Readmission is a word on the lips of every healthcare provider these days. From acute care to the front lines of post-acute care, everyone seemingly is obsessed with eliminating the hardship that 30-day readmissions represent. This article will focus on any and all admissions to the hospital from a skilled nursing facility (SNF), readmission or not, as well as all transfers to the emergency department (ED). They will be referred to generically as hospital transfers.
The gold standard for post-acute care (PAC) facilities seeking to solve the avoidable hospital transfer conundrum is the Interact process, a comprehensive and exhaustive effort to cover all factors that contribute to avoidable hospital transfers. The spreadsheets, forms and flow charts are presented in exquisite detail and present a compelling set of tools that when faithfully implemented should reduce avoidable readmissions.
Several years ago, I spoke with a man who worked for the quality improvement organization in Ohio. He traveled extensively and regularly worked across the table from administrators and directors of nursing as they struggled to address their readmission problems. He said that probably not one nursing home in the state was using the Interact process in its entirety, as it was intended.
That comment stuck with me as I was working with my health system’s network of nursing homes on a quality improvement project. One of our goals was to deconstruct the Interact process to find ways to make the tools and processes more user-friendly and, as a result, more effective in reducing or eliminating avoidable admissions/ED transfers.
We began by looking at the Hospitalization Rate Tracking Tool and Quality Improvement Tool for Review of Acute Care Transfers. In preparation for one of our meetings, I printed the forms that are a part of these two essential areas of the Interact process. As I considered this impressive array of documents, I was struck by the amount of staff time that would be needed to faithfully implement this process from beginning to end for each patient sent out the doors of a PAC facility. Of greater concern was that the true root cause of each discreet hospital admission/ED transfer could easily be obscured by the passage of time, spreadsheets and heavy doses of data entry.
There are many approaches and tools for long-term care organizations to deal with potentially preventable hospital transfers. These include the gold standard Interact process. Added to the mix are indigenous, facility-developed tools as well as electronic medical records' (EMRs') embedded tools (including Interact) for tracking, analyzing and responding to hospital transfers. Because of the variety of EMRs used and the fact that the embedded Interact processes may not be included in the basic system setup of EMRs, great variation exists in how facilities track and respond to hospital transfers.
Looking at these tools and approaches in a broad context, they seem to rely heavily on paperwork, process and analysis. They also tend to be retrospective in nature, possibly missing opportunities for teachable moments and immediate system/process fixes. At times, the very complexity of these approaches compounds the timeliness issues with a potentially significant time disconnect between hospital transfer and a pointed/in-depth review of what went wrong—if anything.
Additionally, some of these tools are quite complicated and require a huge commitment of staff time to assiduously follow from start to finish. Taken together, these tools may not be the ideal approach for quickly, efficiently and effectively identifying issues that constitute the root cause of avoidable hospital transfers.
A corollary to KISS (Keep it simple, stupid) is the injunction to MISS (Make it simple silly). MISS is intended for situations when something has grown in complexity beyond what is necessary and/or supportable with available resources.
With that in mind, I developed a streamlined approach to reduce reliance on paperwork, process, analysis and retrospective review. The priorities:
- Fcus on reducing staff time devoted to tracking hospital admissions.
- Cncentrate on avoidable hospital transfers exclusively.
- Identify opportunities for teachable moments.
- Address immediate fixes of system and process issues.
What came out of this process was a form that was dubbed the Readmission RRT (rapid response tool). This tool is intended to stand alone or to be used in combination with other tools that a facility may wish to use for tracking, analyzing and responding to readmissions.
It is a simple-to-use daily tool, emphasizing the need to address issues quickly to avoid reoccurrences of avoidable hospital/ED transfers. It relies on an informed clinical judgment about avoidable/unavoidable transfers to maximize staff time in only focusing on what are truly avoidable transfers. It can also form the basis for more in-depth root-cause and trend analysis.
The essential elements of the Readmission RRT:
An old business adage goes something like, “If you take care of business, the numbers will take care of themselves.” The aforementioned approach for managing hospital transfers has a laser-like focus on the immediate situation that led to the still fresh hospital admission/ED transfer. It places maximum emphasis on going to the source of the problem (be it a healthcare professional or a system or a process issue) and critically addressing and ideally fixing the issue.