After the Centers for Medicare & Medicaid Services made reducing readmissions a national priority through the Affordable Care Act, UT Health Northeast took major steps to curb rehospitalizations in its own community.

The teaching hospital, which discharges approximately 3,060 patients annually — about 49 percent are Medicare recipients — analyzed its discharge process to identify key drivers of readmissions and implemented best practices to target them.

In 2012, after initial gains, UT Health Northeast joined a readmissions collaborative through the former Essential Hospitals Engagement Network, a federally supported initiative by America’s Essential Hospitals to improve patient safety. The hospital’s work in the collaborative revitalized its readmissions efforts: As of February 2013, UT Health Northeast was on its way to meeting the federal Partnership for Patients’ goal of reducing 30-day all-cause readmissions by 20 percent by December 2013.

The team analyzed possible causes of readmissions and identified a handful of specific areas that needed attention and resources, including staff follow-up efforts and patient discharge instructions. To address these issues, UT Health Northeast:

  • formed a multidisciplinary team that included residents;
  • hired a discharge nurse to coordinate follow-up care;
  • implemented the teach back method;
  • used Exitcare software to distribute patient education materials; and
  • created a discharge readiness checklist.

The team also observed five “frequent fliers” across a 90-day period to identify other opportunities for improvement. After the team noticed that three of the patients they followed passed away within the 90-day observation period, they discovered that they could prevent approximately 50 percent of their readmissions through enhanced palliative care and/or social support, such as discharging patients to hospice instead of to home.

Since joining the EHEN, the team:

  • developed diagnosis-specific patient education curricula, which are based on a four-day length of stay;
  • performed tests of change using CORE and LACE readmission risk assessments, and adopted CORE; and
  • recruited a social worker to coordinate high-risk patients’ care.

Altogether, UT Health Northeast’s efforts cut readmissions to its facility by more than 20 percent from a baseline of 9.3 percent in August 2012 to roughly 6 percent in February 2013. The leader of the hospital’s readmissions team says the key to successfully restructuring the discharge process and, ultimately, preventing readmissions is to do a complete analysis of the current discharge process — map it out, see how it flows, and find where patients are getting lost. She also emphasized that each patient’s situation is unique, and suggests using a personalized approach to discharge.