Checklist tool helps staff evaluate the entire patient, identify readmissions

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Checklist tool helps staff evaluate the entire patient, identify readmissions

After reading this article, you will be able to: 

  • Discuss the Discharge Planning for Social Work Referral tool
  • Describe how staff encourage patients to stay engaged during the discharge planning

Healthcare professionals tend to focus on the reason patients present to the hospital and sometimes ignore other patient characteristics. 

For example, if a patient presents with pneumonia, the staff member might not consider other comorbidities (e.g., wounds or the patient?s living situation) that do not directly relate to the diagnosis. 

Failure to address these underlying issues can lead to unplanned, preventable readmissions. An examination of the patient?s entire medical condition helps improve patient care, thereby preventing readmissions. 

The case management department at Jennie Edmundson Hospital in Council Bluffs, IA, developed a tool that helps staff members do just that, says Loretta Olsen, MSN, RN, senior director of revenue cycle at the hospital.

Readmission assessment tool 

Before implementing the Discharge Planning for Social Work Referral tool, Jennie Edmundson had a readmission rate of 8%. Despite its already low rate, increased regulatory focus on readmissions prompted Lorrie J. Reddish, RN, the hospital?s lead case manager, to reevaluate the case management department?s understanding of readmissions. 

?When I started talking to our staff, everybody had a different idea of what was important to refer a patient to home health or a lower level of care,? Reddish says. 

The differing opinions had a lot to do with which  area of the hospital the staff member worked. New staff members also had different ideas of what factors could be a warning sign of a possible readmission. 

Reddish created the Discharge Planning for Social Work Referral tool using information from those conversations as well as information that was published in ?Identifying Potentially Preventable Readmissions? in Health Care Financing Review, fall 2008. 

As the tool?s name suggests, patients identified as  readmission risks are referred to a social worker, who in turn arranges for necessary postacute services (e.g., home health, skilled nursing, insurance applications). The result is a tool that helps staff members at Jennie Edmundson identify a patient?s readmission risk at the time the patient admits to the hospital and throughout his or her stay.

The assessment tool in action

The following is an example of how case managers at Jennie Edmundson use the tool: 

A patient receives news that she is diabetic. The case manager reviews the patient?s record and sees that the patient weighs more than 300 lbs. The physician has prescribed insulin. The case manager conducts a screening interview with the patient and discovers that she lives alone. 

Based on this information, this patient would receive four checks: 

  • One check for the diabetes diagnosis
  • One check for her weight
  • One check for her living situation 
  • One check for the insulin 

This patient is at moderate risk for readmission, according to the Discharge Planning for Social Work Referral tool. Staff do not refer patients to social workers based solely on the number of checks. 

The intention of the tool is to allow staff to focus their efforts on the patients who need more attention, says Reddish. 

Based on the research Reddish conducted, some characteristics that would trigger an automatic referral to social work include a patient who:   

  • Exhibits noncompliant behavior
  • Is paying for the stay 
  • Has limited or no coverage for prescriptions 

?Specific diseases are at higher risk for readmission, with the top ones being heart failure, [chronic obstructive pulmonary disease], and pneumonia,? says Olsen.  

For example, patients who are self-pay and/or have limited prescription coverage trigger an automatic referral so the social worker can attempt to find resources that will help them maintain their healthcare after discharge.

Currently, staff members use the tool more as a guide and an educational tool than actual documentation, but Reddish hopes to improve the tool and possibly use it to document the need for a social work referral.

Part of a bigger whole

The Discharge Planning for Social Work Referral tool is just one part of the overall commitment to discharge planning at Jennie Edmundson. Discharge planning starts at admission and, in some cases, extends after the patient has gone home. 

Upon admission to the hospital, patients receive a discharge flyer that includes the patient?s estimated length of stay (LOS) and information about what they can expect during their stay.

?[This flyer] ensures a patient feels confident about their healthcare at discharge,? says Olsen. 

Staff also discuss the LOS with other members of the healthcare team so they can initiate the appropriate discharge planning. Before patients leave the hospital, they must fill out a checklist that ensures patients know what to expect after their hospital stay and encourages them to ask any questions they may have.


Adapted from Case Management Monthly, May 2010, HCPro, Inc.