Elliott Hospital. Manchester, NH. The Perinatal Ticket to Discharge. http://www.ihi.org/knowledge/pages/tools/perinataltickettodischarge.aspx. Published March 26, 2012. Accessed November 19, 2012. The Ticket to Discharge communication tool is given to patients by maternity center staff to help guide educational discussions and to provide a "to do" list of items that need to be completed prior to discharge from the hospital. The Feeding Log helps patients track their newborn's feeding and elimination habits.

Gleason KM, Brake H, Agramonte V, Perfetti C. Agency for Healthcare Research and Quality Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/match.pdf. Revised August 2012. Accessed November 19, 2013. Maintaining an effective and efficient medication reconciliation process for patient safety in every facility is at the forefront of national patient safety goals and initiatives. The process must encompass all areas where patient transitions occur in your facility: admission, transfer, and discharge. The effectiveness of the medication reconciliation process in your facility will also follow your patients in the post-acute setting or at home. A sound medication reconciliation process must involve all caregiver disciplines, must be integrated into their daily workflow, and must have the support of facility leadership to be successful. Interventions and improvements must be appropriately implemented as process gaps are identified, and these corrections should be measured for the effectiveness of your patient safety improvement efforts. This toolkit will guide you through the steps of flowchart and review of your current process, identifying gaps in the process, methods to revise the process, leadership support mechanisms, staff education guidance, and implementing and measuring process changes. Following the steps and guidelines outlined in each chapter of the MATCH toolkit has proven to be the most successful method for hospitals and post-acute setting providers that participated in the AHRQ QIO Learning Network project. The initial and subsequent improvement work to your medication reconciliation process will ultimately result in improved patient care and patient safety outcomes.

Craig C, Eby D, Whittington J. Institute for Healthcare ImprovementCare Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series 2011. http://www.ihi.org/knowledge/Pages/IHIWhitePapers/IHICareCoordinationModelWhitePaper.aspx. Published 2011. Accessed November 19, 2012. Collaborating with individuals with multiple health and social needs will help us to reshape the entire health care system, with benefits gained by all — not just those experiencing vulnerability. As health care costs decline and individuals stabilize their health and reestablish their roles in the community, all of us benefit as our most vulnerable neighbors regain participatory roles in community life. People with social needs, chronic illnesses, mental health issues, and substance-related needs do not pose complex challenges to those systems. Rather, they bring a host of simple needs and often untapped skills and assets. The health care and social service systems are better designed to meet isolated needs than to foster independence, resilience, and good health, and are unnecessarily complex. When the care system offers individuals a genuine opportunity to gain ongoing support through a partnering relationship with a team member dedicated to aligning a diverse care plan with the individual’s own health and life goals, drawing on their assets and fostering their selfcare skill development, the care system can be an integral part of the individual’s health journey. Multidisciplinary, multi-agency collaboration at all levels is key to successful integration efforts with people with multiple overlapping health and social needs. An operating framework can be the social determinants of health: how many social determinants can the integrated, cross-sector team address? What does the individual deem to be the most crucial starting point? Perhaps a “medical home” is little more than the ability to create a coherent care plan around an individual, aligning crucial supports to enable meaningful engagement in health-promoting treatments and activities. With small caseload sizes, care coordinators can consistently assess individuals’ emerging strengths and needs, ramping up support at critical times and cultivating self-management and targeted use of the care system to foster good health outcomes at lower costs.

Boutwell A, Hwu S. Institute for Healthcare Improvement. Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence.http://www.ihi.org/knowledge/Pages/Publications/EffectiveInterventionsReduceRehospitalizationsASurveyPublishedEvidence.aspx. Published 2009. Accessed November 15, 2012. This survey of the published literature regarding the effective interventions to reduce avoidable rehospitalizations revealed that the current body of published interventions fall into four broad categories: 1) enhanced care and support during transitions; 2) improved patient education and self-management support; 3) multidisciplinary team management; and 4) patient-centered care planning at the end of life. The companion document, Effective Interventions to Reduce Rehospitalizations: A Compendium of Promising Interventions, provides information regarding current best programs and practices to reduce rehospitalizations.

