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The Pennsylvania Psychiatric Institute in Harrisburg reduced its 30-day readmission rate from 20 percent in 2013 to 10.4 percent in 2015 after implementing a discharge program modeled after AHRQ's Re-Engineered Discharge (RED) toolkit. Prior to implementing the program, the Institute had a higher 30-day readmission rate than three other acute-care facilities in the region, according to county-level data.

The Institute’s objectives were—

• To reduce the 30-day readmission rate among its high-risk population.
• To improve quality of care by addressing service gaps.
• To improve patient adherence with hospital after-care instructions.
• To reduce penalties for excessive readmissions.

The facility's high-risk population includes patients with the following characteristics: 40 or more outpatient visits per year and at least one inpatient admission or two partial hospital admissions; co-morbidities of substance abuse/personality disorders, posing a higher risk for substance abuse; history of noncompliance with aftercare; diagnosis of bipolar and schizoaffective disorder; dual eligibility for Medicare/Medicaid; and/or home environment not conducive to patient’s recovery.

To meet its objectives, the Institute developed a behavioral health support initiative called the Discharge READY Program, modeled after AHRQ’s RED toolkit. RED tools that provided particular guidance were "How to Deliver the Re-Engineered Discharge," "How to Conduct a Post-Discharge Followup Phone Call," and "Monitor Implementation and Outcomes," according to Janis Seiders, R.N., program coordinator.

Dauphin County data revealed that the Institute had a 50 percent reduction in 30-day readmissions. Other successes achieved during the first 2 years include quality improvement interventions with physicians and nurses. These interventions resulted in not only improved discharge instructions, but better illness management and medication education for consumers.

"Using the toolkit has been a win-win for everyone—patients, health care staff, and family members," noted Theresa Terry-Williams, M.B.A., B.S.N., R.N.-B.C., the Institute's chief nursing officer.

Ms. Seiders added, "The followup calls offer support during the first month after discharge, when patients' transition back into their daily routine is fraught with unanticipated situations, concerns, and system navigation challenges with after-care services."

A nurse introduces inpatients at high risk for 30-day readmission to the program before being discharged. After agreeing to participate in the program, each patient is scheduled for five weekly phone calls by a nurse. The calls begin 48 to 72 hours after the patient goes home. During the calls, the nurse reviews discharge instructions and assesses any issues that might require additional support. Together, the nurse and the patient develop an action plan for each week.

An outcome survey is completed to rate the patients' experience. "Patients rated their experience as 9.21 out of 10, on average, from 2013-2015," said Ms. Seiders. "We are refining our scripted call record to consistently capture data about concerns and to create performance improvement measures," she added.

The regional benchmark for readmissions for behavioral health providers in the Northeast region of the country is 10.9 percent, based on private-industry data from Optum. According to the Office of Mental Health and Substance Abuse Services, the 30-day Federal benchmark for readmissions is 10 percent or less.