Reducing Hospital Readmissions Starts with Better Collaboration

With Medicare upping the ante on hospitals to reduce readmission rates, pressure is mounting on hospitals to get the job done. Crafting collaborative relationships with community-based caregivers to boost patient care is key, researchers suggest.

A pair of research studies released earlier this month on efforts to reduce hospital readmissions reached the same conclusion: There will be no quick fix, but boosting collaboration between hospitals and community-based caregivers is the key to solving the problem.

The task ahead, authors of the studies say, is crafting specialized keys to unlock the unique combination of readmission difficulties that plague communities across the country.

"The hospitals that don't have trusting relationships with local providers are going to face a more complicated challenge," says L. Elizabeth Goldman, MD, lead author of a study published in the Annals of Internal Medicine. "They need to take a different model of outpatient care. There needs to be a structure—a primary care structure and financial structure—that works."

Medicare payments for hospital readmissions cost the federal government about $26 billion annually, with more than half that expenditure linked to avoidable hospitalizations, according to a Robert Wood Johnson Foundation report published last year.

Ariel Linden, DPH, who published a study on readmissions earlier this month in the American Journal of Managed Care, says healthcare providers and the communities they serve will have to walk a fine line. "You need to create collaborative relationships to boost patient care," he says. "But how do you do that without monopolizing the community and increasing the cost of care?"

Resolve in Washington
Officials at the Centers for Medicare & Medicaid Services are determined to push for reduced hospital readmission rates, "while addressing any unintended consequences, particularly for those hospitals serving dual-eligible and low-income beneficiaries," a spokesman said last week.

CMS, he says, is committed to working with hospitals through a multi-step process aimed at reducing readmissions.

"The first step to reducing the readmission rates is to understand what the readmission rates mean and how they are calculated. Prior to publicly reporting the readmission rates, CMS provides hospitals with Hospital-Specific Reports containing a comparison of their summary results to the state and national results as well as detailed discharge-level data. CMS also posts additional resources on QualityNet.org to assist the hospitals in understanding the measures' specifications. Together, these resources will assist hospitals in understanding the type of admissions that are included in the calculation of the readmission measures."

Performance Monitoring
After a hospital and CMS are on the same page regarding readmission rate measures, the next step is for the facility to monitor performance and identify areas for improvement. "Once they understand how the measures are calculated and how their rates compare to the national rates and state average, some hospitals choose to calculate their raw (unadjusted) readmission rates to more closely monitor their performance on these measures as they work on improving their systems for transitioning patients to the outpatient setting, collaborating with communities and providers, and communicating with patients and caregivers," he said.

CMS is also providing resources to help hospitals build readmission intervention programs. "CMS [has] designated Quality Improvement Organizations to reduce unnecessary readmissions to hospitals and promote seamless transitions between healthcare settings. Hospitals may reach out to their QIOs for assistance in identifying ways to reduce their readmission rates," he added.

The federal agency has also identified several "initiatives and peer-reviewed studies" that have demonstrated success in reducing readmissions. Those readmission intervention models include Partnership for Patients, a CMS initiative that is pushing participating hospitals to achieve a 40% reduction in hospital-acquired conditions and a 20% reduction in hospital readmissions compared to 2010 levels.

Rising to the Challenge
Turner West, MPH, palliative care leadership center director at Lexington, KY-based Hospice of the Bluegrass, says there is no one-size-fits-all approach to creating readmission intervention programs.

"A wide range of models exist to reduce hospital readmissions. There is variability among these models largely based on the patient population served, available community resources, and the type of hospital, so it is difficult to say a specific intervention is feasible or replicable in all settings," he says.

"Generally, however, successful interventions to reduce hospital readmissions require identifying patients at high risk for readmission, collaborating with the patient and family on a specific discharge plan, medication reconciliation, and effective discharge planning and care coordination with community providers—primary care, specialty care, home health, skilled nursing and hospice."

West says communities with relatively high levels of resources can supplement hospital-based readmission intervention models with technology and a constellation of patient-focused specialists.

"Some of the more successful models are innovating by leveraging technology and developing community partnerships to support patients and families," he says. "There are transition programs, health coaches and navigators, high-risk case managers, telephonic support and tele-health programs that we can all learn from."

Boosting collaboration between hospitals and community-based caregivers is a daunting but surmountable hurdle, West says.

"The starting point for any collaboration is identifying the unmet need of the patient or gap in service delivery. Both partners must be able to articulate how the collaboration enhances patient care and fills the service gap," he said. "Finally, any collaboration also requires that all partners understand each other's financial incentives and costs associated with new programming."

The research Goldman and Linden conducted identified elderly, seriously ill patients as not only prone to readmission, but also difficult to help with intervention efforts. "I wish there was a simple answer, but there is no simple answer," Linden says. "When you have congestive heart failure, you're at the end of the road."

Turner said part of solving the readmission puzzle has to be a change in mindset away from always striving for curative care and toward acceptance of a more comprehensive approach to end-of-life care.

"For many individuals with serious illness, a primary goal of care is avoiding hospitalization, and a primary driver for hospitalization is an exacerbation of pain and symptoms," he said. "Palliative care teams can often obviate readmission through expert pain and symptom management, and effective communication on prognosis and goals of care. Moreover, the interdisciplinary composition of a palliative care team helps identify social determinants that may contribute to hospitalization."