When Houston Methodist Hospital noticed patients in one particular zip code were failing to make it to follow-up appointments after hospital discharge, they looked into it.
“We found it wasn’t on a bus route,” says Janice Finder, RN, MSN, director of the hospital’s Transitions in Care program and a part of SHM’s Project BOOST, which focuses on successful discharge outcomes. So in collaboration with the Texas Department of Aging and Disability Services, the hospital provided cab vouchers for these patients to travel to and from appointments.
The hospital also realized that to improve the chances its large Hispanic diabetic population remained healthy, it would need to tailor its disease management efforts to their culture, particularly when it came to diet.
“Their eating habits are very different, and we want to ensure they have meals based on what they actually eat,” Finder says.
These are exactly the kinds of approaches a new guide developed for the Centers for Medicare & Medicaid Services (CMS) by the Disparities Solutions Center (DSC), based at Massachusetts General Hospital (MGH) in Boston, is looking to promote in an effort to reduce unnecessary hospital readmissions.1 CMS recently made the Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries available on its website.
“We know readmissions is an issue for diverse populations, that they are more likely than their white counterparts to be admitted within 30 days of discharge,” says Aswita Tan-McGrory, MBA, MSPH, deputy director of DSC within the Mongan Institute for Health Policy at MGH. “So there was a good business case for creating this guide.”
Keys to Success
Within the guide is a collection of evidence-based information, case studies, and seven recommendations the DSC team assembled to assist hospital leaders looking to reduce readmissions among some of the nation’s highest-risk populations.
While Tan-McGrory acknowledges it may be impractical for hospitals to adopt each recommendation, she says they can pick and choose which they can most effectively adopt.
“We put together these seven steps and looked for who does this really well, and the honest truth is not very many are,” she says. “It’s a complicated process, but it’s some guidance because there really wasn’t anything out there.”
Included in the recommendations: Create a “strong radar” (engage in robust data collection), identify root causes, begin to think about discharge at admission, deploy a team, consider systems and social determinants, focus on culturally competent communication, and foster community partnerships.
“It’s not just medication reconciliation or discharge instructions in a different language,” Tan-McGrory says. “What happens when a patient gets home?”
These types of questions are important because CMS now penalizes hospitals for what it deems excessive avoidable readmissions within 30 days of discharge. In 2016, hospitals can lose up to 3% of their Medicare payments under the Hospital Readmissions Reduction Program.
In 2014, nearly 18% of Medicare patients were admitted within a month of discharge at a cost of $26 billion.2 According to the new guide, Agency for Healthcare Research and Quality data indicate African-American and Hispanic patients make up a higher share of these readmissions, in part because they are disproportionately affected by chronic high-readmission-risk diseases like congestive heart failure.
Though it’s challenging for healthcare providers, one way to reduce readmissions is to address the social determinants of health, Tan-McGrory says.
“Hospitals have felt in the past that it’s not their domain, but their patients are coming back,” she says. “How do you address people’s isolation at home? How can you send them from the hospital when no one is there to follow up or take care of them?”