Dear Colleagues,
As you may know, the State of Maryland is closely monitoring 30-day readmissions in all Maryland hospitals. As an avoidable utilization of health care resources, readmissions are wasteful; moreover, they cause dissatisfaction for patients who would be better served recovering in their homes and/or community setting.
At UM Shore Regional Health, hospital readmissions have become an important focal point for all of us. Under the umbrella “Readmission Matters” we have developed several initiatives – some new and some well in progress – to reduce the number of 30-day readmissions at UM Shore Medical Centers at Chestertown, Dorchester and Easton. As a member of our physician and advanced practice provider community, you play a role in this endeavor — your appreciation of our Readmission Matters initiatives (and in many cases, your direct participation) will be key to our success in helping patients maintain their best health outside the walls of our hospitals.
There are three broad arenas in which we can intervene to reduce readmissions: at discharge from the hospital, post-discharge (as patients heal in their home settings), and upon their return to the hospital for possible readmission.
AT DISCHARGE
Enabling our patients to successfully transition back home is the goal of every discharge. We have seen that among patients readmitted within the first week after discharge, the precipitating factors have been issues with medication and/or the discharge plan.
In the area of Medication Reconciliation, we are now engaging strategies to ensure that patients are discharged with the right medications and that they fully understand their new medication orders. Beyond that, we also are investigating possible barriers patients face in affording or accessing their medications, and whether or not we can work with local pharmacies ensure that certain high risk patients leave the hospital with their medications in hand.
We also have expanded the scope of our Discharge Planning process to include the holistic needs of our patients. Our caseworkers and transitional nurse navigators not only help patients understand what their care needs will be in their home environment, they also connect with the patient’s primary care provider to ensure proper follow-up, and provide links to needed community resources offering services such as transportation, home care, meals, home technologies and social support.
HEALING AT HOME
Comprehensive discharge planning leads to expanding our responsibilities to patients after discharge. Our Transitional Nurse Navigator (TNN) Program, inaugurated last fall, provides continued care coordination for high-risk patients from the beginning of their hospital stay through up to 30-days after discharge. There are two TNNs at Easton and one each at Chestertown and Dorchester, and they work not only with patients but also with family members and caregivers to provide education and support, resolve insurance issues, order needed medical equipment and supplies, provide referrals to specialists and much more.
Another key initiative is the expansion of our Palliative Care Program to provide patients with relief from the symptoms and stress of serious illness and improve the quality of life for them and for their families. Our Palliative Care team is training our hospital providers to identify patients for whom a palliative care consult is appropriate prior to discharge; later this month, our Outpatient Palliative Care Services will be launched, with providers seeing patients in the UM Community Medical Group – Primary Care office in UM Shore Medical Pavilion at Easton.
Working more directly with the community providers is another important strategy for reducing hospital readmissions. We are empowering primary care providers to take a more active role in their patient’s post-discharge care and working to improve two-way communication with hospital personnel. We also hope to develop a process for high-risk patients to obtain “Golden Tickets” for prompt appointments with certain specialists (e.g. cardiology, pulmonology) to avoid delays in their follow-up care.
AT THE PATIENT’S READMISSION VISIT
In line with our goal of providing “the right care, at the right place, at the right time,” we have two strategies in development for patients who present in our Emergency Departments for readmission. The first is the establishment of Observation Units in our hospitals – dedicated areas for patients who are placed under observation so that providers, nurse and ancillary service staff can focus on ensuring timely discharge. Our first Observation Unit is now in operation on the 2nd floor of UM Shore Medical Center at Easton; we are working on establishing similar units at Chestertown and Dorchester.
Also, because our hospitalists are usually the physicians most familiar with patients returning to the hospital, we have have created a process for Readmission Consults that empower them patients presenting in the Emergency Department to determine where the patient can receive appropriate care.
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We are confident that as these measures continue and coalesce, we will achieve our goal of reducing our 30-day readmissions rates in our three hospitals. I trust we can count on your engagement in these efforts, and if you have thoughts or observations on readmissions, I do hope you will share them with me.
In the meantime, my best wishes for an enjoyable summer season.
Sincerely,
