Abstract TP198: Reducing Stroke Readmissions

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jessica Douglas ◽  
Heather Ramsey ◽  
Kelly Venters ◽  
Amber Parker
Keyword(s):  
Primary Care ◽  
Hospital Care ◽  
Negative Impact ◽  
Hospital Readmissions ◽  
Phone Call ◽  
Healthcare Organizations ◽  
Post Discharge ◽  
Readmission Rates ◽  
Call Process

Background and Purpose: Hospital readmissions have become a priority focus for healthcare organizations. According to the Centers for Medicare and Medicaid, 20% of all patients who are discharged from a hospital will be readmitted within thirty days (CMS, 2015). This not only has a negative impact for the patient, but also imposes a financial impact on the healthcare organization. Baseline data from 2014 at Lake Cumberland Regional Hospital (LCRH) showed a stroke readmission rate of 9.6%. The purpose was to decrease stroke readmissions through development of a discharge call process that targets risk factors for readmission and ensures transition from hospital care to post-discharge follow-up. Methods: The discharge call process was implemented in June 2014. Calls were conducted by the facility’s stroke educator. All stroke program participants excluding discharges to nursing homes, rehabilitation center, or hospice were included in the discharge call process. Minimally, 3 attempts per patient were made to conduct the phone call within 3 days of discharge. In addition, the Lake Cumberland Area Stroke Support Group was established in May 2016 for stroke survivors and their caregivers. Results: Stroke readmission rates at LCRH decreased to 7.9% in 2015 and further declined to 1.6% as of 2nd quarter 2016. Interventions completed as a result of the discharge phone call process include: expediting follow-up appointments, collaborating with primary care practitioner for needed prescriptions, clarifying discharge instructions, reinforcing stroke education, and scheduling additional follow-up calls to provide assistance when needed. Conclusions: Stroke readmission rates decreased from 9.6% in 2014 to 1.6% through second quarter of 2016. Multiple opportunities were discovered to close the communication gap between hospital care and primary care follow-up. Maintaining contact post-discharge is needed to transition from the hospital to home care.

Abstract WP394: Needs of Stroke Survivors Post Hospital Discharge Stroke Follow-up Call

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Joseph Mojares ◽  
Sherydahn Aldrich ◽  
Maria Novales-Fiel
Keyword(s):  
Primary Care ◽  
Patient Satisfaction ◽  
Hospital Readmissions ◽  
Primary Care Providers ◽  
Phone Call ◽  
Care Providers ◽  
Stroke Patients ◽  
Post Discharge ◽  
Stroke Education

Background: This project attempts to discover the subjective response needs of 30-day post-acute stroke patients and their family members that were treated in two Northern California hospitals. The goal is to determine the functional level of the Stroke Survivor (SS) as measured by the Modified Rankin Scale (mRS) and to identify post-discharge needs. Purpose: The objective of this project is to identify the patient’s mRS score and post-discharge needs. The study includes stroke education reinforcement, primary care physician follow-up, ancillary services follow-up, discern hospital readmissions rates, and increase patient satisfaction. Methods: A list of discharged acute ischemic stroke patients over a three month period was provided to the Stroke Nurse Champion (SNC). A stroke phone call template was created to elicit the patient’s history, diagnosis, and mRS score. Patients with intracranial hemorrhage diagnosis, patients discharged to Skilled Nursing Facilities, and deceased patients were excluded from the study. The SNC performed chart review to determine patient course of hospitalization and stroke care management; places follow-up phone call to patient or family member; and identify the SS needs. When needs were discovered, they were addressed using electronic in-house messaging to patient’s primary care providers and ancillary staff. Results: Of the 63 participants, nine required stroke resource follow-up. The average mRS score of 1.84 revealed the patient’s knowledge of self-management to be 100%. There were 13 cases that needed outpatient therapy and Home Health therapy with mRS >2. The study outcome includes readmission rate of 0.03% (n=2) and stroke patient satisfaction >12.5%. Conclusions: Based on the mRS score, the SS appropriately met the level of care including rehabilitation needs at home. Post discharge needs of SS included psychosocial support, medication modification and appropriate durable medical equipment. Overall, the SS were satisfied with their care with low incidence of hospital readmission due to their stroke education provided during their hospitalization. Further plans for each hospital facility to consider continuing this project or to change the focus to outpatient support services as well.

