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HRC Study Highlights Unique Ways of Reducing Avoidable Rehospitalizations


Almost one fifth of senior patients are rehospitalizationed within 30 days of being discharged from the hospital. A third are rehospitalized within 90 days. The estimated annual cost due to rehospitalization is more than $17 billion.

A new study from Hebrew Rehabilitation Center (HRC), an affiliate of Harvard Medical School, demonstrates a unique approach using a three-pronged intervention that combines standardized admission templates, palliative care consultations, and root-cause-analysis conferences reduces rehospitalization by nearly 20%.

The study was conducted by Randi E. Berkowitz, M.D., a geriatrician at Hebrew Rehabilitation Center and medical director of the RSU, and colleagues and is published in the June issue of the Journal of the American Geriatrics Society.

Berkowitz and colleagues compared patients' discharge disposition from HRC's Recuperative Services Unit (RSU) in Boston, a skilled nursing facility, before and after implementation of the intervention. The rate of patient rehospitalization fell from 16.5% to 13.3%, a drop of nearly 20%.

Discharges to home increased from 68.6% to 73.0%, and discharges to long-term care dropped to 11.5% from 13.8%.

"The change in discharge disposition observed between the two periods, we believe, reflects an improvement in patient outcomes," says lead author Randi E. Berkowitz, M.D., a geriatrician at Hebrew Rehabilitation Center and medical director of the RSU. "Specifically, a lower acute transfer rate likely reflects improved processes of care in the SNF."

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There are many risk factors that correlate with future hospitalization such as recent hospitalization, specific diagnoses (such as congestive heart failure), acute medical illnesses, depression, and other factors.

The admission template developed by HSL's Department of Medicine and key nursing, administrative and social service leaders to help prevent rehospitalizations includes care guidelines for common geriatric syndromes, medication reconciliation, and goals of care, as well as a question about how many times the patient had been hospitalized over the past six months. A section on advance directives asks whether the patient or health-care proxy would want subsequent hospitalizations if the patient's condition deteriorated while on the SNF.

Patients who had three or more hospitalizations within the past six months received consultations with HRC's palliative care team. The consultations were to determine whether rehospitalization was consistent with the patient's goals of care, or if worsening symptoms would be managed best on a SNF, in long-term care, or at home.

Team Improvement for the Patient and Safety (TIPS) conferences were held bimonthly to examine the root causes of rehospitalizations. Selected cases of preventable rehospitalizations were reviewed to identify ways in which the team could have operated more effectively. Depending on the specific causes identified, further information would be sought and additional staff or outside experts would be invited to participate in subsequent TIPS sessions.

"Reducing rehospitalization has become a national target of health-care reform," says Robert J. Schreiber, M.D., HSL's chief medical officer. "Readmissions have a significant impact on the nation's health system and are often preventable."

As part of national health-care reform legislation, Medicare will stop paying hospitals for preventable readmissions for conditions such as heart failure and pneumonia, beginning in October 2012. Two years later, the list will expand to include additional medical conditions.

Hebrew Rehabilitation Center; press release 6-13-2011

Rehospitalizations Among Patients in the Medicare Fee-for-Service Program; Stephen F. Jencks, M.D., M.P.H., Mark V. Williams, M.D., and Eric A. Coleman, M.D., M.P.H.; New England Journal of Medicine, April 2, 2009 360(14):1418–28