NYC Health + Hospitals/North Central Bronx (NCB) is making significant strides to reduce its readmission rates. It has adopted a multidisciplinary approach that involves the hospital’s medical professionals and patients’ families in an effort to keep readmissions to a minimum. As a result, the hospital’s readmission rate has dropped from 16.4 percent in 2012 to 13.0 percent in 2015 for serious illnesses (such as angina, asthma, stroke and heart failure).
“We saw numbers were on higher side three years ago,” says Dr. Vimala Ramasamy, NCB Director of Medicine, “so we looked at gaps where we could improve and come up with a multidisciplinary approach to prevent readmissions.”
“We’re not going to prevent all readmissions, but we want to prevent avoidable readmissions,” she says. “Could we have done something for the patient during their hospital stay and in the community to prevent avoidable readmissions?”
A major factor in reducing readmissions is educating patients with serious illnesses so they can “self-manage” their illness along with their medical team once they are discharged. In the Bronx community where many of the hospital’s patients live, that often involves changing long-ingrained habits.
“It often means connecting patients with affirmative providers as opposed to having them picking up the phone and calling 911,” says Roy Ramnanan, Director of Care Management at NCB and NYC Health + Hospitals/Jacobi. “So it’s a culture change. We’re making a lot of improvements in that area.”
The hospital now tracks readmissions and sends readmission reports to all departments, with detailed information on the root cause of the readmission. Then the medical team comes up with an intervention plan to prevent future readmissions.
“We tag them as high-risk patients for readmission and provide individually appropriate interventions to prevent readmissions,” Dr. Ramasamy says. The medical team makes sure at-risk patients are not discharged too early and that there is follow up with the patient and their family. “We have to educate family members and caregivers,” she says.
“A team is created for every patient who is admitted, but the team pays more attention to high-risk patients and readmitted patients,” she says. “The team meets at the bedside of the patient and gets the family and the patient involved in a care management plan. Once the patient is discharged, the transition care team follows up in 30 days. We coordinate to see if the patient needs medicine or home visits.”
In addition, the leadership of the care management team meets weekly to look at cases of readmission to see “where did we go wrong and how can we fix it,” Dr. Ramasamy says. The medical teams are led by physicians and include the emergency department, outpatient and ambulatory practice, social workers, care managers, nurses, nutritionists and pharmacists.
“Readmission is something we have been tackling for a long time,” she says. “We want to prevent avoidable readmissions.”