Abstract TP288: Overcoming Obstacles Making People Healthy (OOMPH): A Patient Centered Post Discharge Follow-up Program for Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jonathan Muller ◽  
Barbara Gatton ◽  
Linda Fox ◽  
Joseph A Bove ◽  
Johanna Donovan Turner ◽  
...  
Keyword(s):  
Support Groups ◽  
Medical Information ◽  
Patient Adherence ◽  
Hospital Readmissions ◽  
Phone Call ◽  
Stroke Patients ◽  
Post Discharge ◽  
Phone Calls ◽  
Stroke Support Groups

Background and Purpose: At least 12% of stroke patients are readmitted to a hospital within 30 days of discharge. We know that patients hospitalized for other conditions are less likely to be readmitted within 30 days if they are seen by their PCP shortly after discharge. However, less than a third of patients in the New York metropolitan area admitted for heart failure, heart attacks, and pneumonia see their PCP within 14 days after discharge and nearly 40% of patients do not adhere to their prescribed regimen. In the case of cerebrovascular diseases, outpatient follow-up may prevent the majority of avoidable readmissions. The purpose of this project is to identify and reduce unnecessary, unplanned hospital readmissions after stroke. Our goal is to encourage patient adherence to prescribed medication and other therapies, as well as to ensure timely follow-up with their PCP. Methods: Stroke and transient ischemic attack (TIA) patients with a disposition of either home or short-term rehabilitation are visited and offered enrollment. Participants are given a kit which includes a personalized binder (to manage essential medical information) and a 28-slot pill box. Each patient then receives 3 phone call interviews at 7, 21 and 32 days after discharge. The aim of the phone calls is to identify obstacles to compliance with treatment regimen and follow-up care. Results: From January 2015 to June 2016, 247 patients were enrolled and followed up. Within 30 days of discharge, 10% were readmitted and 50% of all readmissions occurred within the first 7 days. Of those readmitted, 19% were due to an injury from physical therapy. Data from follow-up phone calls revealed that 83% were taking all prescribed medications, 89% had completed a follow-up with any physician, 69% were using the binder, and 61% had done all three. Conclusions: While we have not enrolled enough patients to see a statistically significant reduction in readmissions, our interviews showed that weather, depression, as well as a lack of insurance, family support, and a home health aide are all determinants on how patients will follow their prescribed regimen. The results of this study have allowed us to begin implementing stroke support groups and pre-discharge follow-up appointment scheduling.

scholarly journals Implementation and Evaluation of a Team-Based Approach to Hospital Discharge Transition of Care

PRiMER ◽  
2021 ◽  
Vol 5 ◽  
Author(s):  
Matthew Van De Graaf ◽  
Hemal Patel ◽  
Brynn Sheehan ◽  
Jennifer Ryal
Keyword(s):  
Hospital Discharge ◽  
Transitional Care ◽  
Data Extraction ◽  
Hospital Readmissions ◽  
Cost Of Care ◽  
Phone Call ◽  
Readmission Rates ◽  
The Cost ◽  
Discharge Transition

