Reducing Hospital Readmissions and Improving Care - SBH Health System
Image of a doctor talking to a patient to reduce hospital readmissions

When it comes to reducing 30-day hospital readmissions, it’s no longer a matter of hospital “bragging rights,” but one of financial necessity.

As a result of the Hospital Readmissions Reduction Program (HRRP) established by the Affordable Care Act, hospitals now face financial penalties from Medicare for their failure to reduce 30-day patient readmissions occurring after initial hospitalizations for heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), and elective hip or knee replacement.

According to results published earlier this year by the Centers for Medicare & Medicaid Services (CMS), 140 hospitals in New York State were penalized, with an average penalty of 0.75 percent (with some as high as 2.5 percent). At a time when virtually all of the state’s urban hospitals faced higherthan-average penalties, SBH Health System, along with a handful of suburban and rural hospitals, had among the state’s lowest
penalty rates (0.19 percent).

Image of Dr. Manisha Kulshreshtha
Dr. Manisha Kulshreshtha

This improvement has not happened by chance. Since 2011, the hospital has experienced an across-the-board reduction of more than 14 percent in its 30-day patient readmission rate. “This has been a priority not only for our Medicare patients, but with all our patients,” says Dr. Manisha Kulshreshtha, SBH’s medical director, care transitions and physician practice. “A good part of this effort comes down to doing a better job communicating among ourselves and educating our patients.”

The campaign to reduce hospitalization readmission rates began by breaking down the process from patient admission to discharge and forming a readmission committee (comprised of a diverse group of providers). Closer attention was paid to patients’ medication, with a clinical pharmacist assigned to a high risk patient floor and the hospital offering medication options and/or assisting patients with the cost of their meds when necessary.
According to Rachel Sussman, the clinical pharmacist assigned, “Having a clinical pharmacist on the medical units assists in high risk patient education and in resolving medication access issues, which is a significant barrier to their care.” Additionally, Dr. Kulshreshtha credits these hospital-wide changes for the dramatic turnaround:

Image of doctor writing on whiteboardIntroduction of “white boards” used in daily meetings with as many as 15 to 20 clinicians. “We discuss each patient, with a discharge plan developed at the time the patient is admitted,” says Dr. Kulshreshtha. “The white board is colorcoded so clinicians know when patients are being discharged, whether they have been readmitted (which means they are at renewed risk), and their care moving forward. It’s made for far better communications.”

Enhancement of electronic Medical Records. Made possible through a grant, the improved EMR system has enabled the hospital to focus on such things as creating alerts for 30-day readmissions and high-risk medications, and doing a better job of transmitting clinical discharge summaries to primary physicians and other providers.

Improved patient and caregiver education at the patient’s bedside. This has included a “rounding” process whereby providers educate high-risk patients, including those with congestive heart failure and diabetes and their caregivers, in order to better prepare them for discharge. This has included, for example, “teach back” sessions where nurses have patients tell them what they will need to do following discharge. All exit materials for patients are now prepared in both English and Spanish, with the hospital making additional provisions for communicating to patients originally from such areas as West Africa and Albania.

Collaboration with a large private physician practice in making “house calls.” It is estimated that as many as 25 patients, for the most part elderly and chronically ill, are seen monthly through a collaborative program with Essen Medical Associates. The program facilitates the transition of patients most at risk for re-admission back into the community and consists of regular telephonic follow-up and at-home physician visits for up to 30 days following hospital discharge. Since the partnership’s inception in 2013, EssenMed House Calls has cared for over 2,400 SBH patients.
“Working with high-risk patients, many of whom are not always compliant, can be very challenging,” says Dr. Kulshreshtha. “But not only do our numbers (in terms of 30-day hospital readmissions) continue to trend down, which obviously is important in light of the financial incentives, but we feel that we’ve improved the overall quality of our care.”


Steve Clark