Self-management of chronic disease and hospital readmission: a care transition strategy
Michelle D Kelly
1801 East Cotati Ave,
Rohnert Park, CA 94928
Telephone: 707 498 7773
kelly md (2011) Journal of Nursing and Healthcare of Chronic Illness 3, 4–11
Self-management of chronic disease and hospital readmission: a care transition strategy
Aims and objectives. To identify current trends in readmissions and practices for preventing readmissions in client populations with chronic disease. The objectives are to review evidence and ascertain if best practice guidelines to prevent readmissions exist. An emphasis was placed on the identification of low resource and easy to implement models for the prevention of readmissions.
Background. Chronic disease is increasing in prevalence, and quality improvement is needed as clients transition between a variety of healthcare settings, particularly from hospital to home. People with chronic disease are more likely to need inpatient care, yet studies indicate that readmissions within 30 days of discharge occur. Hospitalisations are considered preventable if linked to unresolved conditions present at the time of discharge and not remunerated by Medicare. In such cases, hospitals bear 100% of the cost of avoidable readmissions.
Method. A literature review of databases in English, Internet searches of CINAL, Cochrane database of systematic reviews as well as Agency for Healthcare Quality Research guidelines were conducted. The search terms used were; care coordination, self-care, self-care management of chronic disease, readmission, preventing readmission, and care transition(s).
Results. The association of chronic disease care with the emergence of readmission rates as indicators of quality of care is explored utilising Coleman’s Care Transition Model. This model is suggested as a practical, evidenced-based intervention, which hospitals can implement to reduce avoidable readmissions.
Conclusions. The review of evidence revealed a lack of high-level research identifying which interventions designed to avoid readmissions were most effective. The available literature provided several recurrent themes concerning effective strategies to prevent readmission. The themes identified were; patient empowerment and carer inclusion, bridging discharge process from hospital to the client’s home, improving self-care capacities and better client understanding of self-administration of medication. Coleman’s model consisting of four pillars coincided with effective strategies prominent in the literature. The concept of care transitions is contemporary and very much evolving. New higher-level evidence is needed as models addressing decreasing readmission are rigorously evaluated.
Relevance to clinical practice. Putting measures into place known to prevent hospital readmission is essential in the provision of quality of care and to addresses rising healthcare costs. Supporting clients with chronic disease through care transitions has been identified as a means to avoid hospital readmissions. Coleman’s model provides a low resource template to build self-care into a client’s discharge process after hospitalisation.
In 2005, chronic disease accounted for 70% of all deaths of people in the USA. Nearly half of all people in the USA currently live with one or more chronic diseases. Chronic disease, such as cardiovascular illness (heart disease and stroke), cancer, diabetes and respiratory illness, accounts for 80% of all healthcare dollars spent in the USA (Centers for Disease Control 2009). Thus, it cannot be overstated that chronic disease is associated with high medical-care costs. Expenditures are attributed to the frequent utilisation of health services, particularly with regard to the use of inpatient hospital services. People with chronic diseases are more likely to be readmitted to the hospital within 30 days of discharge, and when they are readmitted, they often present with an avoidable condition. Considered as preventable conditions, these avoidable readmissions are essentially adverse health outcomes from one or more unresolved conditions from the first admission (Halfon et al. 2006).
Inefficient and poor-quality care leads to increased rates of hospital readmission of patients who have been recently discharged (Medicare Payment Advisory Commission (Medpac) 2007). High readmission rates are attributed to a variety of influences. One of the most significant factors leading to readmission is the inadequate preparation of clients and their caregivers with during the hospital discharge process. Returning home after a hospitalisation, clients are often unable to monitor and manage their disease. In contrast to patients who are transferred to a skilled nursing facility or receive home health care after discharge, the problem of hospital readmission is greater for clients who are 65 years old and over, have one or more chronic diseases, and are discharged to their own home, (Coleman 2003). Populations who live in rural areas or in marginalised communities are also at higher risk for preventable hospital readmission. Thus, a consistent model of effective clinical practice is needed to address and circumvent avoidable readmissions.
