hospital readmission rate reduction: building better interfaces within the community.

Transcription

1 hospital readmission rate reduction: building better interfaces within the community. Whitepaper By Ken Taverner, M.Sc.

2 the issue of hospital readmission rates Leaving the hospital after being admitted and treated for acute myocardial infarction, heart failure or pneumonia can be the beginning of an uncertain and risky time for patients and hospitals alike. Medicare has for the moment singled out these Diagnosis Related Groups (DRGs) as a focus of efforts to reduce preventable readmissions. 1,2 It is felt that a focus on reducing preventable readmissions of Medicare patients will have the effect of increasing quality and decreasing costs of care. 3 In a study of Medicare patients discharged between October and December 2003, approximately 20% were readmitted within 30 days of discharge. Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34% were rehospitalized within 90 days. 3 Less than half of discharged patients who were readmitted within 30 days of discharge generated a bill for an outpatient visit, indicating that Hospitals and physicians may need to collaborate to improve the promptness and reliability of follow-up care. 3 The estimated cost to Medicare of unplanned readmissions in 2004 was on the order of $17 billion. The authors of the study note that Further studies will be needed to understand the relative contributions to this risk of failures in discharge planning, insufficient outpatient and community care, and severe progressive illness. 3 In the August 2012 update to the CMS guidelines, CMS stated: The Hospital Readmissions Reduction Program requires a reduction to a hospital s base operating DRG payment amount to account for excess readmissions of selected applicable conditions, which are acute myocardial infarction, heart failure, and pneumonia. This provision is not budget neutral. A hospital s readmission payment adjustment is the higher of a ratio of a hospital s aggregate dollars for excess readmissions to their aggregate dollars for all discharges, or 0.99 (that is, or a 1-percent reduction) for FY In this final rule, we estimate that the Hospital Readmissions Reduction Program will result in a 0.3 percent decrease, or approximately $280 million, in payments to hospitals. 1 Discharge planning should begin upon admission to the hospital. Processes for arranging home health care, durable medical equipment (DME)/supplies, transfer to step-down facilities, transportation needs, communication with primary care physicians (PCPs) and discussions with patient caregivers are all considered critical but complicated factors in a patient s discharge. The extended care team, which typically includes caregivers and PCPs, can help provide the support a patient needs to recover at home post-discharge, but their efforts are likely to be most effective when carefully coordinated. For example, the extended care team may have difficulty managing and coordinating the patient s medications without close communication. In addition, patients are sometimes discharged with a continued need for general education related to their ongoing wellness and recovery. Frequently, electronic medical

3 record (EMR) systems are not fully integrated, which can lead to difficulties sharing information between stakeholders. Improving the interactions between patient, hospital, caregiver and PCP can improve supportive care for newly discharged patients in particular. According to Coleman, Patients and their caregivers who received tools and support from a nurse transition coach were significantly less likely to experience rehospitalisation. 4 In addition to real logistical difficulties in the discharge process, there are pressures from CMS to decrease readmission rates. In 2013, Medicare will reduce payments by up to 1% for more than 2,200 hospitals, which comprise about two-thirds of U.S. facilities. 5 While readmission rate reduction is widely perceived as a quality improvement and centers on improving clinical outcomes for patients, reducing readmission rates will also have the added advantage of reducing or avoiding CMS reimbursement penalties. The CMS penalties are to be phased in over a three-year period during which they will become progressively more onerous to noncompliant organizations. For hospitals that don t improve, penalties will grow to a maximum of 2% for the 2014 program year and 3% for ,6 The reduction in reimbursement is planned to apply to all Medicare discharges. Thus, there exists an immediate window to allow hospitals to initiate effective compliance measures and protect their Medicare reimbursement while increasing their patients satisfaction and institutional reputation for having low readmission rates. scope of the issue A 2009 analysis estimated that the cost to Medicare of unplanned re-hospitalizations in 2004 was $17.4 billion. 3 Looking at data for a cohort of Medicare patients discharged in the last quarter of 2003, that same study found that of every five of those Medicare patients hospitalized, about one will be readmitted within 30 days of discharge. 3 Failure to comply with CMS goals for readmission rates will result in penalties of 1% in year one, 2% in year two and 3% in year three. 2, 6, 7 The reimbursement cuts will have a direct effect on hospitals bottom lines. Hospitals should know their readmission rates and consider There exists an immediate window to allow hospitals to initiate effective compliance measures and protect their Medicare reimbursement while increasing their patients satisfaction and institutional reputation for having low readmission rates. benchmarking their specific rates against other organizations in their area. 8 Knowing and benchmarking readmission rates helps allow the institutions to appropriately set goals for readmission reduction. In a recent study, 90% of 537 hospitals indicated that they are taking steps to reduce readmission rates for patients with heart failure or AMI. This same study found that a process to alert outpatient physicians within 48h of the patient s discharge and a process to follow-up on test results that were returned after a patient s discharge were present in 37% and 36% of hospitals, respectively. 9 Some hospitals are trying to tackle the issue in-house and avoid the costs of outsourced solutions. 9 Even the in-house solutions have costs attached, however, in addition to the costs of evaluation, development and implementation. Furthermore, some of these solutions may be untested. Outsourcing the solution may also have the advantages of reducing institutional distraction and implementation burdens. Outsourcing will have associated costs, but it may also save the institution costs by reducing CMS penalties related to readmission rates. four common factors associated with readmissions within 30 days of discharge There are at least four major factors contributing to readmission rates being higher than necessary. The four pillars are described by Coleman as directly correspond[ing] to the content areas hospital readmission rate reduction: building better interfaces within the community. 3

