perhaps due to an exacerbation of congestive heart failure, for example. While at the time of the call, it may not have been appropriate to care for the patient further at the LivingCenter, it is possible that this condition was gradually worsening and could have been headed off by an intervention such as a medication adjustment, a treatment adjustment, or closer monitoring earlier in the week. Post-admission studies have varied in their estimates, but one expert review of 200 Nursing Home resident readmissions to the hospital classified 68% of readmissions to be either definitely or probably avoidable.  When analyzing readmissions judged by skilled nursing center staff to have been unavoidable, third party investigators frequently conclude that early intervention could have made a significant difference in a large proportion of hospital transfers.
At Golden Living, we understand that there are plenty of instances where hospital readmissions are the right thing to do at the time, and where the circumstances leading to this readmission were neither predictable nor preventable. It is consistent with our mission and values to always do the right thing by the patient. We do need, however, to do what we can to prevent unplanned, avoidable hospital readmissions when it can be done by improving our patient monitoring, care, and communications.
It is known that readmissions can result in undesirable outcomes for the patient. Switching venues of care has inherent safety risks, and our frail elderly patients in particular are more at risk for hospital-acquired infections, pressure sores, medication errors and delirium when transferred back to the hospital. Even something seemingly as straightforward as an emergency department visit for evaluation can result in an elderly patient laying in a gurney for several hours without appropriate medications or meals while awaiting test results.
Golden Living has been tracking hospital readmissions for years, and as an organization has had a steady decline in readmission rates. Nevertheless, rates significantly vary between facilities, and only recently has CMS decided on a risk-adjusted measure.
Does anything need to be done in your LivingCenter?
Talk to your Executive Director and DNS. Typically this is a good conversation to have in your Quality Assessment and Performance Improvement (QAPI) meeting. Find out what your rates are relative to the company 30-day average, how it’s trended historically, and how this fits in with your LivingCenter clinical priorities. If you and your ED and DNS agree that avoidable readmissions should be specifically targeted, then you should engage your QAPI system by beginning a Performance Improvement Plan (PIP).
Why use QAPI methods?
One of my former mentors used to say about nursing homes that they reminded him of the first line of Anna Karenina.
“All happy families are alike; each unhappy family is unhappy in its own way.”
While LivingCenters with low readmission rates typically have good practitioners, processes and communication with the hospital. LivingCenters with high rates of readmissions, can have disparate individual problems which render patients vulnerable to avoidable readmissions and they vary from facility to facility. One might have a real problem with medication management and reconciliation, whereas another may have an issue with physician responsiveness when called on the phone. Another facility may not have any communication when sending a patient to the emergency department for evaluation, where the ED attending may be unaware of a LivingCenter’s ability to provide IV fluids or medications. Another might not be following through with appropriate discharge education practices.
Deciding on an intervention without taking the time to analyze weaknesses in the process (root cause analysis, or RCA) is akin to ordering a medication for shortness of breath without diagnosing the cause. It’s very tempting, when in a hurry to fix a problem, to throw an intervention at it right away. However, the intervention may not address a true weakness in the system, or may address an area which can be improved, but may not affect the majority of patients. For example, a LivingCenter may try to develop a program to begin in-house dialysis. While this may decrease the number of LivingCenter patients readmitted directly to hospitals directly from local dialysis centers, if kidney failure patients do not represent a significant proportion of one’s readmitted patients, it may involve a costly and labor intensive implementation plan that misses the mark and fails to affect the target.
What is a PIP?
A Performance Improvement Plan is an approach to improving a process, and is a way to harness proven techniques. One easy mnemonic to help with making a PIP is “ADLI”. ADLI stands for
Approach – how are you going to approach this problem? What is going on in the system that is possibly causing the results that you’re getting (in this case, readmissions)? What is the root cause of the identified issue and what is the specific goal that you want to achieve?(i.e. The LivingCenter will decrease the average readmission %to at or below the state average of XX% within 4 months.)
Deployment– Now that you’ve Identified the root cause and diagnoses of the problem, what are you going to do to improve the system? What actions will you take based on the identified causal factors?
Learning – What have you learned from your intervention? Evaluate data to determine if you are progressing toward achieving your identified goal. If you are not making progress, revisit root cause and update your actions. If you are making progress, you may choose to continue with current actions until you achieve the desired outcome. Do you need to take additional actions to sustain the achieved results?
Integration – is your system adjustment integrated into your LivingCenter’s strategic objectives that drive the business?
The ADLI can be cycled, as one evaluates how the Quality improvement actions are going.
Root Cause Analysis
One major area where your help will be needed is in the Approach. Here, you will need to help the team figure out why avoidable readmissions are happening. One way to do this is to “drill down” with Root Cause Analysis (RCA). For example, when talking about readmissions for fever, if one just stops at “well, we have to send many patients out because of fever.” Then one may not get very far. Perhaps the next question is “well why they are getting fevers? Do we have an infection control problem? What sorts of infections are occurring?” Maybe you find out that you have a significant number of respiratory infections. If you keep asking “why?” (Five times or more: 5 Whys) then you may uncover some important issues, such as issues with how your COPD patients are cared for, or that the LivingCenter has to improve compliance with isolation techniques, and so forth.
Round up the usual suspects
We know from several studies that hospital readmissions are typically the result of a complex interaction of factors, some more modifiable than others. When you do a root cause analysis with regard to readmissions, be sure to look into some of these common contributors:
Poor medication management – This could include poor reconciliation upon admission from the hospital, continuation of medications which should have had a stop date, and presence of drugs which are inappropriate for the elderly.
Missing “red flags” – Early indicators one should watch with patients with particular diagnoses. Often, improved communication with the hospital can improve knowledge of this. In ‘Thursday Huddles’ at Golden Living, patients who are at high risk for readmission are identified going into the weekend, and what may change about their condition.
Delayed initial visits or infrequent follow ups – patients are discharged sicker and with more comorbidities than ever before. If you have practitioners on your staff who still see everyone once every 30 days, or who take several days before doing the initial H&P, then it’s quite easy for a change in condition or complication to get worse before being detected and addressed.
Problems with laboratory tests – not checking following appropriate laboratory tests can result in easily preventable changes which may ultimately result in admission to the hospital.
Poor communication during change in condition – While Golden Living has systems such as STOP AND WATCH for CNAs and SBAR for nurses to help staff report changes in condition. A poorly communicated narrative in the middle of the night is often a guarantee that the attending physician at the end of the phone will send the patient to the Emergency Department for an evaluation without considering what could be done in the LivingCenter.
Lack of Patient Engagement – patients who are engaged are much more likely to have a timely follow-up with their PCP or specialist, less likely to have medication errors upon discharge or to miss signs or symptoms that should warrant contact with their doctor.
Golden Living and AMDA have resources to help you learn more about the QAPI process. Feel free to reach out to your GLC facility leaders for guidance, as well as your Regional Medical Directors or me. Stacey Hord, our VP of Quality, and she is an expert in QAPI who can help you and your facility leadership develop effective Performance Improvement Plans.
In our efforts to improve care in the LivingCenters, we have stressed the importance of integrating the Medical Director into the leadership team. Nowhere is your input and assistance more vital than in our efforts to decrease avoidable hospital readmissions and the negative impact that can have on patients and their families.
 Ouslander, JG et al, Potentially Avoidable Hospitalizations of Nursing Home
Residents: Frequency, Causes, and Costs, Journal of the American Geriatrics Society 2010:58:627-635