Birk S. Reducing Hospital Readmissions.Healthcare Executive.2012 Mar/Apr; 27(2):17-24.http://www.ihi.org/knowledge/pages/publications/reducinghospitalreadmissions.aspx. Accessed November 19, 2012. Reducing avoidable hospital readmissions takes collaboration among a full range of health care settings and stakeholders beyond the "hospital walls," and requires understanding and attending to the experiences of patients over time, across settings. This article describes how some are working to reduce avoidable hospital readmissions, including organizations participating in the IHI-led STAAR initiative.

Bradley EH, Curry L, Horwitz LI, Sipsma H, Thompson JW, Elma M, Walsh MN, Krumholz HM. J Am Coll Cardiol 2012;60(7):607-614. http://content.onlinejacc.org/article.aspx?articleid=1221473. Accessed November 19, 2012. Although most hospitals have a written objective of reducing preventable readmissions of patients with heart failure or AMI, the implementation of recommended practices varied widely. More evidence establishing the effectiveness of various practices is needed.

The Institute for Healthcare Improvement. Readmissions Diagnostic Worksheet. 2009. http://www.ihi.org/knowledge/Pages/Tools/ReadmissionsDiagnosticWorksheet.aspx. Published 2009. Accessed November 15, 2012. This diagnostic tool helps hospitals perform an in-depth review of the last five rehospitalizations to identify opportunities for improvement. This includes conducting chart reviews of the last five readmissions as well as interviews with recently readmitted patients and their family members. This tool was initially developed as part of the STAAR initiative.

The Health Care Improvement Foundation. Preventing Avoidable Episodes.PAVE: Smoothing the Path for Better Transitions. Transitions of Care Summary Report: Comparison to Baseline. December 1, 2011. http://www.hcifonline.org/content/document/detail/1184. Accessed October 25, 2012. Each participating hospital was asked to complete the Transitions of Care Survey at the start of the project to establish baseline measures and again at project end in order to assess the qualitative improvements in the region as a whole. Participating hospitals reported monthly readmission data to monitor same-hospital readmission rates in the region. Baseline measurements were taken at the start of the project to determine a regional readmission rate. Eighteen hospitals submitted enough data to be included in the analysis.

Sevin C, Evdokimoff M, Sobolewski S, Taylor J, Rutherford P, Coleman EA. How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations. Institute for Healthcare Improvement; June 2012. http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionsfromHospitaltoHomeHealthCareReduceAvoidableHospitalizations.aspx. Accessed October 25, 2012. This How-to Guide is designed to support hospital-based teams and their community partners in creating an ideal reception into home health care in the first 48 hours after the patient is discharged from the hospital, a post-acute care setting, or a rehabilitation facility.

Herndon L, Bones C, Kurapati S, Rutherford P, Vecchioni N. How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations. Institute for Healthcare Improvement; June 2012. http://www.ihi.org/knowledge/pages/tools/howtoguideimprovingtransitionhospitalsnfstoreducerehospitalizations.aspx. Accessed October 25, 2012. Patients are most at risk for experiencing gaps in care that lead to rehospitalization during the transition between care settings. The focus of this guide is the transition of residents from the hospital to the skilled nursing facility (SNF) setting and the associated transfer of responsibility from the hospital to the SNF care team. (SNF is an umbrella term that includes nursing homes, long-term care facilities, acute rehabilitation facilities, and post-acute care facilities.)

Schall M, Coleman E, Rutherford P, Taylor J. How-toGuide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations. Institute for Healthcare Improvement; June 2012. http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionsHospitaltoOfficePracticeReduceRehospitalizations.aspx. Accessed October 25, 2012. This How-to Guide focuses on the reception of patients back into the office practice after hospitalization. Patients are especially vulnerable to adverse events in the period immediately following discharge, and they need immediate access to a trusted clinician who can answer questions, provide advice, and help ensure that their clinical condition remains stable. Optimal post-discharge care is an important component of the overall care provided in primary care and in specialty practices. The approaches presented in this How-to Guide are intended to be a resource for clinicians and staff in office practices as they create new ways to provide optimal care for their patients.

