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Best Practices

Updated on August 28, 2017

“By changing nothing, nothing changes.”
Tony Robbins

Percentage of new home care patients with unplanned hospital readmissions within 30 days after acute hospital discharge is a priority indicator for the QIP. This indicator measures the percentage of patients who were newly referred for home care services from the hospital that had unplanned hospital readmissions within 30 days of the initial hospital discharge. Generally, a lower percentage is better. In Ontario 11.6% of new home care patients were readmitted to the hospital within 30 days after discharge.

Below are best practices for reducing the percentage of new home care patients’ unplanned hospital readmissions. They are graded according to Type of Evidence. Evidence-informed best practices are based on quality evidence, they can optimize outcomes and should be implemented into practice where possible.

To help you move from best evidence to best practice you can refer to HQO’s Best Path Transitions of Care Workbook or the RNAO’s Care Transitions Clinical Practice Guideline.

  1. Accreditation Canada, Canadian Institute for Health Information, Canadian Patient Safety Institute, Institute for Safe Medication Practices Canada. Medication Reconciliation in Canada: Raising the Bar – Progress to Date and the Course Ahead. Ottawa (ON): Accreditation Canada; 2012. 

  2. American Medical Association. The physician's role in medication reconciliation: issues, strategies and safety principals. Making Strides in Medication Safety Program. 2007:1-37.

  3. Bell CM, Brener SS, Gunraj N et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-847.

  4. Berkman ND, Sheridan SL, Donahue KE, et al. (2011).
    Health Literacy Interventions and Outcomes: An Updated Systematic Review.
    Evidence Report/Technology Assessment No. 199. AHRQ Publication No. 11-E006. Rockville (MD): Agency for Healthcare Research and Quality; 2011 Mar.

  5. Boockvar KS, Blum S, Kugler A et al.
    Effect of admission medication reconciliation on adverse drug events from admission medication changes.
    Arch Intern Med. 2011; 171(9):860-861.

  6. Burt S., Berry D., Quackenbush P. (2015).
    Implementation of Transitions in Care and Relationship Based Care to Reduce Preventable Rehospitalizations.
    Home Healthcare Now; 7: 390 – 393.

  7. Chen HF., Calrson E., Popoola T., Suzuki S. (2016).
    The impact of rurality on 30-day preventable readmission, illness severity, and risk of mortality for heart failure medicare home health beneficiaries.
    The Journal of Rural Health; 32: 176 – 187.

  8. Chen HF., Popoola T., Radhakrishnan K., Suzuki S., Homan S. (2015).
    Improving Diabetic Patient Transition to home healthcare: leading risk factors for 30-day readmission.
    American Journal of Managed Care; 21 (6): 440 – 450.

  9. De Winter S, I Spriet, C Indevuyst, et al.
    Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department.
    Qual Saf Health Care. 2010; 19:371-375.

  10. Dhalla I, O’Brien T, Ko F, Laupacis A.
    Toward safer transitions: how can we reduce post-discharge adverse events?
    Healthc Q. 2012 Apr;15(Spec No.): 63-67.

  11. Gleason K, Brake H, Agramonte A, Perfetti C.
    Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.
    AHRQ Publication No. 11(12)-0059. Agency for Healthcare Research and Quality; [revised 2012 Aug].

  12. Hayes C, Yousefi V, Wallington T et al.
    Case study of physician leaders in quality and patient safety, and the development of a physician leadership network.
    Healthcare Quarterly. 2010; 13(Sp): 68-73.

  13. Health Quality Ontario. Impressions and Observations 2016/17 Quality Improvement Plans.
    Toronto: Health Quality Ontario 2017.
    Retrieved from: http://www.hqontario.ca/Portals/0/documents/qi/qip/analysis-home-care-2016-17-en.pdf

  14. Karapinar-Carkit F, Borgsteede SD, Zoer J et al.
    Effect of medication reconciliation with and without patient counseling on the number of pharmaceutical interventions among patients discharged from hospital.
    Ann Pharmacother. 2009; 43(6):1001-10.

  15. Kwan JL, Lo L, Sampson M et al.
    Medication reconciliation during transitions of care as a patient safety strategy: a systematic review.
    Annals of Internal Medicine. 2013; 158(5 Pt 2):397-403.

  16. Living a Healthy Life with Chronic Conditions South West Self-management Program.
    South West Self-Management Program Helping People Help Themselves [Internet].
    South West CCAC and South West LHIN; [cited 2012 Dec 19].

