Abstract
Background: Care transitions between inpatient and outpatient providers are quickly becoming a surrogate marker of quality for care of the hospitalized patient. Almost one in six (17.6%) Medicare patients are readmitted within 30 days of hospital discharge. As a result the Centers for Medicare and Medicaid Services (CMS) is targeting readmissions as a probable marker for both poor quality of care and money going down the drain. The Geisinger Transitions of Care Initiative (TOCI) focuses on creating reliable, sustained change that is broad based, cross platform and applicable to all patients.
Methods: Geisinger’s approach to address transitions of care is a team-based model. It begins with nurses screening patients’ readmission risk status using an electronic health record tool developed from national evidence and modified based upon GHS’s local experience. Once a patient identified as high risk is admitted, nursing performs a checklist of activities for early care activation (e.g. screening for the need for post acute infusion) and care management prepares a discharge plan and completes a detailed assessment of the patient’s support environment. On selected units, high risk patients are followed for a month post-discharge using an outpatient care management protocol that leverages telephonic case management and remote monitoring tools that can be customized to the patient’s medical plan. The final core pilot encompasses our transition bundle. This includes automation of primary care physician follow-up appointment scheduling and discharge communication.
Results: The pilots were implemented in May and June of 2008. Because of the low frequency of readmissions, we have yet to evaluate whether early promising results are statistically significant. We have been able to demonstrate reliable emergency department screening and transition bundle performance and the reliability of implementing this complex model is improving each month. Approximately 2,000 patients have been discharged from units where the pilots were in operation.
Conclusions: The TOCI approach is interdisciplinary at all level’s governance, coordination, and patient care. We believe the methods that are developed and utilized, including specialized screening tools, nursing and care management protocols, interdisciplinary team rounds, discharge protocols and post acute care management strategies, will be essential components of the national strategy to reduce readmissions.