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Institute for Healthcare Improvement; June 2012. http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx. Accessed October 25, 2012. This How-to Guide is designed to support hospital-based teams and their community partners in co-designing and reliably implementing improved care processes to ensure that patients who have been discharged from the hospital have an ideal transition home or to the next community care setting. Based on the growing body of evidence and IHI‘s experience to date in improving transitions in care after a hospitalization and reducing avoidable rehospitalizations, IHI has developed a conceptual framework or roadmap that depicts the cumulative effect of key interventions to improve the care of patients throughout the 30 days after patients are discharged from a hospital or post-acute skilled nursing facility.

Gleckman H. "New Readmission Laws: Catholic Providers Are Positioned to Lead," Health Progress 93, no.5, (September-October 2012): 7-16. www.chausa.org/workarea/DownloadAsset.aspx?id=9947. Accessed October 25, 2012. Almost 1 of every 4 Medicare beneficiaries who has transferred from a hospital to a nursing home is rehospitalized within 30 days, and as many as 60 percent of those readmissions are preventable. These events increase both risks to patients and costs to payers such as Medicare, Medicaid and managed care plans. As a result, nursing facilities are coming under pressure to reduce these events.

Pittsburgh Regional Health Initiative. PRHI Readmission Reduction Guide: A Manual for Preventing Hospitalizations. http://www.prhi.org/documents/ReadmissionReductionGuide-Final2-1-11.pdf. Published January 2011. Accessed October 25, 2012. In an effort to improve the processes of care that result in an avoidable readmission, the Pittsburgh Regional Health Initiative (PRHI) launched two pilot readmission reduction projects in 2007. With support from the Richard King Mellon Foundation, PRHI Strategic Initiatives Consultant Harold Miller recruited a community hospital and two large primary care physician practices willing to transform the way they delivered care in order to achieve significant reductions in readmissions for patients with Chronic Obstructive Pulmonary Disease (COPD). The first pilot focused on patients admitted to UPMC St. Margaret Hospital (a 250-bed community hospital that is part of the larger University of Pittsburgh Medical Center) along with Renaissance Family Practice (a practice of 26 physicians, the largest that admits patients to UPMC St. Margaret). The second focused on the patients of Premier Medical Associates – a suburban primary care practice of 50 physicians caring for more than 3,000 patients with COPD and the largest source of admissions to the Forbes Regional Hospital (a community hospital that is part of the West Penn Allegheny Health System). A methodical, 3-year process ensued that resulted in a 44% reduction in readmissions in the first year of the project, maintained consistently low rates of readmissions in two different sites, and also identified steps that could be taken by most hospitals and primary care practices in order to achieve significant readmission reductions for a broad range of chronic disease patients. The PRHI Readmission Reduction Guide describes the key steps needed to transform care and break the admission-readmission cycle. In addition, the Guide includes an overview of PRHI’s Perfecting Patient CareSM (PPC) process improvement methodology. Throughout the Guide, individual steps in the improvement process are illustrated with chronic disease readmissions examples taken from PRHI’s COPD pilot projects. This information is intended to be helpful not only to those looking for specific examples to illustrate the general steps, but also those interested in conducting a readmissions reduction project geared specifically to patients with COPD.

Jencks SH, Williams MV, Coleman EA. Rehospitalizations Among Patients in the Medicare Fee-for-Service Program. N Engl J Med 2009;360:1418-28. http://www.nejm.org/doi/pdf/10.1056/NEJMsa0803563. Accessed October 25, 2012. Background: Reducing rates of rehospitalization has attracted attention from policymakers as a way to improve quality of care and reduce costs. However, we have limited information on the frequency and patterns of rehospitalization in the United States to aid in planning the necessary changes. Methods: We analyzed Medicare claims data from 2003–2004 to describe the patterns of rehospitalization and the relation of rehospitalization to demographic characteristics of the patients and to characteristics of the hospitals. Results: Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. In the case of 50.2% of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician’s office between the time of discharge and rehospitalization. Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition. We estimate that about 10% of rehospitalizations were likely to have been planned. The average stay of rehospitalized patients was 0.6 day longer than that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously. We estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion. Conclusions: Rehospitalizations among Medicare beneficiaries are prevalent and costly.

