Screening and Referral of Orthopedic Patients into Care Coordination to Decrease Readmissions

Abstract

Background The negative impact on patient outcomes due to unplanned hospital readmissions places a financial strain on the health care system. The Centers for Medicare and Medicaid reported 30day readmission rates as a fair indicator of quality services. Hospitals face monetary penalties for readmission rates exceeding the national benchmark under the Affordable Care Act. Hip and knee replacements were added to the list of conditions in 2014 authorizing Centers for Medicare and Medicaid to penalize hospitals for readmissions within 30 days of discharge. Local Problem When comparing an urban academic hospital to other hospitals in the state of Maryland, 44 hospitals have lower readmission rates for knee and hip replacement patients. Analysis of knee and hip replacement readmissions for two hospitals in Maryland within the same system for year 2017 reported readmission findings of 21 for both knee and hip, 79 for hip only, and 91 for knee only. Both hospitals had a 12% readmission rate in 2017. Interventions The healthcare team identified high, intermediate, and low risk total hip or total knee revision replacement patients at discharge by using the LACE risk-screening tool. Patients were referred into care coordination. Low-risk patients received a telephone phone call prior to their first appointment post-discharge. Intermediate and high-risk patients received follow-up phone calls for 30 days post-discharge, and then received a visit by the care coordinator during their outpatient follow-up visits with the surgeon to review the plan of care. Readmissions, emergency department visits, and no-show appointment rates were tracked before and after implementation of the LACE risk screening and care coordination.

Results Readmission rates, emergency department visits, and no-show appointments in the first quarter (July-September, 2018) were compared to the second quarter (October-December, 2018) when the LACE screening tool was implemented. Readmissions within 30 days post-discharge decreased from one to zero. The no-show appointments were zero in Q1 and five in Q2 were a Pvalue of 0.02. Reasons for no-show appointments included diarrhea and transportation issues. There was an increase from one to three emergency department visits with a P-value of 0.32. The reasons for the emergency department visits post-LACE included wound check, abdominal pain, and femur fracture related to the revision of hip arthroplasty surgery.

Conclusions The LACE Index scoring found to be helpful in this orthopedic care coordination program for identifying patients at low, intermediate, and high-risk for readmission within thirty days postdischarge. Introducing care coordination appeared to enhance post-discharge support and improve hand-offs between the inpatient and outpatient setting of healthcare.