Postdischarge case management, clinic combat readmissions

A 5-hospital health system improved patients' access to postdischarge care.

Where: Inova Health System, a health system with 5 hospitals in northern Virginia and the Washington, D.C., metropolitan area.

The issue: Decreasing utilization and readmissions by improving access to postdischarge care.


Five years ago, hospitalists at Inova Health System were “kind of stuck in the old way of doing things,” according to John Paul Verderese, MD, FACP. “We would transition our patients to the ambulatory setting without paying close attention to who was going to assume their care. Many of our patients didn't have access to primary care due to lack of insurance coverage, or simply didn't have established primary care, and oftentimes, the patient was left to figure it out on their own.”

Such patients were often readmitted for reasons as simple as not filling prescriptions or not understanding the discharge plan, he added. Starting new, difficult-to-manage medications, such as insulin or anticoagulants, posed particular challenges.

As an initial effort toward a solution, in July 2011, the health system launched a telephonic case management program for Medicare, Medicaid, and uninsured patients with high-risk chronic conditions. Then, about 2 years later, a transitional care clinic was added to offer additional support to patients with gaps in access to insurance and primary care. “Our department always felt that we needed a hospitalist discharge clinic,” said Dr. Verderese, who directs both programs.

How it works

Through the case management program, social workers and nurses monitor and coach Medicare, Medicaid, and uninsured patients with diagnoses that put them at high risk of readmission. The patients are called within 24 to 48 hours after a hospital or ED encounter and are followed closely for 30 days postdischarge. Case managers ensure that patients have follow-up appointments with a primary care physician, access to medication, education about red flags and self-management, and home care if needed. “We closely collaborate with our Inova home health organization so that if the case manager feels like getting a nurse out to the house to do some of these things like medication reconciliation or diabetes education [would be helpful], we will do that,” said Dr. Verderese.

The transitional clinic, meanwhile, serves the entire health system and sees patients within 3 to 5 days after their hospitalization. The clinic also sees patients who are referred directly from the ED instead of being hospitalized. “A lot of times, the ER docs were trying to figure out what to do with the patient that didn't have a primary care physician or the plan wasn't clear,” Dr. Verderese said. “Now they can more safely and easily discharge them to follow up with us in the next day.”

He and another hospitalist rotate among the clinic's 3 sites, which are staffed by nurse practitioners, a pharmacist, and chronic care nurse coordinators. Patients are divvied up between the physicians and nurse practitioners; if there is a complex patient, the nurse practitioner will call in a hospitalist or help the patient schedule a follow-up appointment with one of them. “We try to cover most days of the week here in the clinic or at least be available to the nurse practitioners there in the clinic at all times,” Dr. Verderese said. Residents also help staff the clinic at least once a week.


In 2014, patients who went through the case management and/or clinic programs had much lower 30-day readmission rates than patients in the health system overall. The readmission rate among patients seen at the clinic was 6%, compared to the health system's readmission rate of 12.5%. The clinic's uninsured and charity patients had a 5.8% readmission rate in 2014, compared to the systemwide rate of about 11%. Using these numbers, Dr. Verderese estimates that the clinic saved the health system about 50 readmissions of uninsured patients last year. “We've definitely made a dent in readmissions for our uninsured patients,” he said.

With the clinic as a backstop, Inova's hospital staff can discharge vulnerable patients with less worry. “Now we can sleep at night knowing that they're going to be going somewhere. We know we can watch them and slowly hand them off to some of the community clinics that are available to them when they're actually stable on their medications,” said Dr. Verderese. “We know that there is less of a chance that they are going to return to that revolving door of ED visits and hospitalization.”

The case management program has succeeded in reducing readmissions of Medicare patients with diagnoses targeted by readmission penalties; its 13.7% readmission rate in 2014 for these diagnoses compares to the systemwide readmission rate of 17.2%. Overall, patients served through the case management program had a readmission rate of 11.2% last year.

Another result, albeit anecdotal and speculative, is admission avoidance, as the threshold for ED staff to admit patients has gotten higher because of the clinic, which has seen thousands of patients, Dr. Verderese said. “And if [patients] do need to be admitted, I think it also reduces their length of stay because there's a place for them to go right afterward,” he said.

How patients benefit

At Inova Fairfax Hospital, the health system's 900-bed flagship location, Dr. Verderese and other physicians have switched from telling patients to follow up with their primary care physicians to making appointments for patients, whether it's with their regular doctor or the clinic.

Once patients arrive at their postdischarge clinic visit, they can get additional help scheduling future care, including specialty appointments. “When they're here in the clinic, if they're just overwhelmed with people they need to follow up with, it's sometimes difficult to navigate or to get past the front desk of certain physicians or certain offices,” he said. “We can help them do that.” Also, in both programs, comprehensive case management services help connect patients to appropriate community clinics for a permanent medical home.

Patients are satisfied with the extra attention, which begins with the front desk, Dr. Verderese said. “Our receptionist has been the No. 1 reason why this program has skyrocketed to success. Patients who are anxious, they're not sure what's going on, they come here, and they can get a sense of relief that we have it under control,” he said.


A remaining challenge is getting patients their medications, although hospital pharmacists give patients a limited supply at discharge, Dr. Verderese said. “What we will do is take a look at that med list, pare it down to what's really necessary, and maybe get them on the $4 list if they're uninsured. We do a lot of work in getting them on to pharmacy assistance programs for inhalers, asthma medications, insulin, and things like that,” he said.

Another challenge is transportation. “A lot of times, people either are homebound or they just don't have access to transportation, and it's tough to get them here. I'd say there's about a 25% no-show rate because of that,” he said. “We often work with the discharging hospitals' case management departments to provide transportation to those who clearly need help, which has helped tremendously.”

Words of wisdom

“I think we've unfortunately put up these barriers, calling ourselves either a hospitalist or outpatient doc. Being an internist, I think these are skill sets we all should have. Being able to practice well in an outpatient setting makes me a better inpatient physician and vice versa,” Dr. Verderese said. “And it makes the toils of working in both environments more sustainable from a burnout perspective.”

Next steps

Moving forward, Dr. Verderese and his team aim to expand the acuity of care handled in the clinic. “We're trying to develop a day hospital or an extensivist program,” he said. Dr. Verderese hopes to bring in patients with conditions such as chronic obstructive pulmonary disease, asthma, heart failure, and infections, who would otherwise be admitted, treat them in an ambulatory setting, and get them home before bringing them back the next day. “Right now, with a fee-for-service payment system, it's tough to pay for,” he said. “But with a shift toward more alternative payment models and value-based care, I think this could be more possible.”

Another potential next step is to implement a physician house-call program to provide care for homebound patients. “Those [next steps] all together will create what's needed if you want to truly optimize utilization and readmission rates within the new health care environment,” Dr. Verderese said. “I think we're on the road to doing that.”