Background: Transitional care management (TCM) programs guide patients from hospital discharge to outpatient follow-up with the goal to decrease hospital readmissions and the cost of care. In 2017, the department of primary care internal medicine (PCIM) at Eastern Virginia Medical Group implemented TCM. We aimed to evaluate the efficacy and self-sustainability of this TCM program. Methods: The TCM team contacted patients upon discharge to schedule the follow-up appointment. We coded patient contact as (1) no successful phone-call contact, patient did not attend appointment; (2) successful phone-call contact, patient did not attend appointment; and (3) patient attended appointment. We collected patient demographics, readmissions, and visit costs using manual chart review and electronic health record (EHR) data extraction. We conducted χ2 analysis, one-way analysis of variance, and unpaired t tests to assess associations between readmission rates or costs and TCM care. Results: Initial analysis did not indicate significant associations between readmission rates and level of TCM care at 30 (χ2=1.40, P=.50), 60 (χ2=5.48, P=.06), or 90 (χ2=4.23, P=.12) days or significant differences in patient charges at 30 (F[2,59]=2.85, P=.06), 60 (F[2,91]=2.00, P=.14), or 90 (F[2,126]=1.39, P=.25) days. Follow-up analysis indicated significant associations between readmission rates and any level of TCM care at 60 (χ2=5.40, P=.02) and 90 (χ2=4.21, P=.04) days, but not at 30 days (χ2=1.39, P=.28). Conclusions: Our TCM program review suggests that the benefits of transitional care extend beyond 30 days by decreasing readmission rates at 60 and 90 days after hospital discharge.

scholarly journals Successful hospital readmission reduction initiatives: Top five strategies to consider implementing today

2018 ◽  
Vol 7 (5) ◽  
pp. 16 ◽  
Author(s):  
Bita A. Kash ◽  
Juha Baek ◽  
Ohbet Cheon ◽  
Nana E. Coleman ◽  
Stephen L. Jones
Keyword(s):  
Hospital Readmission ◽  
Discharge Planning ◽  
Hospital Readmissions ◽  
Post Discharge ◽  
Readmission Rates ◽  
Effective Interventions ◽  
Hospital Readmission Rates ◽  
Weighted Means ◽  
Pubmed Database

Only one quarter of U.S. hospitals demonstrated low enough levels of 30 day readmission rates to avoid penalties imposed by the Hospital Readmissions Reduction Program (HRRP) in 2016. Previous work describes interventions for reducing hospital readmission rates; however, without a comprehensive analysis of these interventions, healthcare leaders cannot prioritize strategies for implementation within their healthcare environment. This comparative study identifies the most effective interventions to reduce unplanned 30-day readmissions. The MEDLINE-PubMed database was used to conduct a systematic review of existing literature about interventions for 30-day readmission reduction published from 2006 through 2017. Data were extracted on hospital type, setting, disease type, intervention type, study sample, and impact level. Of 4,886 citations, 508 articles were reviewed in full-text, and 90 articles met the inclusion criteria. Based on the three analytic methodologies of means, weighted means, and pooled estimated impact level, the most effective interventions to reduce unplanned 30-day admissions were identified as collaboration with clinical teams and/or community providers, post-discharge home visits, telephone follow-up calls, patient/family education, and discharge planning. Commonly, all five interventions identify patient level engagement for success. The findings reveal the need for shared accountability towards desired outcomes among health systems, providers, and patients while providing hospital leaders with actionable strategies that can effectively reduce 30-day readmission rates.

scholarly journals A Study of Short Term Outcomes among Covid-19 Patients Discharged without Follow up In the New York Metropolitan Area

2021 ◽  
pp. 85-92
Author(s):  
Louise Molmenti Christine ◽  
Mitra Neil ◽  
Shah Abhinit ◽  
Flynn Anne ◽  
Brown Zenobia ◽  
...  
Keyword(s):  
New York ◽  
Functional Status ◽  
Metropolitan Area ◽  
Phone Call ◽  
Post Discharge ◽  
Readmission Rates ◽  
York Metropolitan Area ◽  
New York Metropolitan Area ◽  
The Impact

