By Michele Rowland

  • Approximately 1 in 5 Medicare patients in the US are re-admitted within 30 days of their discharge from an acute care hospital.
  • Approximately 1 in 3 is re-admitted within 90 dates.

Reducing health care related costs, while improving the quality of patient care, is in everyone’s interest. It just makes good sense to do so. Many national organizations, such as AHRQ (American Healthcare Research and Quality), CMS (Center for Medicare/Medicaid Services) and the Institute of Medicine (IOM), actively support efforts that hospitals make to achieve that goal.

Michele Rowland, RN, LICSW

Preventing unnecessary hospital readmissions is at the top of the list of such efforts, and we at Brattleboro Memorial Hospital are actively focusing on this initiative. CMS defines a readmission as a patient coming back into the hospital for the same condition within a 30-day period. CMS studies of U.S. data show that readmission rates vary widely across the country but, in some communities, as many as 1 in 4 patients are re-admitted with an acute condition before a month has gone by.

Some of these readmissions are unavoidable, but many readmissions can be prevented. A hospital can play a pivotal role in ensuring that happens, leading to a higher number of patients living safely in the community with a greater sense of independence and control over their own care.

Improved communication is a great start. Each morning here at BMH, our Care Management Team notifies the offices of physicians if one of their patients has been admitted. Through the access our affiliated physicians have to our Electronic Medical Record, the physician can then follow the progress of their patient while they are under the hospital’s care. The nursing team works with the patient, their physician and their pharmacy to make sure we have clear information about any medications they were taking at home.

When the patient is ready for discharge, Care Managers schedule appointments for them with their regular physician and any specialists they may need to see. Care Managers and nurses sit with the patient and their family to review the appointments that have been made and discuss any changes in their medication regime. We also discuss important self-care at home to maintain optimum health. The patient’s physician also gets a copy of the patient’s post-hospital medication regime so they are aware of any changes.

Self-care at home after a hospitalization is also important to preventing readmission, especially for more chronic diseases such as congestive heart failure and diabetes. Many patients benefit from having a sort of “health care coach” to remind them to take their medication, do appropriate exercise and eat an appropriate diet. The Community Health Team of the Blueprint for Health provides this coaching for many patients of our affiliated physician practices certified for that program. In addition the team of the SASH program, run through the Brattleboro Housing Authority, also provides such in-home support.

BMH has taken the added step of appointing Dr. Carolyn Taylor-Olson as the medical director of our area sub-acute care facilities, which include Thompson House, Pine Heights and Vernon Green. This patient population is at the highest risk for readmission because of the complexity of their medical conditions. Dr. Taylor-Olson or her colleague Suanne Petroff, NP, will attend the hospital’s daily interdisciplinary care rounds, and will serve as a single point of contact for every one of these patients when they leave our grounds. We’re not aware of any other care facility that has taken this step, but it is a measure that we think will work very well in a community of our size.

CMS has set national readmission rate benchmark levels for each acute diagnosis, and as of 2013 a hospital’s compensation from Medicare will be tied to achieving that standard. BMH is currently well within these set rates. The financial benefit for that is important, but of even greater importance for us at BMH is knowing that we’re providing a better quality of life for our patients, enabling them to be out in the community receiving the support they need to maintain good health.

Michele Rowland, RN, LICSW is the Executive Director of Quality, Utilization and Care Management at Brattleboro Memorial Hospital.