Provinces with Lower Hospital Readmissions: What Can They Teach Us?

Unplanned hospital readmissions can have extremely negative impacts on the lives of patients. They can compromise the efficiency of hospitals and care provider organizations. And of course, they can be very costly.

Unfortunately, readmissions are a major concern across Canada. Growing rates of chronic and complex conditions are bringing discharged patients back into acute care. In a country with a health care system as complex as ours, can leaders find a comprehensive solution?

The truth is, complexity creates challenges. But one of its major upsides is that it can also lead to insight – and innovative solutions. Case in point: the varied health care approaches taken by different provinces.

We all know that each province exercises a lot of authority over how health care is delivered. As a result, policymakers across Canada have a unique opportunity to learn from one another. But this opportunity isn’t always exploited.

When it comes to reducing hospital readmissions, what works? What doesn’t? And what new insights can the data provide? In this post, we’ll explore these questions.

Provincial Hospital Readmissions: an Overview

In 2012, the Canadian Institute for Health Information (CIHI) released a comprehensive report on federal and provincial readmission rates. The results came as a surprise to many. At the time, one in twelve patients returned to the hospital within 30 days of discharge.

Of course, some provinces fared better than others. Nova Scotia and Alberta had rates of 8.2 per cent, the lowest in the country during the period covered (2010-2011).

At 11.2 per cent, Nunavut had the highest rate in the country, followed by Saskatchewan, at 9.8 per cent. Other provinces weren’t too far from the national average, which was 8.5 per cent.

In a subsequent period – 2013-2014 – results were pretty similar. Saskatchewan once again skewed high (9.7 per cent) and was also home to the region with the highest readmission rate in the country (10.7 per cent). Nova Scotia did well again, with a rate of 8.2 per cent.

Clearly, there’s been some consistency. Certain provinces and territories are outperforming others – but not by much. Given how small these differences are, how much credence can we give to the factors that have led to them?

More than comparing rates from one province to the next, leaders should look at factors that had undeniable impacts across the country. The 2012 CIHI report is truly helpful in this respect. It identifies a number of causes that contribute to readmissions that aren’t province-specific.

The rural-urban divide is a great example. According to the report, rural patients had a 9.5 per cent unplanned readmission rate, while those in urban areas sat at 8.3 per cent. Lower socioeconomic status was also associated with a higher likelihood of being readmitted.

Lessons Learned

In a 2014 article, Jeanie Lacroix, manager of health system performance improvement at CIHI, commented on Nova Scotia’s readmissions. Lacroix pointed to two areas that contributed to the province’s positive rates. These included pre-discharge information provided to patients, and the type of community care they received at home.

It’s clear that provincial policy differences exist – and they can make a big difference. But when it comes to readmission rates, the variation is relatively small. As a result, it’s hard to say definitively what’s causing it.

When it comes to finding initiatives that undoubtedly reduce hospital readmissions, specific programs within individual health authorities offer true inspiration.

The INSPIRE program, which has greatly reduced COPD-related readmissions, isn’t confined to any one province. The initiative – which focuses on self-management support, education, and home visits (among other tactics) – was developed in Nova Scotia. Based on its undeniable success, INSPIRE has now been implemented in 78 organizations across Ontario, Quebec, and Western and Atlantic Canada.

According to projections, if the program were implemented across all of Ontario, it would net $263 million in health care savings within five years. This number is based on prevented ER visits and hospitalizations.

Within Ontario, there are other clear successes. A 2014 report from Health Quality Ontario (HQC) reveals how Ottawa’s Queensway Carelton Hospital dropped its (high) readmissions rate from 16.4 per cent to 12.92 per cent. Measures taken included providing patients with better discharge information, and improving the use of clinical pathways.

These projects prove that innovative thinking, better discharge planning, and improved patient education are key. This information isn’t easy to find through a comparison of province-wide trends.

That said, it’s worth noting that there are major provincial changes in the works. Just look at Ontario, where the sector’s structure is shifting dramatically. Provincial initiatives such as Health Links are sure to bring about measurable differences in the months and years ahead.

Towards Better, More Efficient Care – All Across Canada

It’s clear that provinces are taking different approaches to reaching health care goals. That said, provincial comparisons don’t always point to clear solutions. Smaller-scale projects are more manageable and measurable. For example, INSPIRE offered clear results that could be repeated.

For health care decision makers, a willingness to learn from other provinces – and share what works – is key. Far too often, assumptions are made at the provincial level. Decisions are implemented without enough backing data.

Luckily, the collection, standardization, and analysis of provincial and organizational information is becoming commonplace. Advanced technologies are making large data sets more useful than ever. And Organizations like Health Quality Ontario (HQO) highlight the importance of scientific rigour and objectivity.

Unplanned hospital readmissions represent a crucial health care quality indicator. Initiatives related to hospital discharge, home care, and chronic disease management must take this indicator into account.

Existing programs should focus on factors proven to reduce readmissions. Patient education. Hospital discharge planning. Follow-up visits. When these areas are adequately addressed, readmissions drop. This is especially true within the populations that are currently most affected – such as rural patients.

Technology offers effective and cost-efficient solutions. For recently discharged patients, consider the possibilities.

Digital platforms can deliver on-demand educational content, helping at-home patients and their caregivers carry out health procedures safely. They can enable face-to-face check-in sessions with medical professionals – via mobile phones, tablets, and laptops. They can even allow circle-of-care members to access, update, and share patient care plans in real time.

Digital information is widely accessible, quickly transmittable, and relatively inexpensive to store. As a result, it’s not just good for individual patients. It’s good for the decision makers and health care leaders who rely on patient data.

The Bottom Line

Increasingly complex patients. More unplanned hospital readmissions. It’s a problem that’s straining budgets and challenging the wisdom of past strategies. Across Canada, it’s time to take action. It’s time for stronger data. It’s time for more innovative solutions and better collaboration.

Federal and provincial policymakers can make a real difference. But so can health care leaders at all levels. From sector decision makers, to hospital executives and home care workers, those who make care possible can also improve it. In the years ahead, a willingness to learn and share will be more critical than ever.

Feature image courtesy of Toshiyuki IMAI

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COPD Education – Onboarding

Objective

To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Actors
Patient, Educator (Nurse, RT, the Physician could also be the educator)

Timelines
One 60-90 min session with the Educator

Description
  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
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COPD Education – Continuous Maintenance

Objective 

To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

Description
  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
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COPD Respiratory Status Follow-up

Objective

Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

Description
  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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