Population Health and Readmission Prevention

Isha Misra, M.D.
MCMS Public Health Committee Co-Chair

Hospital readmissions pose a significant challenge for the US healthcare system. Each year, about 3.8 million patients are readmitted within 30 days of discharge, generating over $50 billion in hospital costs. Research demonstrates that about 27% of readmissions are potentially preventable. Preventable readmissions are indicative of gaps in care coordination and access to care. They also strain hospital resources, leading to ineffective care delivery and adverse patient outcomes. The burden on the patients and families themselves is also significant, as a return to the hospital exacerbates care fragmentation, disrupts recovery and leads to emotional distress and caregiver burnout. From a capacity standpoint, the literature shows that readmitted patients utilize more hospital resources than other patients and have a longer length of stay. Maryland hospitals have also faced penalties for readmissions under the Total Cost of Care Model and this will continue with the state’s transition to the AHEAD model. As such, readmissions are a widely used metric for hospital performance.

I recently assumed the role of physician lead for population health and readmissions at Suburban Hospital. As physician lead, my role is to help plan and implement population health initiatives to reduce avoidable readmissions and hospital utilization, set specific annual targets, track data on the financial impact of readmissions penalties, and stay informed with regards to potential policy changes that affect readmissions and other pertinent quality improvement programs. I attend system meetings and collaborate with other Hopkins entities to align initiatives across the Hopkins system.  Additionally, I partner with community-based organizations and post-acute care providers to facilitate a smoother transition of care from the hospital to the ambulatory setting.

One of our most successful initiatives is our Transition Guide Nursing (TGN) program. The TGNs review all discharges from our medical surgical units and call patients after discharge. They call patients with Heart Failure, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Diabetes. These patient populations were selected as they are felt to be at higher risk for readmission, and we have recently changed the criteria to include home health patients. Additionally, one of the TGNs focuses on patients admitted to Suburban’s Behavioral Health unit. The TGNs educate patients on their diagnoses and review medication changes. They also connect patients with resources and confirm that they have follow-up appointments scheduled. Follow up calls are placed within 48-72 hours of discharge and the TGNs follow patients for a total of 30 days after discharge. For patients discharging with Home Health, the TGNs follow them until the Home Health agency assumes care and gives a handoff directly to the Home Health staff. The TGN program also has a Case Management Assistant who assists with financial applications, confirms start of care for patients discharging with home care, and follows our VIP patients, which is a program that was created to provide extra support for patients with Heart Failure who identify as Black or African American, Hispanic/Latino, or Asian.

We have also partnered with others in the Hopkins system to obtain access to a predictive algorithm within the electronic medical record (EPIC) to more accurately identify those patients that are at risk for readmission. Once this risk score goes live, patients will be categorized into low, medium, and high-risk tiers. Our plan is to have the TGNs call patients in both the moderate risk and high-risk categories, as a readmission may be harder to avoid for some of the patients in the highest risk category due to complexity and we believe that by including the moderate risk category, this initiative will be more impactful.

In addition to the Transition Guide program, we have planned initiatives that focus on patients with sepsis and those who are discharged to Skilled Nursing Facilities. Sepsis is consistently one of our top two readmission diagnoses (along with Heart Failure), which is the case for most hospital systems. Designing and implementing initiatives has historically been very challenging, as this is a broad and complex population. We are currently working with our nursing educators to expand education for sepsis patients, using evidence-based techniques such as teach back and an educational handout in a “stoplight format”, which uses color coded visual aids to create cognitive associations and has been shown to be especially beneficial for patients with low health literacy. We are also collaborating with Synergy Medical Group, which is a group of providers that can see patients daily at many of the Skilled Nursing Facilities in our catchment area, and assist with their transition home after rehab.

Readmission prevention requires a comprehensive strategy that improves care coordination, addresses social needs and is tailored to the specific needs of the community we serve. We continuously re-evaluate our programs and communicate with our community partners to ensure that our initiatives have the greatest possible impact. My hope is that through an ongoing commitment to population health, we can reduce the burden of hospitalization for patients and improve their health outcomes. I look forward to sharing more about Suburban’s population health team and our projects in future newsletters.