URMC Hospitals Aim for ‘Safe Transitions’

An initiative aimed at reducing hospital readmissions will foster improved communication among care teams, patients and primary care physicians. Launched in January on all adult medical and surgical units, “Safe Transitions” relies on follow-up phone calls and appointments to help patients avoid readmissions.

“National data shows that nearly one in five Medicare patients winds up back in the hospital within 30 days,” said division chief of General Medicine Marc Berliant, M.D.“These readmissions place undue physical, emotional and financial stress on our most vulnerable patients.”

Additionally, in a community like Rochester where inpatient beds are almost always full, avoidable readmissions compound capacity issues, creating challenges to access to care.

“Patients deserve smoother, safer transitions as they leave our doors for a skilled nursing facility or their own home,” Berliant said. For that reason, Berliant, in collaboration with director of Social Work and Patient and Family Services Kelly Luther and associate director of Cardiovascular Nursing Anna Lambert, is leading the effort to improve the discharge process and reduce 30-day readmission rates (for the same or related conditions) by 15 percent.

Marc Berliant, M.D.

Marc Berliant, M.D.

“One thing has become clear to us: We need a better early-warning system for monitoring adverse events in these newly discharged patientsbefore they escalate into true emergencies,” Berliant said. “One part of our solution is to collaborate more intimately with our community health system, doing a better job of informing primary care doctors about what happened during a patient’s hospital stay.”

Engaging patients in their care while they are hospitalized is another goal.

“That way, they feel more knowledgeable and empowered to confidently continue their own care once back home,” Berliant said.

The team at Strong encourages patients to make prompt follow-up appointments with their primary care physicians, aiming to be seen for a visit within three to five business days after leaving the hospital.

“We know that, nationally, half of all readmitted patients never saw their primary care physician for a post-discharge appointment,” Berliant said. “That convinces us that PCPs are a critical part of managing new or worsening health issues in these most vulnerable patients. And many times, PCPs can help address the issue right in their office.”

A key piece of URMC hospitals’ new discharge standards is identifying “high-risk” patients who are predisposed to readmission.

“We’ve created some rules of thumb,” Berliant said. “For instance, certain conditions, like congestive heart failure or pneumonia – or medication regimens, like anti-clotting drugs – automatically place a patient in the high-risk camp. We literally flag their charts, so the entire hospital care team knows.”

Depending on whether a patient is classified as high- or standard-risk, teams at Strong and Highland are aiming to have every adult medical-surgical discharge include:

  • An information transfer. 24 hours after a patient leaves, a “STAT” summary is sent electronically to his primary care doctor, detailing medication changes made, what happened during his inpatient stay, etc.
  • A phone call home to patient. Also within 24 hours, the hospital care team will loop back with discharged patients with a personal call to ensure that patients are taking medicines as discussed, confirm that a follow-up physician appointment is on their calendar, and address any remaining, post-discharge concerns.
  • An appointment on the books. Making sure patients visit their PCPs after discharge provides a vital safety net allowing physicians the chance to spot and deal with adverse events before they worsen.
  • A loop-back conversation with patient’s PCP (for high-risk patients). A hospital provider team member connects with the patient’s PCP to discuss how they can keep the patient on the road to recovery.

“Our hope is that patients and their caretakers feel more confident about heading home,” Berliant said. “We also are looking forward to being more helpful to patients’ primary care physicians, who already play an invaluable role in caring for these patients.”

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