Readmission Warriors Fight to Keep Patients Healthy

doctor smiling and helping elderly patient

When treating complex medical conditions, there’s often more to a patient’s health than what meets the eye.

To keep patients from returning to the hospital unnecessarily, MU Health Care’s Readmission Warriors initiative combines an advanced algorithm with a team of specially trained experts to unearth hidden health concerns before they strike.

Readmission Warriors — nurses, physicians, pharmacists, case managers and more — take a comprehensive look at patients’ health at key points during their hospital stay to keep them feeling good and out of the hospital. When patients are admitted to the hospital, they’re treated for their current health concern and are also evaluated for their likelihood of developing another condition that may put them back in the hospital.

“We care for the health of our patients — both clinically and financially,” said Lori Tebbe, director of care coordination at MU Health Care. “We want our patients to stay healthy but also equip them for those unforeseen circumstances that arise once they return home.”

Using an algorithm developed by Cerner and the Tiger Institute for Health Innovation, patients over the age of 18 are scored based on their likelihood of being readmitted to the hospital. The formula takes into account several factors, such as a patient’s medical and family history, other medical conditions, certain high-risk diagnoses, current medications and other variables. The patient’s case manager can assign a score based on a personal assessment.

About 30 percent of all adult inpatients at MU Health Care are identified as being high risk for readmission once they’re discharged from the hospital. If a patient is scored as high risk, a chain of events is triggered that alerts the care team and directs the care they provide during a patient’s hospitalization.

Areas of Focus

The Readmission Warriors initiative focuses on four areas that are likely to influence the likelihood a patient will be hospitalized again.

1. Taking medications as they’re prescribed

It’s important for patients to understand their medications and to take them as directed. The case manager works with MU Health Care pharmacists to ensure patients have the medications they need, not only while they’re in the hospital but also once they’re discharged. A pharmacist reviews patients’ medications, looking for any potential adverse reactions. The pharmacy often will deliver prescriptions to the patients’ bedside so they have their medications before leaving the hospital.

2. Empowering patients and their families

Bedside nurses and other members of the patients’ health care team will use the teach-back method to help patients understand their condition, treatment plan and what signs and symptoms to report. Understanding and remembering medical information can be a challenge, so staff members work with patients and their caregivers over the course of their hospital stay, asking them to teach back or relay their own understanding of their plan. This helps the care team evaluate the knowledge, attitude and behavior of patients in managing their own disease.

3. Transitioning from hospital to home

A Readmission Warrior takes a holistic look at patients’ hospitalization and charts a course for their treatment when they’re admitted, during their stay and once they're discharged. They help “plan for the day, plan for the stay and plan for the way.” Team members often receive 24-hour notice of patients’ discharges, giving them time to arrange medications, schedule follow-up appointments and coordinate any other needs that will help keep patients from coming back to the hospital unexpectedly.

4. Coordinating continued care

Ambulatory care coordinators follow up with select patients after they get home to answer any questions or coordinate outpatient chronic care management. Patients who continue care at an MU Health Care post-acute care network organization continue to be followed by a registered nurse for up to 90 days after discharge from the hospital.

Seeing results

The team has found that 40 percent of readmissions occur within seven days of discharge.

“This is a critical transition time for patients,” Tebbe said. “They no longer have a nurse or doctor at the other end of a call light and must navigate their recuperation. We want to ease that burden of those first few days and find the best ways to transition patients to their next setting of care, whether that’s at home or in a post-acute environment.”

Since implementing the Readmission Warriors initiative in 2017, the team has seen the 30-day readmission rate for patients drop from 13.1 percent to 10.6 percent.

“This is a huge improvement,” Tebbe said. “Many complicated factors come into play that we are simply unable to plan for, but we can take steps to identify and address them during their stay with us.”

Read more stories like this