Resources: Senior Health Issues at Hebrew SeniorLife

What is Prevention of Rehospitalization

A primary goal of health care provided by Hebrew SeniorLife is helping seniors avoid functional decline and disability. Unfortunately, hospitalization poses a threat to that goal. All too often older patients end up in emergency rooms, leave the hospital even frailer than when they were admitted, and "bounce back" at alarming rates. As medical director of the Rehabilitative Services Unit at HRC, Dr. Randi Berkowitz spends a fair amount of time exploring ways to reduce rehospitalization and is attacking the problem on three fronts:

  • First, implementation of rigorous advanced care planning helps patients and their caregivers determine the most appropriate treatment plans.

  • Second, Project RED (Re-Engineered Discharge) counsels patients using a special software program to better understand and comply with discharge instructions. Studies show that Project RED alone has reduced rehospitalizations by 30 percent.

  • Third, multidisciplinary TIPS (Team Improvement for the Patient and Safety) conferences, during which staff analyze the root causes of avoidable readmissions and near misses in a blame-free environment, encouraging open discussion about what steps can be taken to improve patient outcomes.

Once patients are back home, home health-care providers can help reinforce the Project RED program and become the eyes and ears for their physicians. That's how Executive Director Patricia O'Brien describes the role HSL Home Care can play in preventing unnecessary hospitalization. Her staff provides in-depth monitoring of patients so they can detect health-related problems before they turn into acute episodes that require hospitalization.

In June 2011, a study of Dr. Berkowitz's program was published in the Journal of the American Geriatrics Society, which compared patients' discharge disposition from HRC's Recuperative Services Unit before and after implementation of the intervention. The rate of patient rehospitalization fell from 16.5 percent to 13.3 percent, a drop of nearly 20 percent. Discharges to home increased from 68.6 percent to 73.0 percent, and discharges to long-term care dropped to 11.5 percent from 13.8 percent. Read USA Today article.

"We designed the intervention to promote the importance of patients' goals of care and to help staff see transitions of care as an important part of their work product," says Dr. Berkowitz.

All of these efforts show how change is possible to improve outcomes for older patients while reducing soaring health-care costs. Read Press Release.

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