In a city with one of the highest readmittance rates in the country, Swedish Covenant Hospital improves outcomes with innovative care transition program that targets at-risk patients

CHICAGO  (Jan. 7, 2014) – While Medicare data emerged this week revealing Chicago has more hospitals with higher-than-average patient readmission rates than any other city in the country, one community hospital is pioneering an aggressive intervention program that is enabling it to buck this trend. 

According to government statistics compiled between July 2011 and June 2012, Swedish Covenant Hospital was one of 19 Chicago hospitals with a Medicare patient readmittance rate higher than the national average of 16 percent within 30 days of a procedure. But following the implementation of a unique care transition program, this north side hospital decreased its rate to 14.25 percent during the first 10 months of 2013, the last period statistics are available from Medicare monitoring firm Telligen. 

“Reducing the number of patients readmitted after receiving treatment at Swedish Covenant Hospital is a top priority,” said Mark Newton, Swedish Covenant Hospital CEO. “Our nurses and physicians have taken the initiative to develop a remarkable post-discharge intervention that drives down health care costs while simultaneously improving the patient experience, resulting in a lower readmittance rate since implementation.”

A growing body of research suggests that helping newly-discharged patients better understand their conditions and medications, while providing them with the tools needed to manage their conditions, is crucial to preventing costly hospital readmissions. Focusing on patients with chronic conditions is necessary to lower this rate, as they account for the vast majority of readmittances. 

Currently, eight in 10 older adults in the U.S. are living with a chronic condition. This exacts a tremendous human and economic toll – three out of every four healthcare dollars spent are on chronic diseases and adults with these conditions account for 80 percent of all hospital days. 

While poor disease management often causes readmissions, chronic disease patients who experience rapid rehospitalization often do so as a result of other health complications. For example, a 2009 study found that for more than 60 percent of Medicare patients hospitalized for heart failure or COPD who experienced a readmission within 30 days, the cause of the readmission was something other than heart failure of COPD. 

To lower its readmittance rate, Swedish Covenant Hospital designed a care transition program unlike any other in the country, combining traditional home health services with sophisticated telehealth monitoring and electronic health records integration. This tiered program delivers a wide spectrum of services, including disease management coaching, home visits, telephonic follow-up care coordination, and, for those at highest risk, daily home telehealth monitoring. 

During the first ten months of 2013, Swedish Covenant Hospital’s care transition program has driven the following results:

• Reduced the percentage of chronically ill patients readmitted at Swedish Covenant Hospital within 30 days following a procedure from 27 percent to 16 percent.
• Contacted 1,800 patients in their homes, with hospital staff answering questions related to signs and symptoms or worsening health conditions or ineffective medications.
• Nurse Wellness Coaches performed approximately 175 home visits, aiding patients with complex questions and needs. 
• 88 percent of patients scheduled an appointment with their physician within 14 days of discharge.

Thanks in part to a $175,000 grant awarded by the G. A. Ackermann Memorial Fund, Swedish Covenant Hospital’s chronically ill patients will have access to an expanded care transition program in 2014 that includes additional services like nutrition screening and management. This component was added in response to research indicating malnourishment after discharge is a strong predictor of readmission.

Grant funding also enables the program to target vulnerable patients who are not covered for home health services because they’re not considered “home bound” by insurance providers. 

“Our program fills a gap in the current system of care because it specifically targets high risk patients who are either uninsured or do not meet the strict federal eligibility criteria to receive home health services,” said Kathryn Donofrio, Swedish Covenant Hospital associate vice president and nursing director. “Without these crucial services, these patients would fall through the cracks of the health care system and remain at higher risk of complications, dramatically impacting their quality of life.” 

As part of the program, all Swedish Covenant Hospital inpatients are screened for readmission risk before discharge. Those scoring above a risk cutoff receive an annotation in their EHRs and are then visited by a Wellness Coach (registered nurse) who assesses the patient’s ability to become an active collaborator in the management of his/her illness. Owing to the diverse ethnic and socioeconomic patient population served by Swedish Covenant Hospital, the program has a multi-lingual team (English, Spanish, Polish, Greek, Romanian and Tagalog) of Wellness Coaches who deliver linguistically and culturally competent care. 

Within two days of discharge, a home visit by a Wellness Coach provides care coordination, medication reconciliation and a nutrition screening. Follow-up telephone calls are then conducted throughout the patient’s recovery period. Those at need for additional support receive continued home visits, disease management coaching, telehealth monitoring via remote sensors and care management delivered over a three-month period.  

The care transition program is entirely funded through grant money and Swedish Covenant’s Hospital’s general account.