Aug 082011

A colleague asked an important question: Which tools are best for reviewing causes of readmissions? Two examples, from Georgia and New Jersey, are attached to this posting. Georgia’s form requires starting from a patient/family interview review, and does not pull much from the record of the hospitalization. New Jersey’s form starts from the other direction – all pulled from charts, with just the contact information that enables an interview if someone undertakes it.  Each has targeted a certain set of issues — clear plan, medications, teach-back, advance directives, social problems, and so on.  Although the two forms overlap on many targets, on others they do not.

NJ_Readmission Chart Review tool

NEW_GA ReadmissionWorksheet

The Institute for Healthcare Improvement (IHI) has developed another useful form, which can be found on page 88 at this URL:  It “feels” more succinct, because it is set up to do 5 readmissions at a time and to focus upon themes.  But it also requires a more insightful reviewer, one who has thought about what it is that makes for rapid readmissions and what might work to make transitions bette

One way to get started is to simply review just a few charts of people who were readmitted to the hospital with which you are most familiar, and see what you most wanted to learn. You might start with the IHI form and then try filling out the other two to see what additional elements you might consider. Call a few patients or families, or, if that is not appropriate, call the main attending physician in the community. Try to gain some insight from the perspectives of people involved.
Keep track of the time it takes to do this review.  If you can get someone to pull the charts, the work to this point will take about two or three hours. Of the time involved, what seemed most productive and what was most illuminating?

Then put together your own form, starting with whichever one is most suited and adding or deleting the elements to end up with the ones that you found to be most useful.  Test that form on another two or three records, perhaps asking a colleague to do those (to learn what instructions are needed and whether another perspective identifies other things that are very important to include.
My prediction would be that you’ll find some remarkable stories–people in fragile condition whose community doctors did not really know they were out of the hospital or doctors who were unfamiliar with the patient’s situation and medications; people who could not afford the treatment prescribed; and people who simply greatly misunderstood what they were to do. (I recall the patient who told me about having to eat fresh vegetables for his heart – whereupon he opened a fresh can of peas every day!) Those stories will greatly help you galvanize the will to move ahead.  And you’ll have a process and form that you can persuade the quality improvement team at each hospital to do: Perhaps at large hospitals, five each week for four weeks and at small hospitals, five in the month.  Within a month, you’d have enough data and stories to build the endeavor, and continuing to collect the data provides rapid feedback about progress. Pick a lead intervention or two and get it tested and underway!

You are likely to find a certain sense of chaos– that there is a lot of “catch as catch can” processing with thorough unreliability on all sides. If this is the case, your coalition might well work on standardizing the process simply so that it is reliable.  You may find that the issues affecting the frail elders are different from those affecting younger populations– more complexity and fragility in the elders and more lack of access or barriers arising from mental illness in the younger.  Whatever you find, this is the “root cause analysis” that you’ll need to decide priorities and to apply for CCTP funds.

Key words: root cause analysis, reviewing readmissions, discharge record review, quality improvement tools, CCTP funding

Jul 222011

Community coalitions can be an effective way to engage diverse stakeholders in achieving common goals. Establishing such coalitions to address problems in care transitions is likely to be an essential tool for ensuring that such transitions become routinely good. Shortcomings in transitions today reflect larger, systemic problems that can best be addressed by community organizations working together. Indeed, no single organization will be able to resolve the broader issues, or work on its own to improve care transitions. It will truly take a village to make transitions safe, effective, and routine.

Many organizations around the country are looking to build coalitions that focus on care transitions. For many, similar experiences building community connections will enable them to establish and lead such coalitions. But many others will need guidance and support for learning the basics of coalition building, and for understanding issues specific to care transitions.

The Center for Eldercare and Advanced Illness posted a workbook, “It Takes a Village,” that offers  community leaders ideas and pointers for how to get started – and how to get going. It can be read in its entirety on the website at:

The guide provides an overview of coalition building, ranging from recruiting partners to resolving governance. It describes what to consider when setting priorities for the work. Much of the text is devoted to issues of measurement – how will coalitions know that their work is improving patient care and experience? The guide explains how to usemeasurement to advance the coalition’s goals, how to find good data sources, and how to decide on what to measure. It provides very specific information on fixing care transitions, including how to fix the hospital discharge process and how to target rehospitalizations. Because care transitions have a major effect on very sick and vulnerable patients and families, the guide also includes ideas for how coalitions can coordinate their efforts with palliative care programs and services.

Community coalitions have proven effective at addressing diverse public health issues, from improving maternal and child health to creating healthier environments. Coalitions are defined by their focus on a particular issue, by their willingness to collaborate, and by their ability to bring a range of resources and perspectives to problem-solving. The guide offers a starting point – we hope you find it compelling and useful.

We’d like to hear about your experiences – what works for you and what doesn’t, where are your successes and what have been your challenges. Please join the dialogue by offering comments here, or emailing us at [email protected]. We look forward to hearing from you!


Key Words: care transitions, rehospitalization, readmission, quality improvement, coalition building, data sources, measurement