The transition from inpatient to outpatient medical care can be a challenging process and can lead to frustration for both patients and health care providers. Hospital readmissions and adverse outcomes are unfortunate consequences of these challenges.

A new approach at Eskenazi Health has started to reverse these outcomes and the goal is to continue to see readmission numbers drop as the program develops. Through the work of Eskenazi Health Transition Support, the hospital system provides multidisciplinary care to each patient as they transition from inpatient to outpatient.

Data tracking the most common conditions resulting in readmission shows Eskenazi Health has seen a 10 percent drop  when comparing numbers from the same time period a year ago. The common conditions analyzed include acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and pneumonia (PN), as defined by the Centers for Medicare & Medicaid Services (CMS).

Rachelle Davis, director of transition support at Eskenazi Health, said one of the biggest enhancements has been understanding what factors result in patients being readmitted. She said Eskenazi Health formed a committee that includes physicians, pharmacists, nurses, social workers and others to study ways to combat readmissions.

“One of the first things we did was identify patients at high risk of being readmitted after discharge,” Davis said. “Once we began understanding the multifaceted reasons a patient was readmitted it provided us insight into how we could more effectively reduce the chances of a patient readmitting.”

Davis said strong coordination of services starting at admission along with patient education at the bedside have been key activities employed to assist with combating readmissions. She said Eskenazi Health has created a culture where all hands are on deck. This effort is supported by ancillary and clinical teams across the system.

Another new concept that has been introduced is the Eskenazi Health Center Transitional Care Clinic (TCC). There are two groups of patients that the clinic is targeting. The first group includes patients hospitalized who do not have a primary care physician. The second group includes patients who are determined to be at a high risk for readmission or death within 30 days of discharge.

“Despite careful planning and ample resources, preventing readmissions hasn't been a straightforward endeavor,” said Dr. Kevin Tolliver, medical director of the Eskenazi Health Center Transitional Care Clinic.

The TCC, which is located on the second floor of the Eskenazi Health Outpatient Care Center on the main Eskenazi Health campus, provides a comprehensive medical evaluation. In addition, there are pharmacists, social workers, substance abuse counselors and mental health providers available to see patients during their outpatient visit following discharge. Once a patient responds to treatment and is deemed to no longer be at high risk for readmission, they are scheduled back to their primary care provider, or the Eskenazi Health patient navigators will assist in finding one.

“Hospital readmission and transitions of care remains a major point of emphasis in health care,” Dr. Tolliver said. “At Eskenazi Health, we are able to increase the likelihood of patients showing up for hospital follow-up appointments and reduce the chance of hospital readmission.”

According to published data, as many as one in five Medicare patients are readmitted within 30 days of hospital discharge, with six percent readmitted within seven days. The Dartmouth Atlas of Health Care reported that readmission rates across the country have progressively increased between 2004 and 2009. These adverse post-discharge events cost the U.S. health care system an estimated $12 to $44 billion annually.