Hospital readmission is a growing problem within our health system. Many Medicare patients discharged from an inpatient stay find themselves back in the hospital within 30 days1. Jenny Minott, from Academy Health, states that “some of these readmissions are planned, and others may be part of the natural course of treatment for specific conditions; but, increasingly, some hospital readmissions are being thought of as avoidable and as ‘indicators of poor’ care or missed opportunities to better coordinate care”1.
The Dollars
Coordinated care? What a concept! Hospitals might want to give it a try given that Medicare patients discharged from the hospital have a readmission within 30 days, 
accounting for $15 billion in spending1, (it’s not a typo…$15 billion!!!!), with $12 billion of that amount being preventable. If the cost expenditure wasn’t enough to get hospitals and providers thinking more and more about collaborated efforts of care, maybe the fact that under healthcare reform, healthcare providers with high levels of preventable readmissions face the potential of losing a portion of their federal payments2. In addition, the Centers for Medicare and Medicaid’s (CMS) Hospital Readmissions Reduction Program will reduce Medicare reimbursements, ranging from $10,000 to $500,000, to hospitals with high levels of preventable 30-day readmissions for three high-volume conditions: acute myocardial infarction, heart failure and pneumonia2. And as I mentioned in my last blog post, CMS’ Hospital Value-Based Purchasing Program will only further penalize hospitals for high rates of preventable readmissions.
Prevention
So what can be done to help avoid these penalties and above all else prevent patients from returning to the hospital? With the help of industry experts, Cheryl Clark from Health Leaders has compiled a great list of some strategies that may help reduce this growing problem3:
- Discharge Summaries
Dictate discharge summaries within 24 hours of discharge. Amy Boutwell, MD, an internist at Newton-Wellesley Hospital in Newton, MA and Director of Health Policy Strategy for the Institute for Healthcare Improvement states, “Standard practice and policy at most hospitals is that discharge summaries are completed within 30 days of the discharge. What we need today is anticipatory guidance. Patients get discharged and go home. They can’t fill their meds, insurance doesn’t cover the med or they have questions. They’re nervous and worried. They call their primary care provider, who didn’t even know they were admitted. Information needs to be available at the time of discharge.” - Lengthen the Handoff Process
At every juncture in the patient care process, especially discharge, have teams talk to each other about the patient. And by the way, don’t call them discharges, call them transitions.” Standardize them for a variety of providers, from hospital to rehabilitation facility to skilled nursing facility to home and back. Boutwell says that “taking this person-centered approach shifts the concept from discharge, which is a moment in time and you’re done with it, to a transition–a shared accountability. We need to make sure the receiving providers understand who this patient is, with a 360-degree view.” - Provide Medication on Discharge
Send the patient home with 30-day medication supply, wrapped in packaging that clearly explains timing, dosage, frequency, etc. Some health centers with Medicaid patients may be trying this strategy, which is difficult for hospitals to do with Medicare patients because of distinctions between Part A and Part B payment. Still, for some high-risk populations, such as patients with congestive heart failure and those who have been readmitted before, it might be worth it for the hospital to absorb the cost, it would be a lot less than the cost of a readmission. - Make a Follow-up Plan before Discharge
Have hospital staff make follow-up appointments with the patient’s physician and don’t discharge the patient until this schedule is set up, typically 5-7 days post discharge. A key is to make sure the patient has transportation to the physician’s office, understands the importance of meeting that time frame, and following up with a phone call to the physician to assure that the visit was completed. - Telehealth
Possibly use video monitors to communicate on a daily basis with the use of such software as Skype. It’s an interesting approach to keep up visual as well as verbal communication with patients, especially those that are high risk for readmission. Some technologies even allow for monitoring and reporting of vitals. This is especially important for those patients residing in rural areas. - Identify Frequent Flyers
Customize your hospital’s admission and re-admission rates for demographic and disease characteristics to identify those at highest risk, and expend extra resources on their care needs. - Understand What’s Happening after Discharge
Some institutions are using video cameras to chronicle home settings and the entire care process to determine what’s happening to the patient after discharge that provoked a readmission. Institutions are also using video of the care team, from the pharmacist, home care providers, nurses, and physicians about their care of that patient, to highlight wrinkles and cracks in the system that brought the patient back to the hospital. - Provide Home Care on Wheels
Just like Meals-on-Wheels can be scheduled in advance, so can case management, housekeeping services, transportation to the pharmacy and physician’s office. - Consider Physician Medication Reconciliation Medication reconciliation is comparing the medications the patient is taking at admission with the medications prescribed at discharge. This is a common gap with transitions of care. Stephen F. Jencks, M.D., says “we are to make sure that patients are able to get and take medications, get recommended follow-up, and generally do as they are told. But we know that physicians often recommend a time-to-follow-up that is too long, that discharge plans are often written in ignorance of the patient’s pre-admission history and experience. In general, we need to be much more critical of the plans patients get.”
- Make Sure Patients Understand
Patient communication and education is a critical component of readmission prevention. Patients may nod, and say they understand what they’re supposed to do after they leave the hospital. But “teach back,” in which they and their caregivers repeat back those instructions, even to more than one hospital caregiver, needs to be constantly reinforced. Jencks says that caregivers need to understand that their patients are often heavily medicated, stressed, groggy and confused. And that their disease state may impair their ability to understand what they are being told, much less remember it two days later. - Focus on High-risk Patients
Examine the readmission patterns at your hospital and see which patients, with which conditions, diseases or procedures, have the most readmissions. If resources are limited as they are at most hospitals, push them toward a select group of patients in a more intense way to see if increased effort makes a difference.
By combining the above listed strategies with the effective implementation and use of analytics, and continuing to coordinate care efforts, hospitals can reduce avoidable readmissions, improve quality, reduce unnecessary health care utilization and costs, promote patient-centered care, and increase value in the healthcare and stop the revolving door to the hospital.
Resources cited in this blog:
- http://www.academyhealth.org/files/publications/ReducingHospitalReadmissions.pdf
- http://www.beckershospitalreview.com/quality/10-proven-ways-to-reduce-hospital-readmissions.html
- http://www.healthleadersmedia.com/content/QUA-260658/12-Ways-to-Reduce-Hospital-Readmissions
