BestPractice
February 9, 2018

Across Johns Hopkins Medicine, efforts are underway to avoid unnecessary readmissions. The initiatives are designed to help keep patients recently discharged from the hospital from suffering a health setback that requires readmission, with a focus on educating patients and their caregivers about disease management, increasing patients’ access to appropriate outpatient care and focusing resources on patients at elevated risk of readmission. The goal  of these efforts is multifold: To improve the patient’s health and experience of care, to keep the costs of care down, and to achieve targets for readmission rates set by the Centers for Medicare and Medicaid Services and by Maryland’s Health Services Cost Review Commission.

“Patient and family/caregiver education is a critical factor in reducing readmissions,” says Amy Deutschendorf, vice president of care coordination and clinical resource management for the Johns Hopkins Health System. She cites the use of The Johns Hopkins Hospital’s Patient Access Line —known as PAL— for contacting patients after discharge to reinforce key aspects of self-care. Over a three-year study period, patients who did not get connected with PAL had a 45 percent greater odds of readmission compared with patients connected with PAL, she says.

The use of PAL for patient education is just one of many interventions that allowed The Johns Hopkins Hospital to lower its readmissions rate beyond the defined target for 2016, the last year for which data are available, says Deutschendorf. Seeking to reduce its rate by 9.5 percent, the hospital achieved a 12.66 percent reduction.

Patient and caregiver education is a focus as well for Suburban Hospital’s Transition Guide Nurses Program, launched in 2010, says its director, Margie Hackett.

When patients leave the hospital, they receive a lot of information at once, says Hackett, such as instructions for wound care, medication schedules and follow-up appointments. “It can be overwhelming,” she says.

The program emphasizes educating the patient or the family in managing the patient’s condition at home. The Transition Guide Nurses call patients after discharge to reinforce the key aspects of self-care that they were taught in the hospital, including which medications to take when, how to avoid falls and when to see physicians for follow-up.  Transition Guide Nurses also explain what signs and symptoms indicate that the patient’s primary care physician should be contacted for guidance.

And for those patients who lack a primary care physician, the Transition Guide Nurses connect them with one.

Additionally, the nurses on the team manage care transitions and make home visits to patients at particularly high risk of returning to the hospital within 30 days, such as those who are very frail. 

“We work hard to reach the patients who need more, such as help with transportation, personal care, exercise and food, and want to ensure that those who live alone are safe and can manage independently,” she says.

Data on patients touched by the program are still being collected and analyzed, but overall the hospital has seen a drop in readmissions, says Hackett.

The After-Care Clinic, located at the Johns Hopkins Outpatient Center on the East Baltimore campus, offers multidisciplinary post-discharge care to adult patients identified as being at high risk of readmission or emergency department (ED) use. The clinic, which sees about 60 patients a week, is directed by internist Ro­salyn Stewart and emergency medicine physician Arjun Chanmugam. Its multidisciplinary team includes nurses, pharmacists, social workers and community health workers.

Patients are referred to the clinic while in the hospital or ED. They typically face many challenges, says Stewart, including poor health literacy and a lack of secure housing or reliable transportation, and many do not have a regular care provider. The After-Care Clinic aims to address their most pressing needs in the short term while connecting them to primary care for longer-term follow-up.

During a typical visit, which can last up to 90 minutes, patients receive instruction in self-care from a nurse and in medication management by a pharmacist. A social worker provides assistance on overcoming the logistical barriers to care many face, for instance by helping some get bus vouchers to use for medical appointments. Community health workers act as health coaches and offer peer support.

In 2016, the After-Care Clinic saved the health system about $1.4 million in avoided hospitalizations, says Stewart, who adds that data on avoided ED visits is being analyzed now.

(To see 30-day Medicare readmissions rates for Johns Hopkins Medicine adult hospitals, visit Hospital Compare.)