Chen JY, Kang N, Juarez DT, Yermilov I, Braithwaite RS, Hodges KA, Legorreta A, Chung RS. Heart Failure Patients Receiving ACEIs/ARBs Were Less Likely to Be Hospitalized or to Use Emergency Care in the Following Year. J Healthc Quality. 2011 Jul-Aug; 33(4):29-36. Accessed October 24, 2012. Angiotensin-converting enzyme inhibitors (ACEIs) have been shown to decrease morbidity and mortality in heart failure (HF) patients in randomized-controlled trials; observational studies have confirmed this benefit among patients discharged with HF. Investigating the benefit of ACEIs or angiotensin receptor blockers (ARBs) among general HF patients has important implications for quality-of-care measurement and quality initiatives. The objective of this study is to assess the impact of receipt of ACEIs/ARBs among patients with HF on hospitalization, emergency care, and healthcare cost during the following year. Using administrative data, we identified HF patients between 2000 and 2005 in a large health plan (n=2,396 patients). We conducted multivariate analysis to assess the impact of receipt of an ACEI/ARB on likelihood of hospitalization and emergency care, and on total healthcare cost. We found that patients who received ACEIs/ARBs were less likely to be hospitalized (odds ratio [OR]=0.82, p<.05) or use emergency care (OR=0.82, p<.05) in the following year. Receipt of ACEIs/ARBs was not associated with significantly increased cost. Incentivizing the receipt of ACEIs/ARBs in a general population with HF may be a suitable target for pay-for-performance programs, disease management programs, or newer complementary frameworks, such as value-based insurance design.

Pracht EE, Bass E. Exploring the Link Between Ambulatory Care and Avoidable Hospitalizations at the Veteran Health Administration. J Healthc Qual. 2011;33(2):47-56. http://onlinelibrary.wiley.com/doi/10.1111/j.19451474.2010.00125.x/abstract;jsessionid=EF008FBF2B6AF41C54885CF85CEE5503.d01t01?systemMessage=Wiley+Online+Library+will+be+disrupted+on+27+October+from+10%3A00-12%3A00+BST+%2805%3A00-07%3A00+EDT%29+for+essen. Accessed October 24, 2012. This paper explores the link between utilization of ambulatory care and the likelihood of rehospitalization for an avoidable reason in veterans served by the Veteran Health Administration (VA). The analysis used administrative data containing healthcare utilization and patient characteristics stored at the national VA data warehouse, the Corporate Franchise Data Center. The study sample consisted of 284 veterans residing in Florida who had been hospitalized at least once for an avoidable reason. A bivariate probit model with instrumental variables was used to estimate the probability of rehospitalization. Veterans who had at least 1 ambulatory care visit per month experienced a significant reduction in the probability of rehospitalization for the same avoidable hospitalization condition. The findings suggest that ambulatory care can serve as an important substitute for more expensive hospitalization for the conditions characterized as avoidable.

Ahmed OI, Rak DJ. Hospital Readmission Among Participants in a Transitional Case Management Program. Am J Manag Care. 2010; 16(10):778-783. http://www.ajmc.com/publications/issue/2010/2010-10-vol16-n10/AJMC_10octOsmAhmed778to783. Accessed October 24, 2012. Objective: To examine the relationship between participation in a large wellness and care management company's transitional case management (TCM) program and hospital readmission. Study Design: Retrospective cohort study. Methods: A total of 10,258 members were identified as either participants or nonparticipants in TCM from data archives of a large healthcare company. Engagement and claims data were analyzed using multivariable logistic regression. Readmission predictors that were studied included TCM engagement, the major diagnostic categories of "musculoskeletal" and "digestive," length of stay for the initial hospitalization, cost of initial inpatient stay, risk score, age, and sex. Results: Readmission rates were lower among individuals who were engaged in TCM compared with those who were not engaged. Within 30 days, 12.66% of individuals participating in TCM were readmitted to the hospital compared with 35.85% of those not participating (P <.0001). In the first 30 days, individuals who did not participate in TCM were almost 4 times more likely to have a hospital readmission than those who did participate. The most important predictor of hospital readmission was engagement in TCM. Individuals who were engaged in the program were less likely to be readmitted than those not engaged in the program (P <.0001). Conclusion: Implementation of a telephonic TCM program was associated with lower rates of readmission within 30 days. Timely engagement in TCM was associated with a lower likelihood of readmission.