  17. Means A., Werneke C., Paquin T., Greenberg EL. (2016). Partnering with the ED Improving Home healthcare referrals to reduce hospitalizations and Repeat Emergency Visits. Home Healthcare Now; 34 (3): 165 – 167.

  18. National Center for Ethics in Health Care.
    “Teach Back” a tool for improving provider-patient communication.
    IN focus Topics in Health Care Ethics. 2006 Apr: 1-2.

  19. Newton A, Sarker SJ, Parfitt A, Henderson K, Jaye P, Drake N.
    Individual care plans can reduce hospital admission rate for patients who frequently attend the emergency department.
    Emerg Med J. 2011;28(8): 654-57. A

  20. Ontario Health Technology Advisory Committee.
    OHTAC Recommendation: Impact of Advanced (Open) Access Scheduling of Patients with Chronic Diseases (Draft).
    Toronto: Health Quality Ontario; 2012 Aug.

  21. Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E.
    How-to-Guide: Improving Transitions from the Hospital to Post-Acute Care Settings to Reduce Avoidable Rehospitalizations.
    Cambridge (MA): Institute for Healthcare Improvement; 2012 June.

  22. Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL.Discharge planning from hospital to home. Cochrane Database Syst Rev. 2013 Jan 31;1:CD000313.

  23. Sinn CL., Tran J., Pauley T., Hirdes J. (2016).
    Predicting adverse outcomes after discharge from complex continuing care hospital settings to the community.
    Professional Case Management; 21 (3): 127 – 136.

  24. Smith S, Mango MD.
    Pharmacy-based medication reconciliation program utilizing pharmacists and technicians: a process improvement initiative. 
    Hospital Pharmacy. 2013; 48(2):112-119.

  25. van Walraven C, Dhalla IA, Bell C, Etchells E, Stiell IG, Zarnke K, Austin PC, Forster AJ.
    Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community.
    CMAJ. 2010 Apr 6;182(6):551-57.

  26. White CM, Schoetter PJ, Conway PH et al.
    Utilising improvement science methods to optimise medication reconciliation.
    BMJ Qual Saf. 2011.

  27. Wood SL. (2015).
    A Home Visit Checklist to Reduce Rehospitalisation.
    Home Healthcare Now; 33 (8): 431 – 436.

Measurement

Updated on August 28, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How do we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another.

Indicator Percentage of new home care patients with unplanned hospital readmissions within 30 days after acute hospital discharge
Topic Integration, Readmission
Quality Dimension Effective
Type of Indicator Outcome
Measure Percentage (%)
Data Source Discharge Abstract Database (DAD), Home Care Database (HCD), Registered Persons Database (RPDB)
Data Collection Instrument Collected by the Institute for Clinical Evaluative Sciences (ICES)
How to Calculate

The percentage is calculated as: (Numerator/Denominator) x 100

Numerator: # of unplanned hospitalizations by home care patients newly referred to home care services within 30 days of initial hospital discharge.

Denominator: # of patients newly referred to home care when discharged from hospital and received first home care service visit within the time period of interest.

Target Lower is better
Range 0 – 100%
HQO Reporting Tool Public Reporting, and Quality Improvement Plans (QIPs)

This data can be presented using Run Charts to track improvement over time. To read more about general measurement in QI refer to Measurement for Quality Improvement or the QI Getting Started Section.

Background

Updated on August 28, 2017

Issue

Sometimes patients need to be hospitalized again soon after being discharged from a previous hospitalization; this is called a readmission (HQO, 2015; 2017). Readmissions are sometimes unavoidable due to a worsening of the patient’s condition unrelated to care. In other cases, readmissions indicate problems in the quality of care patients received, either while in hospital or during follow-up after leaving hospital. While this indicator does not give us an absolute picture of the readmissions due to inadequate care, improving or worsening performance does suggest improvement or worsening of the quality of care provided (HQO, 2015).

In Ontario, one of the key areas of focus in home care is reducing avoidable hospitalizations in order to provide the best quality and safety of health care for all Ontarians, and to optimize the use of health care resources (Baker et al. 2011). The overall percentage of new home care patients who return to hospital after being discharged is 11.6% (Figure 1).

FIGURE 1 Percentage of people aged 16 and older who report that their primary care provider always or often involved them in decisions regarding their care, in Ontario, by LHIN region, 2015.

Source: Discharge Abstract Database (DAD), Registered Persons Database (RPDB), Home Care Database (HCD), provided by the Institute for Clinical Evaluative Sciences (ICES).