Background: A shortage of beds, high case volume, decreased availability of outpatient medical doctors, and limited disease knowledge resulted in the premature discharge and poor follow up of COVID-19 patients in the New York Metropolitan Area. Objective: The primary objective of this retrospective study and phone survey was to characterize the demographics and clinical outcomes (e.g., readmission rates, comorbidities, mortality, and functional status) of COVID-19 patients discharged without follow-up. The secondary objective was to assess the impact of race and comorbidities on readmission rates and the extent to which patients were escalated to another care provider. Methods: Electronic medical records were reviewed for COVID-19 patients discharged from 3 NYMA hospitals in March 2020. Follow up data regarding medical status, ability to perform activities of daily living and functional status was also obtained from patients via phone call. The Chi-square, Fishers exact test and t-tests were used to analyze the data. Results: 349 patients were included in the analysis. The hospital readmission rate was 10.6% (58.8% for pulmonary reasons) and did not differ by race. 74.3% of readmissions were <14 days after release. The post-discharge mortality rate was 2.6%. Hypertension was the most common comorbidity (43%). There was a statistically significant association between mortality and number of comorbidities (p=<0.0001). 82% of patients were contacted by phone. 66.6% of patients returned to pre-COVID baseline function in ≥1 month. As a result of information obtained on the follow up phone call, 4.2% of patients required “escalation” to another provider. Conclusion: Discharging COVID-19 patients without prearranged follow up was associated with high readmission and mortality rates. While the majority of patients recovered, prolonged weakness, lengthy recovery, and the need for additional medical intervention was noted. Further work to assess the effectiveness COVID-19 post-discharge programs is warranted.

scholarly journals Discharge Medication Counseling and its Correlation with Reducing Readmissions for Patients with Chronic Obstructive Pulmonary Disease Exacerbations

2015 ◽  
Vol 6 (3) ◽  
Author(s):  
Emily M. Laswell ◽  
Elizabeth A. Svelund ◽  
Melody L. Harzler ◽  
Kasandra D. Chambers ◽  
Aleda M.H. Chen
Keyword(s):  
Hospital Readmissions ◽  
Phone Call ◽  
Control Group ◽  
Chronic Obstructive ◽  
Original Research ◽  
Post Discharge ◽  
Readmission Rates ◽  
Discharge Medication ◽  
Medication Counseling ◽  
The Impact

Objective: To determine the impact of pharmacist-provided discharge medication counseling on 30 and 90 day hospital readmissions and ED visits in patients admitted with COPD exacerbation. Methods: A hospital-wide improvement was initiated, where COPD patients received discharge medication counseling and follow up phone call by a pharmacist. A pilot study was implemented, and data on readmission rates at 30- and 90-days were collected and compared to a hand-matched, retrospective control group that had not received discharge counseling by a pharmacist. Differences in readmission rates were analyzed using Chi-squared tests. Results: A total of 28 patients received discharge counseling by the pharmacist and were compared to 28 retrospective patients. Differences in 30-day and 90-day readmission rates were not significant (p=1.000 and p=0.589, respectively). After thirty days, 7 (25%) intervention and 7 (25%) retrospective group patients had been readmitted. After ninety days, 11 (39.3%) intervention and 13 (46.4%) non-intervention patients had been readmitted. Since a small cohort of patients received discharge counseling, the study did not meet power. Conclusions: Although not statistically significant, patients who received discharge medication counseling provided by a pharmacist had lower 90-day readmission rates post discharge. As regulations are implemented that penalize hospitals for readmissions that occur within 30 days of discharge, it is imperative that health care systems develop new strategies aimed at reducing readmission rates. Further studies that are adequately powered are needed to assess the impact pharmacists can have on readmission rates.   Type: Original Research

Abstract 360: A Simplified Post-Discharge Telephone Intervention To Reduce Hospital Readmission for Patients with Cardiovascular Disease.

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Gene F Kwan ◽  
Lana Kwong ◽  
Yun Hong ◽  
Abhishek Khemka ◽  
Gary Huang ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Statistical Significance ◽  
Hospital Readmissions ◽  
Intervention Group ◽  
Phone Call ◽  
Post Discharge ◽  
Coronary Syndrome ◽  
Phone Calls ◽  
Administrative Assistants

