Care Coordination Program Improves Outcomes, Cuts Readmissions

A care coordination program designed to promote safe and effective hospital discharges is effective in lowering readmissions to nursing homes, resulting in better patient outcomes and higher quality care, according to a study published in Clinical Nursing Research. 

After observing how the Re-Engineered Discharge Program (RED) developed by researchers at Boston University Medical Center lowered hospital readmissions, Lori Popejoy, PhD, RN, FAAN, an associate professor at the University of Missouri Sinclair School of Nursing, wondered if it could have the same effect in nursing home settings.

RED focuses on improving care coordination by addressing common issues that come up post-discharge. For instance, the program helps ensure patients are discharged with the correct medications and a proper schedule for home health services in place.

“Ensuring that appointments are scheduled, services have started, and medications are correct and available will help ensure the discharge process goes as smoothly as possible, ultimately resulting in improved patient care and better health outcomes,” Popejoy continued.

To test RED’s effectiveness in nursing home discharges, Popejoy and her research team implemented the program into mid-Missouri nursing homes using two different strategies. One nursing home team received all of the training in a one-day workshop upfront, while the other team received the training gradually over a couple months.

Both strategies successfully improved the quality of care after patients were discharged from nursing homes, the study found.

However, the group that received the training gradually saw greater buy-in from the care teams, which led to a smooth implementation of the intervention program and lower patient rehospitalization rates.

“Discharge plans always vary from patient to patient depending on their condition, and the plan is often developed by a health care team involving physicians, nurses, therapists, family members, and the patients themselves,” Popejoy said.

“This program can hopefully be utilized to improve the discharge outcomes for more nursing home residents,” she continued. “If we can keep people recovering at home and avoid sending them back to the hospital, the better off they will be overall.”

In addition to making sure patients are discharged with the correct medications and home health services in place, Popejoy said that the RED program promotes better care coordination by determining who will be the patient’s main care giver once the patient is home.

“Figuring out who the primary family care provider will be to support patients when they go home is critical to ensure the appropriate services are in place and everyone is on the same page,” she noted.

Popejoy noted that while follow-up phone calls after discharges have traditionally revolved around patient satisfaction, providers should really be asking whether the patient and their support team are following the discharge plan as it was designed.

Although the study focused on nursing homes in mid-Missouri, RED can be implemented in nursing homes nationwide to help improve patient outcomes and lower nursing home readmissions.

As hospitals and nursing homes alike shift to value-based care models, readmissions are a key metric to assess progress.

Since the passage of the Affordable Care Act (ACA) in 2010, CMS has focused on addressing hospital readmissions through the Hospital Readmission Reduction Program (HRRP).

The implementation of HRRP led to an 8 percent reduction in hospital readmissions from 2010 to 2019, providing further evidence that care coordination programs can help providers improve patient outcomes and quality of care.

The program, like RED, stresses the importance of patient and family caregiver engagement in post-discharge care management.