Highlights of Outreach and Collaborative Efforts of the
Beneficiary and Family Centered Care - Quality Improvement Organization (BFCC-QIO)
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Optimizing Patient Transitions Through Effective Discharge Planning |
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Transitioning from the hospital to another care setting is pivotal in a Medicare beneficiary's healing journey. Care transitions, such as discharge from the hospital or another care setting, can significantly impact a person’s recovery. In fact, the Centers for Medicare & Medicaid Services (CMS) established the Hospital Readmissions Reduction Program (HRRP) to encourage healthcare providers to engage patients and caregivers in discharge planning to help reduce avoidable readmissions, protect the Medicare Trust Fund, and ensure high-quality healthcare delivery.
Today's issue of The Livanta Compass reviews the importance of implementing comprehensive discharge practices and tools. Livanta would like to thank Towson University intern Gena John for contributing to today's issue.
CMS, “Hospital Readmissions Reduction Program (HRRP)”
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Effective Discharge Planning |
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According to the Agency for Healthcare Research and Quality (AHRQ), successful care transitions hinge on personalized discharge plans by the patient’s healthcare professionals. Effective discharge plans emphasize post-discharge follow-up care, including scheduled appointments with healthcare providers. The IDEAL process, outlined in AHRQ’s handbook, guides the transition of care from hospital to home. This comprehensive approach engages patients and caregivers throughout the discharge planning process.
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I – include patients and caregivers throughout the discharge planning process.
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D – discuss potential issues with patients and caregivers.
- Review medications
- Highlight warning signs and problems
- Explain test results
- Make follow-up appointments
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E – educate patients and caregivers using plain language.
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A – assess how well doctors and nurses communicate the patient’s diagnosis, condition, and next steps to family members and caregivers.
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L – listen to patients and their family members' goals, preferences, observations, and concerns.
The IDEAL toolkit is geared toward healthcare professionals helping patients and their caregivers transition from hospital to home care. However, patients and their caregivers must also understand their rights to ask clarifying questions from their care team and be fully aware of what the transition process entails.
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Vital Facets of Safe Discharge |
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Significant aspects of discharge planning include medication review, patient education, and provider communication. ARQH’s Patient Safety Network (PSNet) states that providers should review the reconciled medication list with patients and caregivers to ensure they fully understand the prescribed medications. For example, patients and their caregivers need to know the names of their medications, when and how to take them, and how much to take. Understanding and managing medicines are fundamental for ensuring patient safety, effective treatments, and overall well-being.
Educating beneficiaries and caregivers about their medical conditions and treatment plans is also crucial for a successful discharge, according to PSNet. Additionally, doctors and nurses need to communicate clearly with beneficiaries and their families and caregivers regarding the patient's diagnosis, condition, and next steps in the patient's care by employing the teach-back method. The teach-back method is a simple tool that helps patients and caregivers repeat instructions using their own words, which helps reinforce key points and identify if more clarity is needed.
Furthermore, PSNet states the discharge summary helps the patient’s care team communicate when a patient moves from the hospital to another level of care. The discharge summary explains the diagnoses and treatments during the patient’s hospital stay. The care team can then provide accurate and informed follow-up care and reduce the risk of complications that may result in avoidable readmissions. Involving the whole care team in health-related decision-making can lead to better outcomes.
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PSNet, “Patient Safety During Hospital Discharge”
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Preventing Avoidable Readmissions for Improved Patient Care |
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According to CMS’s Guide to Reducing Disparities in Readmissions, hospital strategies for preventing avoidable readmissions include enhancing discharge and care transitions for ethnic minorities, reducing language barriers, and improving health literacy. Furthermore, ongoing quality improvement initiatives are necessary to enhance patient safety and satisfaction throughout the discharge journey. CMS’s Guide to Reducing Disparities in Readmissions highlights other ways to help reduce avoidable readmission rates. Some of these methods include:
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Collect Critical Data: Collect data such as the beneficiaries' race and ethnicity, language, education, social determinants, disability, and linkage to primary care/ usual source of care.