Background: Readmission rates are high for patients with cardiovascular disease, particularly heart failure (HF) and acute coronary syndrome (ACS). Telephone calls by clinical staff have had mixed effects. We aim to evaluate the degree of implementation and the effect of a quality improvement initiative using a simplified post-discharge phone call by administrative assistants. Methods: Clinical data were retrospectively reviewed at a single urban public hospital. From January through October 2012 all patient discharged home from inpatient cardiology services (intervention group, n=1034 discharges) were identified. Within 7 days, administrative assistants contacted patients via telephone and queried regarding (1) medication compliance, (2) awareness of follow-up appointments and (3) if clinician contact is requested. Outcome events were defined as readmissions (for any cause) within 30 days to the same hospital and are reported as patients experiencing readmission, and total readmissions. A comparison group of all patients discharged home from inpatient cardiology services from January through October 2010 (n=746) were selected as controls (no phone calls). Categorical data were compared in a univariate fashion using the Chi Square test. Statistical significance is defined as p<.05. Results: Of the 1034 discharge events in the intervention group, 620 (60.0%) had phone calls attempted. Of those, 419 (67.6%) were directly contacted. Patients were statistically different with respect to language, ethnicity and insurance status. Of the patients called, 48 (7.7%) reported medication abnormalities, 13 (2.1%) did not understand their follow-up and 38 (6.1%) had a question for a clinician. The rates of patients experiencing events was not statistically different (132 [17.7%] vs. 156 [15.1%], OR 0.85, p=.14). Total readmissions were significantly reduced (157[21.0%] vs. 179 [17.3%], OR 0.82, p=.047). Pre-specified subgroups of ACS and HF patients showed a trend towards decreased re-admissions but were not statistically significant. Conclusion: A simplified post-discharge telephone call strategy is associated with a trend towards reduced hospital readmissions for cardiology patients. Further refinements are needed to improve program implementation.

Abstract T P341: Transitions of Care: Increasing Follow-up and Decreasing Readmission Rates After Hospitalization for Acute Ischemic Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Joyce Maygers ◽  
Erin Lawrence ◽  
Cheryl Woolford ◽  
Rafael H Llinas ◽  
Elisabeth B Marsh
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Hospital Readmissions ◽  
Case Manager ◽  
Stroke Survivors ◽  
Post Discharge ◽  
Readmission Rates ◽  
Discharge Plan ◽  
Neurology Clinic

Background: Acute ischemic stroke accounts for nearly 800,000 inpatient hospitalizations annually in the United States. Post-discharge disposition varies greatly among stroke survivors. The transition to home or nursing facilities post-hospitalization provides an opportunity to improve quality of life; but also increases the potential for miscommunication between patients, care givers, and health care providers. This may result in the need for hospital readmission, which further complicates patient care. A timely post-discharge neurology clinic visit would be the ideal forum to address miscommunication and reduce readmission. Without dedicated infrastructure, it is difficult to see patients quickly, resulting in a poor follow-up rate. Our Stroke Center sought to improve transitions for stroke survivors with the addition of a neurology nurse case manager, creation of a targeted post-discharge plan, and implementation of the Bayview Stroke Intervention Clinic (BaSIC). Methods: Beginning in September 2013, all patients admitted with acute ischemic stroke were assessed by our case manager prior to discharge and a specific post-discharge plan was developed including a plan for follow-up within 4-6 weeks. This was achieved with the implementation of a weekly neurology clinic dedicated to post-stroke care, staffed by two cerebrovascular neurologists. To gauge the effectiveness of our intervention to improve follow-up rates and decrease hospital readmissions, we retrospectively compared stroke patients discharged in fiscal year 2013 (prior to implementation) to those discharged in 2014. Annual readmission rates as well as follow-up rates in neurology clinic at 30, 60 and 90 day post-discharge intervals were assessed. Results: With implementation of targeted post-discharge planning and BaSIC clinic, the 30 day follow-up rate (2.6% pre versus 8.4% post; p=0.01), 60 day follow-up rate (8.3% pre versus 16% post; p=0.01), and 90 day follow-up rate (14.4% pre versus 20.6% post; p=0.10) all improved. Hospital readmissions fell from 10.5% to 8.7% (p=0.63). Conclusion: Implementation of a targeted post-discharge plan and specialized stroke follow-up clinic decreases readmissions and increases follow-up visits with neurology.