4 that patients and caregivers who recently underwent posthospital care transitions expressed as most essential and most needed. stay and at discharge. This ongoing education can help reinforce key messages about ongoing care and help appropriately prepare patients for discharge. 11 Medication self-management A patient-centered record Primary care and specialist follow-up Knowledge of red flags, warning symptom or sign of worsening condition. 10 Patients often leave the hospital without a strong support system waiting for them back home, and many of them could use an enhanced support system to keep them on their discharge plan and from needing to be readmitted. There are many more than four ways to address these four pillars. The following five steps could help address the identified issues and help prevent readmissions: 1. Patient Education: Education can help identify red flags. Empowering the patient and caregiver, if one exists, with information on how to manage predictable events after discharge is important. When patients and caregivers take an active role in care transition and management, patients are less likely to be readmitted. A 2004 Journal of the American Geriatrics Society study found that patients who receive intervention measures from a nurse practitioner during the transition process are less likely to return to the hospital. 10 Part of the education process is ensuring that patients understand why, when and how to access medical attention, as this may result in a reduction of inappropriate hospital utilization. The teaching process should occur upon admission, throughout the hospital 2. Handoff Communication A patient-centered record can aid in the handoff of patients from hospitals to their PCPs. Communication and coordination are critical to smooth and safe transitions between hospital and PCPs. A smooth handoff should be the goal from the hospital and between sites of care. Unfortunately, sufficient communication is relatively rare. A 2007 Journal of the American Medical Association study found that direct communication between hospital physicians and primary care doctors occurred in less than 20% of cases. 3 In addition, Kripalani et al. found that on analysis of data from 73 observational studies, The availability of a discharge summary at the first post-discharge visit was low (12%-34%) and remained poor (51%-77%) at four weeks, affecting quality of care in approximately 25% of follow-up visits and contributing to PCP dissatisfaction. 12 Furthermore, discharge summaries often lacked important information such as test results, discharge medications, test results pending at discharge, patient or family counseling or follow-up plans. They conclude this paper stating, Deficits in communication and information-transfer at hospital are common and may adversely affect patient care. 12 So another component to preventing readmissions is improving coordination and communication postdischarge.

