6. Identify Frequent Flyers
Customize your hospital's admission and re-admission rates for demographic and disease characteristics to identify those at highest risk, and expend extra resources on their care needs. This may involve special programs for homeless patients, such as the one effort by a cohort of Los Angeles hospitals who grappled with how to safely discharge homeless patients without violating city laws.
The Los Angeles project now discharges homeless patients who meet certain criteria to a half-way type of house in nearby Bell, and saved $3 million for hospitals in its first few months. Expansions in other parts of Southern California are underway.
7. Understand What's Happening After Discharge
Kaiser Permanente is using video cameras to chronicle home settings and the entire care process to determine what's happening to the patient after discharge that provoked a readmission.
The team is also using video of the care team, from the pharmacist, home care providers, nurses, and physicians about their care of that patient, to highlight wrinkles and cracks in the system that brought the patient back to the hospital.
So far, Kaiser officials say that the video project has contributed to a reduction in readmission rates at some hospitals where it has been tried, such as from 15.7% to 9% at Kaiser's South Bay Medical Center near Los Angeles, because it gave the team information to streamline care, says Kaiser's Neuwirth.
8. Provide Home Care on Wheels
Just like Meals-on-Wheels can be scheduled in advance, so can case management, housekeeping services, transportation to the pharmacy and physician's office. At Piedmont Hospital in Atlanta, in collaboration with the Area Agency on Aging, patients having elective knee surgery get coupons and prescheduling, "so that by the time you get out of the hospital, it's waiting there for you," Boutwell says. She adds that this kind of a pre-arrangement for post-transition care is "spreading like wildfire," among a number of hospitals, but so far it's mainly being tried with elective patients.
9. Consider Physician Medication Reconciliation
A recent paper in the New England Journal of Medicine by Yuting Zhang, of the University of Pittsburgh noted the wide geographic variation among physicians' prescribing practices with medications that should be avoided in patients over age 65. She also noted variation in prescribing practices for drugs that have a high risk for negative drug-disease interaction.
Jencks says that Zhang and colleagues "are pointing us to a rather important gap in the most common thinking about transitions—that we are to make sure that patients are able to get and take medications, get recommended follow-up, and generally do as they are told. But we know that medication plans can be in life-threatening error, that physicians often recommend a time-to-follow-up that is too long, that discharge plans are often written in ignorance of the patient's pre-admission history and experience. In general, we need to be much more critical of the plans patients get."