A study published July 18 in the Journal of the American College of Cardiology (JACC) found substantial variability in hospital practices to reduce readmissions of patients with heart failure (HF) or acute myocardial infarction (AMI), suggesting opportunities for further education around successful best practices, particularly in the areas of medication adherence and post-discharge management.
To date, there has been little movement in hospital readmission rates, with nearly one in four patients hospitalized with HF and one in five patients hospitalized with AMI being readmitted within 30 days of discharge. Meanwhile, more and more hospitals nationwide are striving to tackle the prevalent and expensive issue of readmissions, but evidence on proven strategies is limited.
To gain insight into “key hospital practices” for readmissions reduction, 537 hospitals participating in Hospital to Home (H2H), a quality improvement initiative developed by the ACC and the Institute of Healthcare Improvement, were surveyed. The analysis focused on “quality improvement resources and performance monitoring; medication management efforts; and discharge and follow-up processes.” Ten specific practices were evaluated across each of these three areas. Overall results of the study indicated that while most hospitals identify reducing readmissions as a key objective, efforts to meet this objective vary strikingly. In addition, efforts to help patients with medication management and discharge and follow-up processes – key elements identified by the H2H initiative as important to readmissions reductions – were particularly lacking.
Specifically the study found that almost all of the hospitals reported tracking the rate of 30-day readmissions. In addition, unplanned readmissions occurring within 30 days of discharge were reviewed in two-thirds of the hospitals surveyed. Close to 90 percent of hospitals also reported that they had a written objective focused on reducing readmissions for HF and AMI patients and “most hospitals reported having a reliable process to identify patients with heart failure at the time of readmission.” Quality improvement teams were highly prevalent in hospitals for reducing HF (87 percent), but were less common for the treatment of AMI (54 percent). Multidisciplinary care teams were used in a just over half of the hospitals to manage high risk patients and about two-thirds of the hospitals worked with home care or skilled nursing facilities.
In terms of medication management, the majority of hospitals reported that all patients or their caregivers received discharge instructions and names, dose, and frequency of discharge medications when they left the hospital, and the majority reported using ‘teach-back’ techniques for patient and family education. However, about 14 percent of hospitals sometimes failed to formally assign responsibility for medication reconciliation and only 3.2 percent always made contact with an outside pharmacy. Overall, medication management practices were only in place at five percent of hospitals surveyed, indicating that “medication reconciliation processes were nonstandardized at most hospitals.”
Discharge and follow-up practices also varied. The study found that while emergency plans were provided to heart failure patients or caregivers in nearly 60 percent of hospitals, providing an action plan in case of symptom changes, close to 30 percent of hospitals failed to regularly provide discharge summaries for viewing within seven days of discharge. Less than one-third (32.1 percent) of those surveyed reported keeping track of patients having follow-up appointments within seven days of discharge. According to the authors, “the limited use of some evidence-based practices found in the present study was consistent with recent qualitative data suggesting that hospital and professional cultures tend to focus on the inpatient part of the patient’s care and are less endorsing of responsibilities post-discharge.”
According to the study’s authors, “given the diversity of efforts to reduce readmission rates, establishing more definitive evidence about the effective hospital practices in this area is warranted.” However, they also note that “the findings highlight a number of opportunities for continued improvement in communication and care coordination, which may assist in hospital efforts to reduce readmission rates.”
The H2H initiative aims to improve the transition from inpatient to outpatient status for individuals hospitalized with heart disease. At its core, the program is community-based and success is achieved by packaging together proven readmissions reduction methods and partnering with quality improvement organizations. In an effort to reduce readmissions, H2H Community members are challenged to implement simple and targeted strategies for improvement by participating in the H2H Challenges: “See You in 7,” “Mind Your Meds” and “Signs and Symptoms.” To learn more, visit www.H2HQuality.org.