5 3. More Effective Coordination of Patient Care Effective coordination of patient care supports all four pillars. Deficits in communication and informationtransfer between healthcare providers (HCPs) at hospital discharge are common and may adversely affect patient care. Interventions, such as computer generated summaries and standardized formats, may facilitate more timely transfer to PCPs. 12 Beyond this, having someone who can help patients with simple scheduling of appointments and coordination of transportation to and from appointments would be helpful. 4. Post-Discharge Follow-Up Primary care and specialist follow-up are an important component of the four pillars. Successful care transition programs often feature at-home follow-up as well as telephone check-ins for certain high-risk patients in addition to PCP follow-up. This type of post-discharge care may be especially appropriate for elderly patients and patients lacking strong social networks. A 1999 study by Naylor et al. found that An advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. What remains in question is whether such a high level of nursing expertise and associated cost is needed to achieve such results. This study showed that having advanced practice nurses (APNs) visit patients at home had a better effect on reducing readmissions than less specialized vocational nurses (VNs), but the real reason for why the patients did better was not truly elucidated. Home visits alone, however, do not explain the differences in group outcomes demonstrated in this study. One in two control patients visited by VNs immediately after the index hospital discharge were re-hospitalized compared with one in five intervention patients visited by APNs. 13 How does one interpret these results? In fact, the paper states, This intervention benefited from APNs clinical acumen as well as their expertise in communicating, collaborating, and coordinating care with physicians and other health care professionals. 13 It is clear that it is not just the nursing interventions that were important but also the coordination of care for the patients recovery outside the hospital walls. 5. Medication Self-Management Medication self-management is an important pillar and should not be confused with medication reconciliation. Medication reconciliation should be mentioned, which is the process of recording (as accurately and comprehensively as possible) the medications a patient was taking prior to a care episode and checking new medications ordered during the care episode against this list to identify any potential harmful interactions. The Joint Commission mandates that medication reconciliation be conducted upon hospital admission, during transfers and at discharge. Ensuring that patients keep track of what medications they are taking and whether they are following prescription plans is important for accurate and comprehensive medication reconciliation. Medication self-management is about the patient taking their medications as prescribed. Effective care coordination can help patients with this by reminding them to take their medications as prescribed and by reminding them to follow their discharge instructions, including any prescribed medications. According to the Institute of Medicine s report, To Err hospital readmission rate reduction: building better interfaces within the community. 5

6 Is Human, medical errors are associated with between 44,000 and 98,000 error-related deaths per year and may cost individual hospitals significant dollars in avoidable costs each year. 14, 15 Medication errors kill at least one patient every day and injure over one million people annually, according to the FDA report on medication errors: Common causes of such errors include: Poor communication Ambiguities in product names, directions for use, medical abbreviations or writing Poor procedures or techniques Patient misuse because of poor understanding of the directions for use of the product. 16 A national study found that over a 10-year period ( ), deaths due to medication errors rose more than twofold, with 7,391 deaths attributed to medication errors in 1993 alone. 14 Interventions that can reduce medication errors can be as simple as reminders to patients to take their medications as directed by their physicians or as complex as a full medication reconciliation conducted by a pharmacist. Reducing medication errors and improving medication reconciliation may help prevent hospital readmissions. addressing the issue of 30-day readmissions Hospitals may (1) choose to take no action with respect to reducing preventable readmissions, (2) choose to develop their own internal solution to reduce readmissions or (3) adopt an external commercial solution to reduce preventable readmissions. Those taking no action may believe that much of the preventable readmission problem is related to poor patient compliance combined with several other confounding factors and, as such, is completely out of their hands. Administrators at institutions may also believe that there is no incentive for doctors to help keep patients out of the hospital as there is no direct benefit to them to do so, which also reduces the likelihood that readmissions can be prevented. Those in the second group, who develop their own solutions to preventable readmissions, may be more proactive and proceed quickly to try to reduce readmission rates. Many hospitals have already taken some steps toward reducing readmissions. It could be very helpful for these organizations to benchmark their actual rates to those of other institutions to get a relative idea of whether their programs are succeeding. Setting clear goals for their programs will aid in knowing when they have achieved their objectives. A potential problem that hospitals developing in-house solutions may encounter is that even when they are successful with a small trial of an in-house intervention, it may not be scalable to fit their larger overall patient population needs. For example, a trial of frequent nurse contact with

