Anatomy of a Readmissions Master Plan

Jim Molpus, for HealthLeaders Media , November 14, 2013

"Our case managers do their discharge planning documentation right in … our electronic health record so that all the team members have access," Metzger says. "There's a particular folder in which they document interventions, such as who's going to be handling the patient, what arrangements have been made, or who the providers are so that anybody who accesses that patient's records can know where we are in the planning process and who are going to be the providers of services. The [time spent on] handoffs seems to get minimized because of the accessibility of the electronic data."

The organization is working to extend the accessibility of that data. Memorial Hermann owns many key pieces of the care continuum, including TIRR Memorial Hermann, one of the nation's leading rehabilitation hospitals, and its own home health agency. But for its readmissions program to be successful, the system had to find a way to work with a variety of community partners, says Carl Josehart, CEO of TIRR Memorial Hermann and System Rehabilitation Services.

"We're willing to share our data with them," Josehart says. "It's really being open about not only what we think they can improve, but also asking them if there was anything we did in our care that made it harder for them to receive our patient. We realized there are agencies in the community [for which] we may not share ownership, but when we share our patients, we are really working together in partnership to close the gaps in care."

In addition to discharge planning, the case managers also make certain that discharge education is tailored for the patient's situation, both clinically and at home. Nurses and nurse educators provide the instruction to the patient, while the case managers follow progress to make sure the education happens when it should and involves the right people, Metzger says.

"They're communicating with the families about what the plan is," Metzger says. "The case managers work with patients and their families to decide whether they have the resources, skill, or desire to help manage the process once they leave the hospital. Is it the family member we have to teach? Is it the patient we have to teach? Do we need to look at a postacute provider as an interim step for this patient? So they're doing a lot of assessment about the readiness of the patient, the family, or significant others to assume responsibility posthospitalization for care, and then they'll involve the right people in that."

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