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Identify Root Causes: analyzing demographic and risk data helps identify the root causes of readmissions, enabling the development of targeted interventions, such as provider training and language services, to address barriers and improve equity in care, as outlined in the American Hospital Association's framework.
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Start from the Beginning: establish comprehensive systems for assessing and addressing risk factors throughout the entire healthcare journey, emphasizing early intervention and tailored strategies, particularly for minority populations, to mitigate social, cultural, and linguistic challenges and reduce the risk of readmission.
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Activate a Multidisciplinary Team: achieving success in addressing the multifaceted risks of readmissions requires a well-coordinated, multidisciplinary team, including doctors, nurses, social workers, interpreters, and allied health professionals, with clear leadership and roles, encompassing both traditional and non-traditional team members, and investing in resources such as multilingual coaches and navigators to anticipate and address barriers across inpatient and outpatient settings.
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Systematically Respond to Social Determinants: effective interventions to prevent readmissions, particularly in vulnerable minority populations, involve creating responsive systems and addressing specific social determinants through the support of navigators, community resources, social workers, and community health workers, ensuring culturally and linguistically appropriate patient information and a multidisciplinary inpatient team for reinforcement.
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Provide Culturally Competent Communication: effective clinician-patient communication, particularly in "high-risk scenarios" like medication reconciliation and discharge instructions, is crucial for preventing avoidable readmissions, especially in minority populations, and strategies such as using interpreters, writing low-literacy discharge instructions in multiple languages, and staff training on cultural competency and team communication are essential for addressing communication challenges and improving patient understanding and adherence.
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Foster External Partnerships and Community Linkages to Promote Continuity of Care: to reduce avoidable readmissions, hospitals should establish partnerships with community providers, leveraging existing community benefit activities and programs to address social determinants, promote continuity of care post-discharge, facilitate data-sharing with primary care providers, and collaborate with public health officials for informed readmission reduction efforts.
According to CMS’s Guide to Reducing Disparities in Readmissions, understanding commonalities amongst beneficiaries who return more frequently, such as age, race, number of medications they take, or their overall health, would allow hospitals to improve allocation of resources and planning and monitoring in a way that identifies areas of concern and provides extra help where it is needed. There is also a need to explore how home services, technology, mental health support, caregiver assistance, community partnerships, and the inclusion of new care workers can contribute to keeping patients healthy after their discharge from the hospital. As hospitals continue to focus on reducing avoidable readmissions, it is vital to see if these efforts are effective and can be maintained. If hospitals reduce readmissions, it could lower costs, improve care, and increase beneficiary satisfaction.
CMS, “Guide to Reducing Disparities in Readmissions.”
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Helping Beneficiaries with Care Transitions |
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Transitioning from the hospital to another level of care can be less confusing if patients receive clear information and supportive services before discharge. An effective discharge plan is one in which the beneficiary or their caregiver has participated, understands the plan and the discharge information provided, and has identified concerns about potential post-discharge challenges. However, if a Medicare beneficiary has questions or concerns about their discharge plan, Livanta's Immediate Advocacy service can help beneficiaries and their caregivers communicate with healthcare providers.
As a Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO), Livanta’s advocates intervene on behalf of the beneficiary to communicate concerns to the care providers. Provided at no cost to the beneficiary, Immediate Advocacy supports Medicare beneficiaries and caregivers by helping them communicate effectively with care providers, obtain crucial information, improve patient outcomes, reduce readmission rates, and address patient concerns.
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This material was prepared by Livanta LLC, the Medicare Beneficiary and Family Centered Care - Quality Improvement Organization (BFCC-QIO) that provides claims review services nationwide and case review services for Medicare Regions 2, 3, 5, 7, and 9, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Livanta does not provide medical advice, diagnosis, or treatment. The content of this article is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.12-SOW-MD-2023-QIOBFCC-CP315
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