The majority of healthcare dollars spent in the USA have been attributed to persons with one or more chronic disease(s); an individual with one chronic disease spends four times more healthcare dollars than does an individual without a chronic disease; and 82% of inpatient service utilisation is by people with chronic disease (Anderson 2007, Medpac 2007). The demographic shift of today’s population in the USA is one in which the proportion of older adults (65 and over) has grown to 10%; this figure is expected to increase to 17% by 2030 (Christ & Diwan 2009). The scope of chronic disease in the U.S. population is increasing; today 25% of children already have one or more chronic conditions (Anderson 2007). The demand for care for people with chronic disease is on the rise and economic factors drive the allocation of health services. The high cost of care and higher rates of remissions in aggregates with chronic disease are under inquiry by Medicare, which aims to decrease costs and improve quality for its beneficiaries. In 2008, a review of Medicare cases found nearly 20% of beneficiaries who were discharged from hospitals were readmitted within 30 days; the annual cost was over $17 billion (Jencks et al. 2009).
The Institute of Medicine (IOM 2000) identified readmission rates as the primary contributor to spiralling health costs, and suggested a strong association between low-quality discharge processes and higher readmission rates. Hospital readmissions are defined as patients who are discharged and then readmitted (unscheduled) within a 30-day period. The readmission rate is considered to be a valid metric of the quality of hospital care (Agency for Healthcare Quality Research (AHRQ) 2006).
Coleman et al. (2002) and Dedhia et al. (2009) hypothesised that if clients are satisfied with their preparation for discharge to their home, these clients are less likely to experience a hospital readmission. Inversely, clients who are more likely to report low satisfaction with their preparation for discharge are also more likely to be readmitted. When Worth et al. (2000) interviewed clients and their caregivers about their patients’ experience of discharge to home, caregivers cited feelings of anxiousness, stating that they did not feel prepared to manage their care at home. Shorter hospital stays and other cost-cutting measures have shifted chronic disease care from the formal healthcare system to the client and his or her informal caregiver(s). A majority of people admitted to the hospital with exacerbation of their chronic condition experience a decrease in their ability to function, which is not fully regained by time they are discharged (Anderson 2007). These limits in function impair independence, and a hospital discharge home often requires clients to depend on informal caretakers for personal and chronic disease care. Considering that half of all medication errors occur at transition points (Institute for Healthcare Improvement (IHI) 2009), such as discharge to home, caregivers play a large role in avoidable readmissions. Caregivers are typically unpaid, lack formal training, and are more likely to be 65 years or older (Weinberg et al. 2007).
The ability of the caregiver to provide a safe and effective level of chronic disease care after hospitalisation was identified as a major concern for clients discharged home (Coleman 2003). In particular, the issue was the lack of knowledge of how to give medications appropriately. Coleman indicated that clients and their caregivers recognised their own deficiencies in knowledge, this perceived deficiency was linked to medication mismanagement at home, and ultimately led to readmission within 30 days after discharge. The standard of practice in every discharge is to assist clients and caregivers with understanding how to take their medications appropriately after discharge. Despite this and other standards of practice for patient safety, 20% of readmissions did not have reconciliation of medication orders at discharge (IHI 2009).
Clients with chronic disease are prescribed far more medications than clients without chronic disease. For example, a client with one chronic disease averaged eight drug prescriptions per annum; a client with three chronic conditions averaged 26 prescriptions per year; and people with five or more chronic conditions, which comprise 4% of the population, fill over 57 medication prescriptions in 1 year (Medical Expenditure Panel Survey 2006, Medpac 2007). Avoidable hospital readmission is a problem of complex proportions and increasing occurrence. This is of special concern especially when one considers that readmission rates are costly and that they tend to occur more frequently with clients with one or more chronic disease(s). It should also be kept in mind that such clients have reported receiving low-quality care, and that this seems related to their low levels of satisfaction and to perceived lack of preparation for self-care at home (Bisognanao & Boutwell 2009).
To identify current trends in readmissions and practices for preventing readmissions in client populations with chronic disease. The objective was to review the evidence and ascertain if best practice guidelines to prevent readmissions exist. An emphasis was placed on the identification of any low resource and easy to implement models for the prevention of readmissions.
To accomplish this several literature databases in English were explored: Internet searches of CINAL, Cochrane database of systematic reviews as well as AHQR guidelines were conducted. The search terms used were; care coordination, self-care, self-care management of chronic disease, readmission, preventing readmission, and care transition(s).
The review of evidence revealed a lack of high-level research identifying which interventions designed to avoid readmissions were most effective. The available literature provided several recurrent themes concerning effective strategies to prevent readmission. The themes identified were; patient empowerment and carer inclusion, bridging discharge process from hospital to the client’s home, improving self-care capacities and better client understanding of self-administration of medication. Coleman’s model consisting of four pillars coincided with effective strategies prominent in the literature. The concept of care transitions is contemporary and very much evolving. New higher-level evidence is needed as models addressing decreasing readmission are rigorously evaluated.
