Operating under the assumption that the government is moving toward enacting reimbursement penalties for all-cause readmissions, some hospitals and readmission prevention experts are already developing corresponding strategies.
This article appears in the May 2013 issue of HealthLeaders magazine.
When asked why their efforts to prevent 30-day readmissions focus only on patients with heart failure, pneumonia, or heart attack, many hospital leaders shrug: because those readmissions are the only ones for which hospitals suffer a stiff reimbursement penalty.
While many hospitals intend to target all-cause readmissions eventually, for now, it represents a steep front-end expense their budgets are not yet ready to absorb in a fee-for-service world, especially for readmissions that are not yet at risk for penalties.
Amy Boutwell, MD, MPP, is a readmission prevention expert and practicing physician at Newton-Wellesley Hospital in Newton, Mass. She recalls a seminar she held in December for representatives of 62 New Jersey hospitals.
"I asked everyone in the group, 'Is anyone taking this all-cause approach?' And none of them were," she says. "They just don't have it on their radar. Their 'first phase' of efforts is still very much focused just on one disease. Their challenge in 2013 is to move from one disease-focused pilot to a broad portfolio of efforts."
But a few hospitals are forging ahead on the all-cause front. They're working on pilots and special programs that are reducing readmissions regardless of diagnosis, first on a unit or floor, and then across their entire hospital or system. Integrated systems are working with their physician networks to make sure there's a provider ready to "catch" these patients after they're discharged to give them what they need so they don't come back.
They're hiring specialty care coordinators and transition coaches. And they're tailoring follow-up care for patients with multiple comorbidities, from mental health and literacy issues to poorly controlled diabetes, asthma, substance abuse, and chronic pain.
They're working with skilled nursing facilities and home health agencies in their communities to make sure their discharged patients don't reappear in their emergency departments within 30 days. In some cases, programs track patients for as long as 60 and 90 days, not just because it's good for the patient: Some hospitals say it's good for their bottom lines, especially when the readmitted patient is uninsured or underinsured.
"The reason we've gone beyond those three diagnoses is partially because we assume the government is moving to all-cause readmissions, so we are acting on that," says Lee Ann Liska, chief operating officer for the six-hospital, 1,617-bed Mercy Health in southwest Ohio.
"If you have a vulnerable population struggling with chronic disease, multiple illnesses, and challenges like socioeconomic issues, poor living conditions, poverty, illiteracy, as a mission-based organization we believe if we invest in the front end we'll save on the back end by avoiding unnecessary readmissions," Liska says.
"I would say that many of our readmission reduction programs are disease agnostic," says Zeev Neuwirth, MD, chief medical officer and senior vice president of ambulatory care and corporate services for Charlotte, N.C.–based Carolinas HealthCare System, a 38-hospital network with 7,460 beds in North and South Carolina.
Neuwirth says that through collaborations with skilled nursing facilities, "we're in the process of putting together quality metrics with our nursing homes that we are sending our patients to—a dashboard—and beginning to be transparent, to see who's doing well and who can improve."
These hospitals are biting the all-cause bullet in part because they recognize federal rules expand by four the number of conditions in the penalty algorithm by Oct. 1, 2014, "and to other conditions and procedures as determined appropriate by the Secretary," according to Section 3025 of the Patient Protection and Affordable Care Act. A final rule expected soon may help clarify how far the Centers for Medicare & Medicaid Services will want hospitals to go.
Those four, identified by the Medicare Payment Advisory Commission, are: chronic obstructive pulmonary disease, coronary stent procedures, vascular surgery, and coronary bypass procedures.
In April 2012, the National Quality Forum endorsed two all-cause readmission measures, one of which was "codeveloped" by CMS and researchers at Yale University, and leaders presume it will soon be featured in a proposed payment rule, and a sure sign that is weighing on the agency's thinking. The algorithm includes a risk-standardized rate of unplanned readmissions among adult patients hospitalized for surgery, gynecology, general medicine, cardiorespiratory, cardiovascular, or neurological conditions or procedures.
The second measure, designed for health plan quality monitoring, counts any adult inpatient stay followed by an acute readmission for any diagnosis within 30 days, contrasted with a calculation of the probability of an acute readmission.
"In an effort to reduce inappropriate readmissions, our hospitalists and ambulatory physicians are meeting together to create solutions that provide more seamless coordination of care during the transition from hospital to home," Neuwirth says. "We are piloting numerous innovative initiatives involving technology, which include using iPads to communicate with patients at home and evaluate the safety and healthfulness of homes, and home biometric monitors to track patients on a daily basis."
A project that launched in 2010 enabled the Carolinas' Blue Ridge HealthCare network of Morganton, N.C., a group of 75 physicians and 17 extenders, to work on readmission rates for heart failure, pneumonia, heart attack, and also COPD. While readmissions declined significantly for the three conditions covered by the current Medicare penalty, so did readmissions for patients with COPD, which went from 12.56% in 2011 to 11.59% in 2012.
The Blue Ridge group also tracked all-cause readmissions across its two hospitals. One of them, 184-bed Grace Hospital in Morganton, N.C., saw an improvement in its expected all-cause readmission rates and its observed rate. For example, by 2012, its expected all-cause rate was 10.13%, but the hospital actually saw only 6.35% of its patients return within 30 days, says Maxine Molter, Blue Ridge HealthCare's vice president of medical management.
Primary care physicians on staff at 241-bed Cleveland Regional Medical Center in Shelby, N.C., meet regularly with hospitalists to work out problems. There are plans to ensure that when any patient is discharged, hospitalists check that a follow-up physician appointment has been made and that a discharge summary is created "with urgent follow-up needs at the top," Neuwirth says. Any readmission that happens in spite of these efforts will be reviewed jointly by the hospitalist and the patient's primary care physician to see what went wrong.