Abhijeet Basoor, MD. Basoor’s Heart Failure Checklist ©. http://www.cardiosource.org/ScienceandQuality/QualityPrograms/~/media/Files/Science%20and%20Quality/Quality%20Programs/HF%20Checklist.ashx. March 24, 2012. Accessed October 23, 2012. Use of a new, simple and inexpensive checklist appears to drastically lower the likelihood of heart failure patient readmission and improve quality of care when used before patients leave the hospital, according to research presented today at the American College of Cardiology’s 61st Annual Scientific Session. The Scientific Session, the premier cardiovascular medical meeting, brings cardiovascular professionals together to further advances in the field. Heart failure (the heart’s inability to pump enough blood to the body) costs $29 billion each year in treatment and carries a relatively high 30-day readmission rate, which can cost hospitals an average of $2,084 per patient per day. Under the Affordable Care Act, hospitals may not be reimbursed for readmissions occurring within a 30-day period. Clinicians who used this one-page, 27-question checklist at discharge were able to cut the percentage of patients who were readmitted to the hospital within one month of a cardiac event from 20 percent to just 2 percent. The readmission rate continued to be lower six months after discharge. If broadly adopted, this would translate into billions of Medicare dollars saved each year. While other studies have shown that home care and patient education can reduce readmissions, this is the first to evaluate the use of such a unique one-page, in-hospital checklist that required no extra cost. “In addition to lowering 30-day and six-month readmissions and the associated costs, we also showed that more patients in the checklist group were likely to be on correct medications and had appropriate drug doses than patients in the control group,” said Abhijeet Basoor, MD, the study’s lead investigator, who developed the checklist at St. Joseph Mercy Oakland Hospital in Pontiac, Mich., where he practices Internal Medicine and Cardiology. The checklist was developed and used after approval of the hospital Cardiovascular Quality Integration Board. Dr. Basoor said that everything on the checklist is derived from and reinforces evidence-based practices for managing heart failure and lowering the likelihood of another cardiac event. It is divided into three parts: medications and their appropriate dose modification; counseling and monitoring intervention; and follow-up instructions. The average heart failure patient will need 12 to 15 of the total 27 interventions listed, so using this checklist can help remind both patients and doctors about the various steps that can be taken to manage the condition. “The checklist provides simple reminders to instruct patients about things like diet, weight, blood pressure monitoring and appropriate drug dose up titration,” said Dr. Basoor. “The physician or nurse practitioner working with the patient uses the checklist, so hospitals don’t have to pay for additional nursing staff or home care follow-up.” In this randomized controlled trial, 96 heart failure patients were followed for six months after discharge for an initial cardiovascular event. Doctors randomly used the checklist before discharge in half of these patients, while the other half received standard treatment including discharge education and instructions. Data were collected at 30 days and six months post-discharge. Both groups were comparable in terms of other cardiovascular risk factors, age, sex and physician groups treating them. After excluding deaths during follow up, only one person in the checklist group was readmitted to the hospital in the month following discharge compared to nine in the control group. At six months, 11 patients in the checklist group had been readmitted, compared to 20 in the control group. Higher proportions of patients were on ACE I/ARB medications (those used to control blood pressure) in the checklist group compared to the control group (40 of 48 vs. 23 of 48, 95 percent CI = 0.17 to 0.53, p < 0.001). Compared to the control group, the rate of dose up titration for beta-blockers and/or ACE I/ARB was significantly more common in the checklist group (21 of 48 vs. four of 48, 95 percent CI = -0.5 to -0.19, p < 0.001). According to the Kaiser Family Foundation, heart failure readmission costs $12 billion in Medicare spending each year and approximately 25 percent of Medicare patients with heart failure are readmitted to the hospital within 30 days of an event. Previous studies have shown 50 percent of these heart failure readmissions can be prevented. When the Affordable Care Act takes effect in 2014, Medicare will begin to penalize hospitals with high readmission rates by refusing reimbursements. “Right now the checklist isn’t part of the standard medical record, so there could be resistance to using it,” Dr. Basoor said, “but if we show it’s really beneficial and easy to use, this could become a common practice. We’ve shown that quality of care can be improved at almost no additional cost. In the era of electronic medical records, we are working on transforming the checklist to an electronic form.”