Emergence of readmission rates as quality indicators
Several health-related institutions have looked at the issue of preventable readmissions, and efforts have been made to identify the contributing causes of the occurrence of avoidable readmissions and the steps that health institutions can take to address this problem. New information on readmissions and the factors associated with it is emerging, sparking discussions on whether and how to measure interventions that affect rates of readmission (IHI 2009, WHO 2005, 2008). Major stakeholders evaluating chronic disease costs and readmission rates in the USA include professionals working on health policy and in research think-tanks, as well as government-funded insurers, especially Medicare. Currently, readmission rates as metrics represent the underpinnings of both quality of care and patient safety initiatives that evolved as a result of IOM’s landmark report, To Err is Human (2000). The IOM has called for significant changes in institutional attitudes regarding basic patient safety on the part of the leaders in health care; it has also called for healthcare leaders to bring new modalities and tools to ‘identify and learn from errors’ (p. 1) in order to improve patient outcomes. Moreover, the IOM has determined that coordination of care, especially aimed at improving coordination of services for the heaviest users of the inpatient care, is one of the top 20 priorities in assuring patient safety. Care coordination activities were identified as a way to increase the effectiveness and efficiency of care. Coordinating care would address gaps in quality of care in an increasingly fragmented service delivery system. The IOM found that the highest utilisation of health services, including admission for inpatient care, was by people with chronic disease, usually older adults who had one or more chronic diseases.
There has been a shift in the healthcare environment. Hospitals now more routinely examine their mistakes; however, the precise tools to measure and address patient safety issues are complex, and many of these tools are still not fully in place (Leape & Berwick 2005). Health outcomes of people with chronic disease, including readmission rates, are linked to medical-care quality and hospital staffs’ ability to internally examine the level of care that their patients receive.
Medicare examines quality as a cost-saving measure
Another party interested in reducing avoidable readmission rates is Medicare. The largest payer of healthcare dollars, Medicare is continually examining expenditures, service utilisation, and outcomes of services delivered to their predominately older-adult group of beneficiaries (Christ & Diwan 2009). Medicare has been a pioneer in assessing and promoting the rational use of health dollars and has highlighted patient safety as an indicator of quality of care. This insurer is unique in linking of chronic disease treatment and the number of inpatient days. Medicare has used a variety of fee-for-service payment schemes to both financially reward and punish major vendors such as hospitals. Unnecessarily high utilisation of inpatient services by people with chronic disease has even caused Medicare to redesign reimbursement policies to make wiser use of ever-dwindling healthcare dollars.
Unique aspects of readmission rates and people with chronic disease
A study funded by the Robert Wood Johnson Foundation (RWJF) (Coleman et al. 2004) identified the unique risks for readmission faced by older persons. In a sample of older adults with one or more chronic disease, the researchers found, on average, that older adults saw eight different physicians in 1 year. Results of the research identified that at each point of care, there is a risk that essential information will not be transferred in a timely manner from one physician to another. The findings also illustrated the frequency and complexity of the different points of care for people with chronic diseases and suggested a correlation between multiple points of care and avoidable readmissions. Finally, the study suggested that patients who are knowledgeable about their health become competent managers of their own disease and act as their own patient safety advocates, which, not surprisingly, means that they will probably be less likely to experience an unplanned hospital readmission.
What has been done to date
Large stakeholders in healthcare delivery, such as World Health Organization, Medicare, AHQR, Aetna, Kaiser, RWJF, and others, have designed strategies or implemented programmes for addressing high readmission rates. Three types of approaches have been aimed at lessening the problem of avoidable readmissions: (1) interagency, (2) service delivery, and (3) client focused. The interagency approach uses case coordination to strengthen communication between healthcare agencies to improve the effectiveness of warm handoffs during the transfer of care. With this approach, essential information is both more complete and available for the next healthcare practitioner(s). The intent of a smooth, effective transition between care settings is to both lower costs and to effect better client outcomes. Moreover, the transfer of information in a timely, effective way is believed to improve client health status and lower the risk of readmission. Care coordination, which is designed to be a multiagency effort among professionals at various points of service throughout the care spectrum, involves the planning of required patient-care tasks, timely communication, and the carrying out of procedures to positively impact the outcome of patients. Care coordination models were designed to foster better health outcomes and bridge the gap as clients transitioned between care delivery systems. Different health agencies use care coordination to meet their specific needs. Care coordination programmes can target a client group with a specific disease (such as asthma, hypertension) or a subpopulation (e.g. such as people over 65, adolescents, or those having a combination of diseases) and demographic specifics (e.g. adolescents with asthma). A Cochrane literature review of care coordination studies, done by Parkes and Shepperd (2000), found a lack of models providing substantial evidence for achieving best patient outcomes. A scarcity of quantitative measures was cited as a major limitation.
