A lot of attention has been given to hospital readmissions in recent years, and the establishment of a readmission outcome measure by the Centers for Medicare & Medicaid Services (CMS) in value based purchasing has incentivized hospitals to work diligently on the problem. The recent article in Kaiser Health News about Beth Israel Deaconess highlights the challenges and obstacles we must overcame to reduce readmissions. The reasons to address this issue go beyond the cost of it. One reason alone should be to improve the overall quality by preventing the re-exposure of a patient to the hospital environment where they can be subject to hospital-acquired infections and other safety concerns, such as falls.
For some of the top readmission diagnosis like Heart Failure and Pneumonia, the biggest obstacles to reducing readmissions have been not what goes on in the hospital, but what occurs when the patient is discharged. It really involves more about the psychosocial aspect of healthcare than the science of the disease and treating it. When the patient is discharged after a heart failure exacerbation, the medical component is typically stabilized. The failures often occur in the process, communication, and overall care coordination.
These are some of the questions that must be asked in order to reduce the risk of readmission.
- Was the follow-up outpatient procedure scheduled before discharge?
- Is a family member or caregiver aware of the follow-up appointment?
- Can the family member or caregiver drive the patient to the follow-up appointment?
- Did the patient receive the proper diet instructions before discharge?
- Do they have the resources at home to help comply with the dietary guidelines?
- Can the patient afford the prescribed medications, and does the patient understand the instructions for taking their medications?
- If the patient needs outpatient intravenous antibiotics, were home health services arranged?
Hospital systems and hospitals that have been successful in reducing readmissions have ensured a coordinated team of visiting nurses, social workers, pharmacist, and case workers all work together to coordinate the process, education, follow-up visits, and overall answers to questions that may come up to family and patients. The future of our healthcare system will be tied to coordinating care using an overall population health analytics system that not only tracts information across inpatient and outpatient settings, but also enables all care providers to communicate more effectively, tying in real time surveillance, monitoring, and alerts. Therefore no matter where the patient is along the continuum (inpatient, outpatient, emergency department, or home) and whoever is interacting with the patient, information is constantly brought together and communicated to improve the health of the patient and reduce risk of readmission for high risk patients and chronic disease.
Byron C. Scott, MD, MBA, FACPE
Medical Director, National Clinical Medical Leader
Complementary to the “Hospital at Home” is the team approach of the Patient Centered Medical Home (PCMH) - not a new concept, but a model that fulfills healthcare reform goals by focusing on making the patient centric in the delivery of health care. Much like the Hospital at Home, the PCMH provides primary care at a community level, actively allowing the patient and their family to participate in their healthcare decisions. It too shows strong results.
The Patient Centered Primary Care Collaborative has monitored the performance of various PCMH models throughout the country and in 2012 published a report of the positive outcomes the initiatives are experiencing including, reduced emergency department events, reduction in hospital admissions, lower inpatient days, and lower readmissions. The chronically ill patient benefits from a care team made up of physicians, navigators, social services, and others in the medical neighborhood that focus on keeping the patient well, satisfied, and out of the hospital.
Senior Consulting Manager
The Medicare penalty is causing hospital systems to pay greater attention to complex patients who are at risk of re-admission. As one who has focused a tremendous amount of time and energy on population health issues, I can tell you this more intense focus is a great step forward. To execute this Medicare penalty with fairness, the severity of the population served needs to be considered. Fortunately, organizations like Truven Health Analytics have developed tools to adjust for the illness burden of the patients treated and can evaluate actual performance against what should occur or can be predicted. By doing this adjustment, hospitals that treat the poorest and sickest people should not be unfairly penalized. And no institution or doctor should feel pressured to not re-admit someone in need.
From a population health standpoint, a hospital admission identifies someone in the community who needs more health care and support. A re-admission is even a greater indication. Our country cannot have a health care system where nearly 20% of its senior citizens who are hospitalized, return for re-admission within 30 days. It demonstrates a need for our delivery system to adjust, and transitions of care are an obvious focus for change.
Most often the physicians and other providers who care for a patient inside the hospital are not the same as those who take over outside the hospital. The handoff between them needs to be coordinated better, with more complete information integrated in the process. Often as well, the patient has limited resources – physical or financial – to assist in their recovery. The hospitalization itself, particularly for the elderly, is debilitating. In some cases, skilled nursing facilities and rehabilitation units need to be better leveraged. Certainly home care services for many of these vulnerable patients needs to be deployed. By focusing on a more comprehensive transition of care process for their patients who are most at risk for readmission, hospitals can reduce readmissions and at the same time provide appropriate support for their communities of patients and providers.
Ray Fabius MD
Chief Medical Officer
CMS has recently imposed penalties of up to 1% of all CMS revenues for hospitals that have higher-than-expected 30 day readmission rates for three diagnoses: congestive heart failure, pneumonia and acute myocardial infarction. Over the next three years multiple other diagnoses will be included. The expectation is that by 2016 all diagnoses will be included in these analyses.
The Truven clinical team has done an extensive review of the medical literature on this topic and has compiled a list of proven interventions can help prevent 30 day hospital readmissions. Key techniques for readmission prevention include:
1. Employ a discharge advocate/patient navigator that can guide the post hospitalization care the patient will require.
2. Educate patients about their diagnosis during the hospital stay.
3. Ensure that high risk patients have a follow-up appointment within seven days of discharge.
4. Use IT and clinical decision support to expedite care transitions especially by digital transmission of discharge summaries and operative notes to primary care physicians, nursing homes and all clinicians involved in patient follow up care.
5. Confirm medication plan and reconcile all discharge medications.
6. For patients who do not speak English, ensure the availability of adequate translators.
7. Consider affiliation with a patient centered medical home to provide follow up primary care for the sickest patients.
Based on our extensive experience in this area, we have devised successful readmission prevention programs, as well as a readmission risk assessment tool to help focus on types of patients who are most likely to be readmitted. While hospitals can ill-afford the penalties that CMS plans, neither can they afford to deploy all possible resources for all patients.
Health care expenditures continue to grow at an unsustainable rate in part due to high readmission rates, hospital-associated infections, and medical errors that can cause adverse events and threaten patient safety. The costs to hospitals are extraordinary. The toll on patients is even higher, with increased treatment costs, longer hospital stays, injuries, and in severe cases, death.
The future of health care quality is now.
I recently had the opportunity to address the future of health care quality at the Institute for Health Improvement and Technology’s (IHI) 24th Annual National Forum on Quality Improvement in Health Care. Alongside Jeffery Softcheck, Director of Laboratory and Outpatient Testing at Silver Cross Hospital, we discussed innovative, targeted approaches to reduce costs by improving care quality for better patient outcomes including:
The growing focus on lowering health care expenditures by improving care quality mean’s that there’s no better time than now then to strategically plan for the future.
- The importance of assessing current hospital performance by identifying areas of quality improvement across the care continuum.
- The need to identify at-risk patients and intervention candidates through proactive, real-time monitoring of patient specific data.
- Providing caregivers the tools and patient-specific information they need, at the point-of-care, to improve care quality.
- The combination of solutions that leads to increased awareness, teamwork, and efficiencies and produces better clinical quality and outcomes.
At Truven Health Analytics, we have a successful history of harnessing clinical data to help predict, manage and improve care quality and patient outcomes. We are now focusing on how we can help hospitals and healthcare partners make the best use of their health care IT systems to reducing costs while never waiving from our shared goal of improving patient care.
I would love to exchange ideas of how we can propel health care quality into the future. Please feel free to email me at William.email@example.com.