The fact that they've "agreed to do this together, across the chasm of the hospital-ambulatory care divide, is huge," Neuwirth says.
Holyoke (Mass.) Medical Center, a 198-bed facility, has an underserved patient mix that includes some of the most socioeconomically disadvantaged in Massachusetts, says Jim Keefe, vice president of inpatient services. With the hiring of two people devoted specifically to the effort, the hospital has had success in reducing 30-day all-cause readmissions.
In January, February, and March of 2011, for example, readmission rates were 13.5%, 14% and 22%, respectively. But in the last three months of 2012, they had dropped to 12.7%, 9.2% and 12.1%, with better health for patients with chronic obstructive pulmonary disease, one of the key targets.
"We realized that the only way to reduce our all-cause readmission rate was to hit every single patient," says Cherelyn Roberts, RN, BSN, program manager for the Holyoke STAAR initiative (STate Action on Avoidable Rehospitalizations), a readmission tool designed by the Institute for Healthcare Improvement. "We started with heart failure, but then took on COPD," because Holyoke's catchment area includes a lot of smokers.
"We interviewed some of our patients who were being frequently readmitted and discovered that many patients had never touched an inhaler. They were given a piece of paper and told to go to a pharmacy and get it, and then they were on their own. No one ever watched them effectively administer it."
Now the patients receive extensive teach-back for multiple days before their discharge with the same type of inhaler they're prescribed so they'll know what to do when they leave.
The second thing the Holyoke team discovered was that the pulmonary program's own policy prohibited people from attending pulmonary rehabilitation sessions if they refused to quit smoking.
"We changed that immediately, offering patients nicotine replacement or smoking cessation support while they're in the hospital."
To date, Holyoke has tripled the number of people attending pulmonary rehabilitation sessions. "We're seeing a volume shift from three to five patients a week to more than 20," Keefe says.
Adds Roberts, "These patients are building up their physical endurance and activity, and I just looked at the stats. Hardly any of these patients is getting readmitted. It's been a real win-win."
Another initiative at Holyoke that is now paying off is the use of a scoring system for every admitted patient to rate his or her own likelihood of readmission, with five points indicating high risk and triggering much closer monitoring after discharge. Cognitive impairment, prior repeat hospitalization, and a repeated emergency department visit within the past three months score three points each, while having an end-stage condition scores a five.
Then, a multidisciplinary effort kicks in involving hospitalists, primary care physicians, the pharmacy, physical and respiratory therapy, "or anyone else who is going to touch that patient." Everyone on the team shares information about that patient, including transportation needs.
Efforts involving skilled nursing care stress "warm handoffs" between the patient's discharge nurse and the facility's nurse, including medication reconciliation, teach-back, and other aspects of the patient's care to prevent the patient from coming back, including cases where the patient returns to the hospital after first being discharged and sent home by the skilled nursing facility.
The program is starting to work because, Keefe says, "I honestly feel that there's a sense that if the nursing facility is not on board, being a partner with us, they lose the opportunity for referral. It's an all-in situation."
At Mercy Health, Margie Namie, RN, MPH, CPHQ, divisional vice president of quality, says care transition teams target specific disease populations "where it makes financial and clinical sense to reduce readmissions," especially Medicaid and self-pay patients, who often have more barriers after discharge.
"These patients are such a cost burden to the system that it really makes financial and clinical sense to provide support for them because it drives cost out of the system that flows to the bottom line." Mercy Health started with pneumonia, heart failure, and heart attack early last year because it was a Catholic Health Partners system objective. Then in October, Mercy Health focused on all-cause diagnoses, tailoring interventions to particular types of patients.
Sometimes, Namie says, preventing readmissions means doing something for patients that has nothing to do with their physical health but improves their mental outlook so that they work harder to stay out of the hospital.
One of the nurses had a patient with no furniture except a bed, "so she stayed in bed all the time. The nurse arranged for her to get a chair, so now she can sit by her window and see her garden."
When teams analyzed why patients were being readmitted for any reason, it became clear that many were illiterate but had developed great skills at covering it up. "It's hard to adhere to a medication regime if you can't read the bottles," she says. Mercy Health worked with these patients to solve the problem by color-coding bottles in patients' homes, she says. Pills taken once a day were in bottles with one color while those taken twice daily were another color. Diuretic bottles were a third color, so when the physician advised a particular patient to take more diuretics, he would go to the correct container.
The physician's nurse often does the color-coding during office visits, and a Mercy Health "parish nurse" follows up in the patient's home.
Outside the hospitals, Mercy Health's care coordination teams now have a program in which nurses are stationed in physician offices, especially for patients with chronic pain, heart failure, COPD, or uncontrolled diabetes, says Lynne McCabe, director of the community care coordination program.
"The majority of our patients had some sort of financial or social behavioral issue, so we have two social workers that are part of the team."
The teams worked on multiple targets, from lowering hemoglobin A1Cs and lowering cholesterol, compliance with ACE inhibitors, and continued smoking cessation for this especially difficult population.
So far this effort has worked with about 300 patients who had a history of frequent readmissions. In the first year of the program, between June 1, 2011, to May 31, 2012, these patients had 51% fewer admissions, more than 35% fewer readmissions, and more than 35% fewer trips to the emergency department than the same group of patients had during the previous year. In addition, 12% of the patients had stopped smoking.
Namie acknowledges that Mercy Health is ahead of the curve on preventing all-cause readmissions. "I think we're probably a little sooner than the tipping point. But I know there's a high level of interest at other facilities. We get calls all the time from other healthcare systems asking us about what we're doing."
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This article appears in the May issue of HealthLeaders magazine.