In early 2021, Coryell Health, a 25-bed critical access hospital (CAH) in Gatesville, Texas, observed an increase in 30-day all-cause readmission rates each quarter during 2020. By June 2021, the readmission rate reached a high of more than 14 percent. Although COVID-19 contributed to readmission challenges and brought unique obstacles, Coryell’s quality improvement department was concerned about the higher-than-normal readmission rate and its effect on patient outcomes.
The Coryell team, led by Chief Quality Officer Lauren Shelton, RN, focused intervention efforts on the transitional care management (TCM) department with the goal of reducing the 30-day all-cause readmission rate by 2 percent by June 2022. The hospital social worker, transitional care management nurse, hospitalist and nursing administrator rounded out the quality improvement team.
“Our solution influences the entire discharge patient population, but is aimed to influence the readmitted patients – which is between 5 and 15 percent,” explained Shelton.
Specifically, the team developed daily care transition intervention plans for all patients. These daily interventions included a psychosocial evaluation, identification of needed resources, such as transportation, and coordination of needed post-discharge care. The care team also:
- Implemented 24-to-48 hour post-discharge phone calls with all patients who were discharged home, and soon expanded to 7-day, 14-day and 21-day follow-up calls.
- Used a standardized script to review key discharge components during follow-up calls to patients.
- Created spreadsheets to track patients and electronic health record templates that guided TCM nurses in asking consistent and relevant questions regarding the patient’s self-management following discharge.
- Ensured that the post-discharge follow-up appointment was scheduled and the patient was aware of the date and time of the appointment.
- Ensured that the patient had obtained prescribed medications and was taking them as prescribed.
Coryell’s readmissions decreased between 1 and 2 percent for the third and fourth quarters of 2021 compared to the second quarter of 2021.
TMF Health Quality Institute has worked with Coryell Health since the fall of 2020 on patient care as part of the Hospital Quality Improvement Contract, a federally funded program through the Centers for Medicare & Medicaid Services. A TMF quality improvement specialist worked closely with the hospital’s chief quality officer on their goal of reducing readmissions by supporting evidence-based practices; reviewing the Plan-Do-Study-Act (PDSA) problem-solving model; and sharing assessment and evaluation tools, such as the Readmissions Tracer Tool, Readmissions Reduction Top 10 Checklist and Readmissions Process Improvement Discovery Chart Audit Tool.
However, rates increased again in January 2022. According to Shelton, hospital readmission tracers identified that patient social factors are directly influencing readmissions. Social determinants of health data collected by Unite Us, a TMF subcontractor, shows that Coryell Health admits patients who have higher rates of unreliable transportation and loneliness than the state of Texas and the nation.
“[We learned that] you must look at the entire readmission picture, including social determinants of health and the available resources that patients can utilize,” said Shelton.
Further analysis of readmission tracers highlighted the fact that additional patient education was needed prior to discharge. The hospital also noted an increase in higher acuity patients, including more patients with long COVID-19 symptoms, during the first quarter of 2022 that required multiple points of care coordination.
Although Coryell did not see continual improvement in readmission rates, it did see improved patient experience with the transitions team as evidenced by improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores. Moving forward, the facility plans to complete a tracer tool on every readmission to identify any gaps in care, implement a post-acute care Navigator Program and continue to review HCAHPS scores to identify areas that may provide insight into readmission causes.
In particular, a Navigator Program could target patients most at risk for readmission by supporting patients and caregivers in navigating an often-fragmented medical delivery system. The post-acute care navigator may assist with obtaining medications, locating transportation to follow-up appointments, connecting individuals with community services and communicating with patients to ensure treatment plans are being followed.
“We will continue to utilize evidence-based interventions and track our progress through PDSA reviews until we reach our goal and see continued improvement,” said Shelton.