Managing hospital discharge at home may improve readmission rates

LAS VEGAS — A transitional case management services program slightly improved hospital readmission rates, according to a poster presented at the National Council for Behavioral Health annual conference.

To improve 30-day readmission rates, access to community resources and discharge plans in a Washington hospital, Jason Martin, LCPC, CPRP, of Family Services Inc., Sheppard Pratt Health System, and colleagues implemented CareLink Transitions, which offers community-based case management services.

“Hospitals are pressured to discharge patients sooner. We have the ability to implement the discharge plan in the home, and connect the client to resources and providers in the community,” Martin wrote in the poster.

A CareLink Transitions team consists of a licensed practical nurse, entitlements coordinator, clinical manager, community health workers and a data manager.

Under the program, the hospital identifies a patient with a high risk for readmission and CareLink Transitions staff meet with the patient in the hospital for a “warm handoff.” Then, a nurse care manager and entitlements care manager work with the patient for 30 days to implement the discharge plan, establish community-based providers and apply for eligible entitlements. Finally, the team uses the “Pathways” care management model.

“The ‘warm handoff’ has been an effective strategy in engaging clients in our program and quickly identifying their needs,” Martin wrote.

This includes building rapport and engagement, verifying current address, providing a cell phone if the patient has no working telephone number, need assessment and collaborating with a referred social worker.

Since implementation, readmission rates have averaged approximately 17%.

A recent increase in readmission rates may be due to the hospital referring more patients and using more resources to verify readmission data, according to Martin.

They have experienced ongoing difficulty with specific populations, including chronically homeless individuals and those abusing substances.

Martin and colleagues plan to expand the program to other hospitals, change staffing, account for changes in funding and use the “Pathways” model. – by Amanda Oldt

Reference:

Martin J. Care transitions in behavioral health — promising ideas and trends. Presented at: The National Council for Behavioral Health Conference; March 7-9, 2016; Las Vegas.

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