Service delivery mechanisms involve both case management and discharge planning. In the hospital, case managers conduct activities to assure that clients prepare for transfer to another facility, are discharged home either with or without home health services, and, if necessary, are referred to appropriate outside services. Discharge planning targets clients with specific needs, such as the need for complex care after discharge or a significant reduction in their physiological function. Such planning involves determining clients’ readiness for self-care and the level of their community support. Discharge interventions in some institutions involve telephone calls after discharge, and perhaps home visits to clients as a follow-up to their hospital stay. An example of enhanced discharge planning for an inpatient newly diagnosed with diabetes would likely involve educating the client about the disease and how to test blood sugars and to self-administer insulin. Discharge processes are evolving in response to a recent Medicare regulation that denies hospitals payment for avoidable hospitalisations of their beneficiaries, thus shifting 100% of the cost of preventable readmissions to hospitals (Medpac 2007).
Interventions that are client-focused involve teaching the client and family the skills to appropriately manage the client’s disease outside of the hospital facility. The preparation of clients and their caregivers before discharge is linked with higher satisfaction rates and positive outcomes, including fewer readmissions, than for clients who report dissatisfaction with their hospital stay (Weinberg et al. 2007).
Possible solution to preventing readmissions: Coleman’s Care Transition Model (2002)
Whereas a variety of interventions have shown evidence of reducing readmissions, Coleman’s Care Transition Model (2002) warrants an in-depth discussion because of its appeal to stakeholders. The intervention is a low-cost, low-intensity model that is easily implemented. It is evidence-based, hence effective at guiding practice, and it has demonstrated potential for sustainability. Successfully implemented in 150 hospitals and community-based agencies, Coleman’s Care Transition Model is aimed at preventing readmission in clients with congestive heart failure and other chronic conditions by empowering clients to competently self-manage their care after discharge. Coleman et al. (2006) conducted a randomised control in which the intervention group was assigned a transitions coach who encouraged participants to take an active role in their care. The intervention of coaching includes communication skill-building for clients; the aim is to exchange essential health information across care settings and to help clients assert their preferences. In the intervention group hospital readmission rates were reduced by 12% in rural areas and 35% in urban areas. Additionally, Coleman’s model requires few resources for implementation and is uncomplicated, so busy staff can easily learn the principles and coach clients with chronic diseases on the principles of self-care and self-management of their health conditions, thereby reducing the potential for readmissions in clients.
Coleman et al.’s (2002) model is comprised of four pillars designed to prepare clients to safely transition between care settings; the pillars frame the relationship between clients and the transition coach; however, the focus remains on empowering clients to become managers of their own care. The pillars are (1) medication self-management, (2) person-centred health record, (3) follow-up appointments with primary care clinician and specialists, and (4) how to notice red flags.
The purpose of this pillar is to reconcile differences between what medications are prescribed with what is actually being taken at each transition point. Transition coaches assure that the clients and caregiver have a complete list of current medications, understand what they are prescribed, are aware of what each medication does, and know how to take their medications.
Person-centred health record
Lack of health literacy is a major problem, as clients are frequently given printed lists of their medications by health staff with no other instructions. Clients and their caregivers are empowered to become health-literate by keeping a record, in their own writing, of essential health information. The coach’s role is to introduce the person-centred health record and encourage clients to use the patient record to keep track of their medical history, questions for the primary care provider, and emergency contact information. The Person-Centred Health Record will stay with clients and is updated with each health encounter.
Follow-up appointments with primary care providers and specialists
Close follow-up after discharge to monitor the effect of newly prescribed medications and prevents worsening of the condition and possible readmission. Writing down questions for health providers, bringing in all medications, and ensuring that appointments are kept are essential to the clients’ best use of the healthcare system.
Noticing red flags
Clients’ and caregivers’ knowledge of early signs of worsening of their chronic disease is key to the successful management of clients’ health condition at home. Knowing what the red flags are and seeking the appropriate level of care, either through a call to their provider or trip to the emergency room, can avert exacerbation of their disease progression.
