Careful analysis of its care transitions and chronic care management procedures enabled one practice to lower its readmission rate and improve care quality
Unplanned hospital readmissions are a nationwide challenge for hospitals and physician practices. Readmissions correlate with greater patient stress, higher mortality rates and increased resource use. Conversely, reduced readmission rates lead to greater patient satisfaction and better clinical outcomes.
Between January 2018 and September 2020, my primary care practice—part of Valley Organized Physicians (VOP) independent physician association—had a Plan All-Cause Readmissions (PCR) rate of around 12%. Located in Harlingen, Texas, we serve patients in one of the nation’s most economically disadvantaged areas. Our patients often lack insurance or are dual-eligible for Medicare and Medicaid. There is also a high prevalence of chronic disease, compounded by socio-economic challenges such as food insecurity, housing/transportation access, financial hardships, health illiteracy, and language barriers. Nearly 90% of area residents are Hispanic, with Spanish being the primary language for many.
A 12% readmission rate is concerning for any patient population, but for our practice it served as a bellwether for underlying social determinants of health (SDOH) that prevent some patients from getting the best possible care. A high avoidable readmissions rate generally suggests the need for better processes related to care transitions and chronic condition management for high-risk patients. By focusing on process improvement in these areas, we hoped to reduce readmissions and address SDOH, with the aim of improving care overall.
Step One: Assembling a team
Health care providers are not usually trained on process improvement. Although doctors and nurses frequently know when something is wrong operationally, we don’t necessarily know how to fix the problem. Our team partnered with outside performance improvement experts from CareAllies, VOP’s management company, so we could accurately identify the root causes of unplanned readmissions and design solutions that would yield meaningful improvement. Together, we identified our goal to reduce readmission rates by 2.5%.
Step Two: Applying the methodology
We applied the principles of a process improvement methodology, Lean Six Sigma, which follows the steps “Define-Measure-Analyze-Improve-Control.” For our project, this meant:
Define: Mapping the current process for managing high-risk patients
Measure: Measuring the frequency of readmissions
Analyze: Determining any patterns and identifying root causes
Improve: Developing solutions that address the root causes
Control: Monitoring performance over time
To map the current state, the team reviewed data and observed processes in action. This allowed us to gather a more holistic picture and determine what was really happening with high-risk patients. Once we understood the root causes, we began identifying where to create new processes and where we should make existing processes more reliable to meet our patient population’s needs.
Step Three: Implementing improvement strategies
Based on data and analysis, our team launched several initiatives that targeted SDOH factors impacting patients and adjusted processes within our practice to provide better care overall These initiatives included:
Educating patients about care locations. We discovered many of our patients didn’t know where to go to receive care. We created materials to guide staff as they educate new patients about after-hours care and urgent care centers. We also launched a “Call Us First” campaign using posters and buttons which let patients know they can call us for non-emergencies—before incurring the cost of an emergency department (ED) visit.
Addressing transportation roadblocks.Many of our patients rely on others, including family and friends, for transportation. This can be unreliable and lead to patients missing crucial follow-up appointments. Our team created flyers to help patients understand how to access community resources and/or use insurance benefits for transportation to the office.
Increasing medication adherence. Our patients also needed an easier way to understand their medications. The team designed information sheets using pictures and simple phrases to help patients remember which medications they’ve been prescribed; why they are taking each medication;when to take each medication; how much of each medication to take and how to take it.
Simplifying chronic condition management. Due to the complexities of chronic conditions and the language barrier that often exists between providers and patients in our community, we saw an opportunity to improve patient education around chronic conditions so patients could self-manage between visits. We developed a series of flyers that employ a red/yellow/green stoplight graphic with condition-specific symptoms and action plans. The care team walks the patient through the flyer, explaining what they can expect and what actions they need to take, or not take, under certain conditions.
We also launched initiatives to better coordinate post-discharge care. These included:
Enhanced patient discharge planning. Patients who have a clear understanding of their hospital discharge care instructions are 30% less likely to be readmitted to the inpatient setting or visit the ED. To ensure we have all the necessary information for the patient’s post-acute care follow-up, the performance improvement team created a script to help us gather post-discharge information—such as patient history—and access post-discharge instructions. The team also spent time identifying potentially high-risk patients and made sure there was a process in place for getting those patients scheduled for a follow-up visit in a timely manner.
Closing the loop with specialists.Collaboration between primary and specialty care providers is key to successful patient outcomes, especially for patients with multiple chronic conditions. To encourage and facilitate communication between primary care and specialists, our team created a non-legal document called the Specialist Care Compact outlining what each party needs to provide top-notch care.
Through these improvement strategies, our practice lowered its PCR rate by at least 10% in less than a year. The average readmission rate is now around 7.3%—significantly better than initially hoped. In addition, our overall PCR results are more stable with less variation month over month.
Looking back on the project, a few lessons stand out. First and foremost, strong leadership is essential. There are many competing priorities but making sure there is one leader who is focused on keeping the project on track and moving forward ensures the rest of the team will also make time for the initiative.
We also found that a “learn by doing” approach helps teams develop new skills as they address issues. It can be intimidating to start new processes but by working with the process engineering team our internal group learned how to engage in process improvement while going through the project. Now we hope to tackle future improvement initiatives even faster.
Additionally, patient empowerment was essential to ensuring that patients receive the care they deserve. Whether it was educating patients on available community resources or providing recognition aids that help them keep track of medications or know when to follow-up, sharing tools that enable patients to manage their health was crucial to success.
Ultimately, bringing a clinical team together with process improvement experts helped us make a meaningful difference in the way we provide care to high-risk patients and meet our patient population’s needs.
Stephanie H. Garcia, M.D. is a family medicine specialist and board member of Valley Organized Physicians.