Preventing hospital readmissions can’t be a solo mission

When a patient is unexpectedly back in hospital, or in an emergency department, soon after being discharged, it’s an indicator that some aspect of his or her recovery is not going according to plan.

In Canada, the Canadian Institute for Health Information (CIHI) reports that 8.5 per cent of patients discharged from hospital are readmitted within 30 days. Nine per cent of discharged patients visit an emergency department within seven days – and almost one-third of those emergency visits result in readmission.

Medical patients have the highest readmission rate and account for almost two-thirds of readmissions – significantly more than surgical or obstetrical patients. Chronic illnesses such as COPD and heart failure are among the most common conditions associated with unplanned readmissions, and patients with co-morbidities are more likely to be readmitted.

Many of these incidents are unavoidable. However, CIHI reports that published studies have found rates of preventable readmissions ranging from nine per cent to 59 per cent. Even at the lower estimates,  reducing hospital readmissions  can deliver better patient outcomes, improve patient’s quality of life and spare patients and their families the disruption of a second hospitalization, and it saves the healthcare system considerable costs.

This is why Women’s College Hospital (WCH) – Canada’s leading academic ambulatory hospital and a world leader in the health of women – is focused on developing ambulatory models of care that help reduce emergency department visits and readmissions. It’s our mission to be the hospital that keeps people out of hospital.

This means providing solutions that improve the health system as a whole. The role of ambulatory medicine in preventing readmissions includes establishing innovative models of care for medically complex patients, enabling more effective care transitions, and building a system of integrated care in the community.

When approaching gaps in care, it’s important to not merely identify them, but to understand them. For example, we know that older adults are high users of emergency departments, but researchers at Women’s College Research Institute are probing the underlying reasons for that. They have discovered there are contributing issues, such as vulnerable transitions like moving patients from hospitals to long-term care facilities, and high-risk groups like older women with little family support. This research provides specific targets that enable us to apply more specific – and effective – solutions.

Often, building those solutions means building healthcare partnerships. Even the most comprehensive plan for care after discharge may not succeed without accessible services in the community and effective transitions to ambulatory treatment and primary care. Optimum patient outcomes often depend upon coordinated care and collaboration from multiple providers, multiple services and multiple levels of healthcare delivery.

Those types of collaborations and partnerships are at the core of everything we do at WCH, and are a cornerstone of the WCH Institute for Health System Solutions and Virtual Care (WIHV).

Launched in June 2013, WIHV is designed to address some of the biggest emerging issues in healthcare, including avoidable emergency department visits, hospital readmissions, and improved care transitions. WIHV acts as an innovation laboratory to design and test new ways of delivering higher quality healthcare more efficiently, and then scale-up these processes so they can be widely implemented. But WIHV doesn’t work alone. Its programs are targeting preventable readmissions through partnerships with healthcare players ranging from providers to industry.

For example, working with St. Michael’s Hospital, the University Health Network (UHN), Sunnybrook Health Sciences Centre and Toronto Central Community Care Access Centre (TC CCAC), WCH operates the Medical Virtual Ward. For patients who have recently been discharged, but are at high risk of readmission, it offers some of the best features of hospital care – fast access to specialists, personalized follow-up treatments and highly coordinated healthcare – after the patient has gone home.

The Centre for Addiction and Mental Health (CAMH) and TC CCAC are working with us to provide a similar model for patients discharged from inpatient psychiatric care. Among this group, readmission rates are higher than one in 10. The program addresses the transitional needs of these patients and targets modifiable risk factors for re-hospitalization, such as difficulties with medication management.

Another example is Bridges SCOPE (Seamless Care to Optimize the Patient Experience) which is providing a group of 25 solo-practice, community-based family doctors with specific services at WCH, UHN and the TC CCAC to help them manage their complex medical patients. The aim is to avert exacerbations of chronic illness that often result in an ED visit or hospitalization.

On the surgery side, surgeons at WCH have worked with QoC Health Inc., a technology company focused on patient healthcare, to test a mobile app that enables them to monitor their post-surgical patients remotely. Using the app, patients send daily reports and photos of their incision sites. Their surgeon uses this information to catch complications such as infection (the most common reason for hospital readmission after surgery) before they escalate.

Effective partnerships are crucial to these programs. Strong and diverse alliances will also be the key to ensuring that the solutions developed and evaluated at WIHV do not just benefit patients at Women’s College, but are applicable across the healthcare system and across the country.

Challenges like preventable readmissions and ED visits affect all hospitals, and the healthcare system as a whole. They won’t be solved in a silo, or by a single facility, or even by a single level of healthcare delivery. Only by working in collaboration can we create and implement tangible solutions.

The work we’re doing today, together with our health sector partners, is a fundamental shift in how hospitals can deliver superior, coordinated care outside the traditional boundaries of our individual organizations.  It presents the greatest opportunity in decades for us to transform our health system and to enable sustainable and truly integrated care.