How a Pennsylvania Health System Slashed Readmissions 25%

The University of Pennsylvania Health System reduced hospital readmissions in one year by joining forces with a payer and using value-based approaches.

A relationship between the University of Pennsylvania Health System (UPHS) and Independence Blue Cross has generated a remarkable reduction in hospital readmissions.

For hospitals across the country, readmissions have become a crucial metric with quality and financial dimensions. A hospital’s readmission rate is a key indicator of care quality and the effectiveness of discharge planning. Since 2012, Medicare has been penalizing hospitals financially for readmissions linked to several targeted conditions such as pneumonia.

After the first year of a five-year contract with Philadelphia-based Independence, UPHS achieved a 25% reduction in hospital readmissions. Hospitals that intervene to reduce readmissions typically achieve 1% reductions.

The new contract took effect July 1, 2017.

Patrick Brennan, MD, chief medical officer and senior vice president of UPHS, says the health system expects further readmission reductions this year and into the future.

"We have already achieved a dramatic reduction through our relationship with Independence, and we can expand on that. In the current fiscal year, we are improving on what we did last year. There are aspects of our work that will be refined and become second nature over time," he says.

Three value-based and innovative approaches are largely responsible for the readmission reductions at UPHS.

1. Embracing value-based partnership
 

Data sharing between UPHS and Independence has been essential to reduce readmissions and redesign care, Brennan said.

"We have a data exchange with them. It was born out of earlier iterations of their pay-for-value program. We weren't getting information in anywhere near real-time—we really couldn’t manage. For example, we would be held accountable for readmissions and go through an entire year and into the next fiscal year without a sense of our performance," he says.

The five-year contract with Independence has a trio of value-based programs.

• The readmissions program, which puts UPHS at financial risk for 30-day readmissions
   
• Reducing the total cost of care for the health system's attributed population, such as establishing preferred provider relationships with skilled nursing facilities
   
• Expanding episodes of care to about a dozen bundles, which include sepsis, hysterectomy, hip and knee replacement, heart failure, and back surgery

UPHS and Independence have invested considerable time and effort to build a mutually beneficial relationship, Brennan says. "This partnership did not happen overnight—it's been developing over years. A mutual trust has developed between the organizations. The fact that we are able to share information has been the foundation."

The Independence contract has prompted UPHS to improve clinical care broadly, he says. For example, patients at high risk for readmission now receive a call from a scheduler who assists in arranging follow-up outpatient appointments.

"This contract galvanized our interest in redesigning care. The trigger was the readmission program; but as we got deeper into the contract, we realized we were going to have to redesign our whole process of care. We could not have done that without the information systems we have enterprise-wide. All of our practices and all of our hospitals are on the same information system," Brennan says.

2. Upgrading information systems
 

UPHS has installed readmission scoring systems in the electronic health record that clinicians can access. "Every discharge gets scored, and we can see who is at risk," Brennan says.

Risk stratification allows UPHS clinicians to focus resources on patients who are at highest risk of readmission. Patients classified at high risk of readmission return to the hospital 16% of the time. Patients classified at low risk of readmission return to the hospital less than 1% of the time.

Redesigning care has necessitated different behaviors among physicians, nurses, and social workers, which has prompted the health system to leverage technology to monitor new metrics, he says.

"We are working hand-in-glove with our informatics folks to enable us to measure our performance. The beauty of the changes we have made to our information system is we can tell how often people are using order sets and we can tell whether the after-visit summary and the discharge plan are fully complete at the time of discharge," Brennan says.

UPHS is planning to roll out more information system upgrades that will help drive down readmissions.

"We're also moving toward the adoption of other systems that will give us predictive information about the best services that would be best-suited for patients at discharge. Other systems will give us insight into the patient records when they are at other facilities. We really want to know how patients who have left us are performing," Brennan said.

3. Avoiding seven-day readmissions
 

UPHS has focused on reducing readmission seven days after discharge.

"We think 30% to 40% of our readmissions occur within seven days—that has been a consistent number over the past 10 years," Brennan says.

Avoiding readmissions within seven days of discharge has become an organizational imperative at UPHS.

"Seven days—we really own that. If we can't keep someone at the next level of care for seven days, something happened in our processes. That gets back to what we call system of care design and how we are getting patients ready for discharge and providing information to the next level of care," he says.

A pair of work groups is focused on readmissions within seven days.

• One work group accurately identifies patient diagnosis at time of admission and adjusts the diagnosis through the course of the hospitalization to ensure that care teams have accurate information on patient status. For example, a patient might be admitted with a diagnosis of stroke but leave with a diagnosis of seizure disorder.
   
• The other work group is focused on discharge—establishing a discharge work plan that includes a readiness assessment for discharge, the risk score for readmission, and tools that provide the patient with an after-visit summary.

UPHS has taken a proactive approach to addressing shortcomings that lead to readmissions within seven days, Brennan says.

"For patients who have seven-day readmissions, they are patients with acute issues that aren't being addressed in a timely fashion, or patients who show up somewhere for follow-up care and there is inadequate information available to the clinician," he says.