Readmission rates in Ontario have remained fairly stable over the last four years. The 30-day readmission rate for short stay patients was 10.5% in 2014/15 and for long stay patients, the readmission rate was 17.6% (Figure 2).

FIGURE 2 Percentage of people aged 16 and older who report that their primary care provider always or often involved them in decisions regarding their care, in Ontario, by LHIN region, 2015.

Source: Discharge Abstract Database (DAD), Registered Persons Database (RPDB), Home Care Database (HCD), provided by the Institute for Clinical Evaluative Sciences (ICES).

Across Ontario’s LHIN regions there is substantial variation in return to hospital after discharge during the 2014/15 fiscal year (Figure 3). Toronto Central has the highest percentage of overall new home care patients who return to hospital after being discharged.

FIGURE : Percentage of new home care patients who return to hospital after being discharged, in Ontario, by LHIN region, 2014/15 - Overall

Source: Discharge Abstract Database (DAD), Registered Persons Database (RPDB), Home Care Database (HCD), provided by the Institute for Clinical Evaluative Sciences (ICES).


Call to Action

Providing safe and effective transitions in care is an important strategy for minimizing unnecessary hospitalizations and ED visits, and reducing avoidable readmissions of patients discharged from hospital to the community (Baker et al. 2011; HQO 2015; Jones et al. 2016). A care transition is the transfer of a patient between different settings and health care providers during the course of an acute or chronic illness (HQO, 2015). Some key transition points include preparing for discharge, discharge, primary care, community care, and self-care follow-up. Risk factors of readmission vary based on patient factors, hospital, region and country and many of them can be avoidable (Jones et al. 2016; Mahmoudi et al. 2016; Naylor 2011). However, usually people are readmitted to hospital during the first 30 days following discharge because of:

  • Unclear or delayed discharge plan and instructions
  • Conflicting plans and instructions from different providers
  • Medication errors, including dangerous drug interactions and duplications.

Hospital readmission has a high burden on both health care systems and patients. Most readmissions are thought to be related to the quality of the health care system (HQO 2015; Mahmoudi et al. 2016). Improving discharge planning, recognition and assessment, patient education, and follow up communication has been shown to reduce readmissions (HQO 2017; Jones et al. 2016; Phillips 2014; Goncalves 2016).

  1. Baker GR et al.
    Enhancing the Continuum of Care: Report of the Avoidable Hospitalization Advisory Panel.
    Toronto: Ministry of Health and Long-Term Care; 2011 November.

  2. Dhalla IA., O’Brien T., Ko F., Laupacis A. (2012).
    Toward safer transitions: how can we reduce post-discharge adverse events?
    Healthcare Quarterly; 15 (Special): 63-67.

  3. Health Quality Ontario.
    Impressions and Observations 2016/17 Quality Improvement Plans.
    Toronto: Health Quality Ontario 2017.
    Retrieved from: http://www.hqontario.ca/Portals/0/Documents/qi/qip-analysis-for-improvement-2012-en.pdf

  4. Health Quality Ontario.
    The Common Quality Agenda 2015 Measuring Up A yearly report on how Ontario’s health system is performing.
    Toronto: Health Quality Ontario 2015.
    Retrieved from: http://www.hqontario.ca/portals/0/Documents/pr/measuring-up-2015-en.pdf

  5. Jones CE., Hollis R., Wahl TS., Oriel BS., Itani KMF, Morris MS., Hawn MT. (2016).
    Transitional care intervention and hospital readmissions in surgical populations: a systematic review.
    The American Journal of Surgery; 212: 327-335.

  6. Mahmoudi S., Taghipour HR., Javadzadeh HR., Ghane MR., Goodarzi H., Motamedi MHK. (2016).
    Hospital Readmission through the Emergency Department.
    Trauma Monthly; 21(2): e35139-44.

  7. Naylor MD, Aiken LH, Kurtzman ET, Olds DM, & Hirschman KB. (2011).
    The care span: the importance of transitional care in achieving health reform.
    Health Affairs; 30(4): 746-754.

  8. Phillips CO, Wright SM, Korn De, Singa R, Sheppard S, Rubin HR. (2014).
    Comprehensive discharge planning with post discharge support for older patients with congestive heart failure: a meta-analysis.
    JAMA; 291(11): 1358-1367.

  9. Goncalves BDC., Lannin NA., Clemson LM., Cameron ID., Shepperd S. (2016 ).
    Discharge planning from hospital to home (Review).
    Cochrane Syst Reviews; 20(1).