Decreasing Hospital Readmissions with Advanced Care Planning

Patients with progressive and terminal disease processes such as chronic kidney disease (CKD), congestive heart failure (CHF), and chronic obstructive pulmonary diseases (COPD), acute myocardial infarction (AMI), and coronary artery bypass graft surgery (CABG), are at a higher risk for hospital readmissions due to the progressive nature of the disease processes and the continuation of symptoms that worsen over time. Regardless of recent hospitalizations, once symptoms escalate, the common response for patients and families is to return to the hospital. To reduce readmissions health care providers should address goals of care and advanced care planning prior to discharge. The palliative care patient navigator is typically the initial person on the interdisciplinary health care team to initiate this conversation. Patients who receive palliative care consults for patient-centered goals of care and advanced care planning conversations early in the disease process will have an increased understanding of symptomology and symptom management allowing them to utilize community-based resources and have more autonomy in the management of their care. As a result, return visits to the hospital are decreased, patients can remain at home to manage episodes of symptom exacerbation and improve the quality of life. Methods: As a collaborative project between the quality and case management departments, this evidence-based process improvement project was designed to reduce 30-day readmission rates for high- risk patient populations. The Gunderson Lutheran Health system Advanced Disease Coordination Respecting Choices model was used to frame the development, implementation, and evaluation of the project. All inpatients readmitted to the hospital within 30-days of discharge were screened using the BOOST tool method within the electronic medical record (EMR). Patients with BOOST scores >15 demonstrate the highest risk for readmission. Those with a score >15 and who met inclusion criteria were triaged and seen by the Palliative Care team for appropriateness of the Respecting Choices Advance Care Planning education and assistance completing health care goals and advanced directives. All patients who received goals of care and advance care plan conversations, were also referred to interdisciplinary teams for follow up and identified discharge needs. The goal of the program was to discharge patients with a specific plan for treatment with the necessary resources for symptom management at home to prevent frequent hospital readmissions. Results: The evidence-based project was implemented over 30 days during the month of August 2023 with aggregate 30-day readmission data collected for September 2023 on October 1. Data collection and analysis began immediately with a comparative analysis of baseline data collected June 2023 and post implementation data from September 2023. The goal of the project was to reduce the hospital readmission rates by 10% within 30 days of implementation. And to increase the amount of advanced care plans/advanced directives by 20%. The goal was surpassed by 15% reduction in hospital readmission rates within 30-days post project completion. The amount of advanced care plans/advanced directives was 9%. Discussion: Comparative analysis pre and post implementation data revealed a 15% decrease in 30-day hospital readmissions. This information has been presented to stake holders proposing continuation of the process to address 30-day readmissions with advanced care planning.