scholarly journals Decreasing Readmissions in Medically Complex Children

2020 ◽  
Author(s):  
◽  
Colleen Bartlett
Keyword(s):  
Medication Reconciliation ◽  
Hospital Readmissions ◽  
Outcome Evaluation ◽  
Evidence Based ◽  
Post Discharge ◽  
Readmission Rates ◽  
Hospital System ◽  
Practice Problem ◽  
Telephone Calls

Practice Problem: There was a report of an existing practice problem of increased 30-day readmission rates in medically complex children at an outpatient clinic within an extensive hospital system. Hospital readmissions can cause clinical, social, and financial burdens to the patients and their families and thus reflected a need for interventions to reduce readmissions. PICOT: The PICOT question that guided this change project: In medically complex pediatric patients ages 0-17, what is the effect of a discharge intervention bundle in reducing all-cause 30-day hospital readmissions compared to current practice within an 8-week timeframe? Evidence: The literature revealed 18 pertinent studies that fit the inclusion and exclusion criteria that promoted a discharge intervention bundle. The themes within the evidence included post-discharge telephone calls, follow-up appointments, medication reconciliation, and education with teach-back to reduce overall readmission rates. Intervention: The evidence-based intervention utilized the bundle of post-discharge telephone calls within 72 hours, follow up appointments within 7 days, and medication reconciliation with education and teach-back through in-person and virtual care. The clinic nurses championed the intervention and tracked all the data using a check sheet. Outcome: Evaluation of the outcome measures confirmed a decrease in all-cause 30-day readmissions from 23% to 14.5% within the project timeframe. Implications of the findings support the existing evidence for implementing a multifaceted bundle to decrease readmissions. Conclusion: The evidence-based change project decreased all-cause 30-day readmissions rates. The results of the project proved that implementing consistent discharge standards in medically complex children helped guide medical staff, improved patient outcomes, saved costs to the organization, and reduced 30-day all-cause hospital readmissions.

scholarly journals Impact of pharmacist-conducted anticoagulation patient education and telephone follow-up on transitions of care: a randomized controlled trial

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Lamis R. Karaoui ◽  
Elsy Ramia ◽  
Hanine Mansour ◽  
Nisrine Haddad ◽  
Nibal Chamoun
Keyword(s):  
Tertiary Care ◽  
Intervention Group ◽  
Bleeding Event ◽  
Transitions Of Care ◽  
Control Group ◽  
Published Data ◽  
Post Discharge ◽  
Readmission Rates ◽  
The Impact

Abstract Background There is limited published data in Lebanon evaluating the impact of supplemental education for anticoagulants use, especially DOACs, on clinical outcomes such as bleeding. The study aims to assess the impact of pharmacist-conducted anticoagulation education and follow-up on bleeding and readmission rates. Methods This study was a randomized, non-blinded interventional study conducted between August 2017 and July 2019 in a tertiary care teaching Lebanese hospital. Participants were inpatients ≥18 years discharged on an oral anticoagulant for treatment. Block randomization was used. The control group received the standard nursing counseling while the intervention group additionally received pharmacy counseling. Phone call follow-ups were done on day 3 and 30 post-discharge. Primary outcomes included readmission rates and any bleeding event at day 3 and 30 post-discharge. Secondary outcomes included documented elements of education in the medical records and reported mortality upon day 30 post-discharge. Results Two hundred patients were recruited in the study (100 patients in each study arm) with a mean age of 73.9 years. In the pharmacist-counseled group, more patients contacted their physician within 3 days (14% versus 4%; p = 0.010), received explicit elements of education (p < 0.001) and documentation in the chart was better (p < 0.05). In the standard of care group, patients were more aware of their next physician appointment date (52% versus 31%, p < 0.001). No difference in bleeding rates at day 3 and 30 post-discharge was observed between the groups. Conclusions Although pharmacist-conducted anticoagulation education did not appear to reduce bleeding or readmission rates at day 30, pharmacist education significantly increased patient communication with their providers in the early days post-discharge. Trial registration Lebanon Clinical Trial Registry LBCTR2020033424. Retrospectively registered. Date of registration: 06/03/2020.

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