A key aspect of assuring safe transition of clients from hospital to home for is providing support to clients after their discharge. The role of the Transition coach helps clients to navigate the priorities in their own care in their posthospital convalesce. Transition coaches focus on skill transfer and building self-efficacy with clients. They do this through the use of specific self-care tools, such as the person-centred health record, and role-playing how, for example, a client might call a medical office to schedule an appointment. Coaches are nurses, social workers, or allied health professionals. The model is used with clients who are ready to be discharged home or to a skilled nursing facility for less than 6 weeks. A trained transition coach would approach clients in the hospital, give an explanation of the care transition programme, offer to see them in their home 2 days after their discharge, and facilitate completing their own personal health record, especially comparing their discharge instructions and medication list to how they are currently taking their actual medications.
Coleman’s model focuses on following through with discharge instructions after discharge. Discharge instructions include a list of prescriptions also know as a medication regime. Once home clients are faced with interpreting nuances in how to take their medication may misunderstand their regime. Clients not taking medication as prescribed are at risk for readmission and may also be categorised with self-care deficiencies or even non-compliant. A Transition coach provides a bridge after the discharge process with a focus on aligning self-medication administration with the actual prescribed medications. At the posthospital home visit, the coach correlates what was prescribed according to the hospital discharge summary with the actual medications the client is taking. Transition coaches visiting the client 2 days after discharge ascertain exactly how the client is taking their medications by having the client demonstrate their self-administration to the coach in their home environment. Putting all medications on the table, the coach will prompt the client to show them exactly how they are taking their medications; it is in this process that medication discrepancies are discovered. Medication discrepancies are errors between what was ordered and what the client is actually taking after discharge.
Studies reveal that 14·1% of clients had one or more medication discrepancies on the initial home visit, and readmission within 30 days occurred with 14·3% of the clients with one or more medication discrepancies, in contrast to 6·1% rate of readmission of clients who did not have a medication discrepancy (Coleman). Coleman’s model demonstrated improvement in clients’ ability with regard to medication self-management, person-centred health record keeping, knowledge of red flags, and follow-up care with primary care providers and specialists (Darwin & Parrish 2008).
A vast majority of healthcare resources are needed for individuals with chronic disease. Avoidable readmissions not only indicate a poor quality of discharge teaching, but also add to spiralling healthcare costs. Readmissions are exacerbated as clients with chronic disease move through multiple points of care with limited continuity and coordinated treatment. An evidenced-based practice model allows hospitals and patients to align their common agenda; patients want to stay out of the hospital, and hospitals want to improve the quality of care after patients are discharged to prevent unplanned readmissions. The AHRQ Medical Expenditure Panel Survey (2006) called for practical answers on how to implement strategies to reduce readmission rates. The complex care required with posthospitalisation of older adults with chronic disease goes beyond giving patients a phone number to call for a follow-up appointment. Discharge activities leave patients and caregivers dissatisfied and unprepared to manage their care, including safe medication administration at home.
Coleman et al.’s (2002) model provides a template for hospitals to use and to build self-care into a client’s discharge process. The literature emphasises that client and caregiver involvement is central to the positive health outcomes and is associated with lower readmission rates. Use of Transition coaches to empower client’s in their ability to manage their chronic disease after discharge was a key element in transitioning safely from hospital to home. With a focus on providing support on medication reconciliation after discharge the risk of medication error and avoidable readmissions were decreased. Coleman’s model identified medication discrepancies putting clients at risk for avoidable readmission and use of this model could provide information to hospitals to rectify root causes of medication errors. Hospitals are faced with significant economic consequences of bearing the cost of avoidable hospitalisations. The literature suggests that Coleman’s Model of Care Transition is an effective way to reduce avoidable readmissions for older adults with chronic disease.
Relevance to clinical practice
People with chronic disease are more likely to experience an avoidable readmission with 30 days of hospital discharge. Health professionals across practice settings need to be aware of the financial impact and tools to improve quality of care in clients transitioning from hospital to home. Putting measures into place known to prevent hospital readmission is essential in the provision of quality of care and to addresses rising healthcare costs. Supporting clients with chronic disease through care transitions has been identified as a means to avoid hospital readmissions. Coleman’s model provides a low resource template to build self-care into a client’s discharge process after hospitalisation.
Biosketch of the Author
Michelle Kelly, RN, FNP, is a community-based practitioner and nurse educator. She has successfully coordinated a care transition programme based on Coleman’s model with BSN students. Kelly has cared for populations with chronic disease in rural communities which were in need of service beyond homecare coverage. She found a way to involve students in providing some of these health services. Students learned quality-improvement measures while coaching people recently discharged from the hospital. Future endeavours will involve creating and implementing a Care Transition Learning Module for nurses and participating in international nursing education.