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Bundled discharge interventions help reduce 30-day readmission rates

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This article was originally published in January 2011.

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At a time when one out of five hospitalized Medicare patients is readmitted within 30 days, a set of new discharge processes piloted at PeaceHealth St. Joseph Medical Center in Bellingham, WA may help break the readmission cycle.

St. Joseph, along with Qualis Health and a host of community partners, is part of the Stepping Stones Project which aims to improve care transitions and reduce hospital readmissions. One of the changes that Qualis Health worked with the hospital's cardiovascular unit to implement was a bundled set of interventions aimed at the unit’s discharge process:

  • Using new standardized discharge orders and patient instructions
  • Making appointments for follow-up visits with outpatient physicians prior to leaving the hospital
  • Making follow-up phone calls to patients post-discharge (see details, below)
  • Using "teach back" techniques for interactions with patients
  • Providing structured information about the patient’s/family’s responsibilties during the care transition

The bundle had a noticeable effect: the readmission rate for those receiving the discharge bundle was 6.8%, compared to 15.2% for those patients not receiving the bundle. Both rates were below the national 30-day readmission rate of 19.6%—demonstrating that even a hospital with lower-than-average readmission rates can improve by implementing the bundle.

Based on data from the hospital’s electronic medical record, 191 patients who received the discharge bundle from April 2010 through July 2010 were compared to a random sample of 203 patients who did not receive the bundle (discharged February 2008 through October 2010). A statistical analysis of a number of factors potentially associated with hospital readmission within 30 days was conducted using Mplus path analysis and included information for all 394 patients. The factors included age, length of stay, DRG complicating condition status, number of prior admissions, and whether the discharge bundle was received. The only significant predictor of readmission was having received the bundle.

One part of the bundle: Follow-up phone calls

In the spring of 2010, unit nurse manager Jennifer Moyes, RN, worked with her staff to integrate the post-discharge patient phone call intervention into the nursing work flow. The unit nurses contacted patients between two and seven days of discharge from the unit.

“It’s the little things that create huge problems.” said Moyes. “In talking to patients post-discharge, we are able to drill down to the right questions and identify patients’ understanding of discharge instructions and medication issues.”

Some of the problems identified by the nurses were patients not recognizing worsening symptoms, not knowing what to do about those symptoms, and not understanding their medications. In some instances, there were issues surrounding home safety. All of these issues can cause a patient to be readmitted.

As part of the post-discharge patient phone call, the unit nurses coached patients on contacting their outpatient doctors or pharmacist for questions or concerns, encouraged them to make a follow-up appointment with their regular doctor, helped with medication questions, clarified discharge instructions, and sometimes referred them to other resources.

“The phone call to the patient lets the unit nurse close the gap patients often feel when leaving the hospital and addresses their concerns before issues become a problem,” said Moyes.