7 patients reaching 25 patients by phone at home on a daily basis may be manageable with existing nursing resources. But if this is found to be successful, it may be very difficult to scale it up to reach all the appropriate discharged patients on a daily basis without outside help. If there were an affordable, comprehensive, commercially available solution to this issue, many hospitals could be interested in it. The hospitals in the third group would choose this route. A potential problem that hospitals developing in-house solutions may encounter is that even when they are successful with a small trial of an in-house intervention, it may not be scalable to fit their larger overall patient population needs. internal solutions Many hospitals are trying to tackle the CMS-mandated readmission rate reductions through in-house devised solutions. Doing it yourself is attractive because it may look like it would cost less than outside solutions and allow the institution greater control. Some focus on enhanced patient education while some are working on flow maps and putting more formal follow-up plans in place. Some hospitals are looking at adding additional emergency department (ED) observation beds and dedicated social workers to their facilities. Some hospitals have plans to encourage home health agencies to enhance their efforts with patients. The specific plans to address the issue vary from hospital to hospital. All of these efforts, however, require significant resources, and the effectiveness of many self-designed solutions are unproven. Some hospitals may devise solutions that appear to work well at first, but scaling it up to reach all of their patients may require outside assistance or more dedicated resources to the intervention. external solutions Any potential comprehensive solution to the problem of reducing hospital readmission rates is going to have several important components. In many cases, preventing avoidable readmissions is a matter of coordinated, supportive care post-discharge, as demonstrated nicely in the study by Naylor et al. 13 Services such as calling patients after discharge to ensure they understood their discharge orders, contacting their PCPs to let them know of their patients discharge, having a nurse hotline available, having a medication management intervention and having the patient communicate vital information about their ongoing health status to their caregivers are all potential components of a comprehensive plan to enhance post-discharge supportive care. 13 An effective program of post discharge patient monitoring and communication has the added potential benefit of identifying patients who really do require a readmission or intervention which may have been missed otherwise, thus improving the level of care for those who need it most while reducing unnecessary readmissions for others and reducing costs to hospitals. The ideal solution to the problem of readmission reduction would allow patients to seamlessly transition from the hospital to their homes and help keep them there, unless they truly do need to be readmitted. This in turn would improve overall quality of care and ideally allow the hospital to comply with CMS guidelines to reduce financial penalties. Such a solution could improve both patient satisfaction and hospital reputation. This solution could become a reality by harnessing the combined capabilities of technology and human interaction. A comprehensive solution should be able to coordinate supportive measures and discharge orders across the patient s identified care team, including hospital staff, PCPs, caregiver(s) and home care nurses. The ability to share electronic records quickly among care team members could also facilitate rapid follow-up with patients. Based on the core components discussed above, an effective program should therefore: hospital readmission rate reduction: building better interfaces within the community. 7

8 Be introduced to the patient early on while he or she is still in the hospital Aid in initiation and execution of the discharge plan Follow up with the patient within 24 hours post-discharge and connect the patient with a nurse should the patient need help understanding the discharge plan Check the patient s health status regularly during recovery Help monitor medication compliance Encourage the patient to seek medical care when appropriate Sharing this information electronically would allow the patient s caregiver(s), PCP, discharge nurse and other members of the extended care team to set follow-up appointments more quickly and monitor patient health status and compliance more completely. Combined, the components of this design could help a hospital more effectively reduce preventable readmissions.

9 references 1. United States, Centers for Medicare and Medicaid Services. (n.d.). Final Rule on Medicare Hospital Readmission Payment Policy. Retrieved from ofr.gov/ofrupload/ofrdata/ _pi.pdf 2. CMS beings penalizing hospitals for readmissions. (2012, August 29). Retrieved from 3. Jencks, S. F., MD, MPH. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. The New England Journal of Medicine, 360, doi: /NEJMsa Coleman, E. A., MD, MPH, Parry, C., PhD, MSW, Chalmers, S., MPH, & Min, S., PhD. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), Fiegl, C. (2012, August 27). 2,200 hospitals face Medicare pay penalty for readmissions. American Medical News. Retrieved from 6. Berenson, R. A., MD, Paulus, R. A., MD, MBA, & Kalman, N. S., BA. (2012). Medicare s readmissions-reduction program: A positive alternative. The New England Journal of Medicine, 366, doi: /nejmp United States, Office of the Legislative Counsel. (2010, May). Compilation of the Patient Protection and Affordable Care Act. Retrieved from 8. Hospital compare. (n.d.). U.S. Department of Health & Human Services. Retrieved from 9. Bradley, E. H., PhD, Curry, L., MPH, PhD, Horwitz, L. I., MD, Sipsma, H., PhD, Thompson, J. W., MPP, Elma, M., MPH,... Krumholz, H. M., MD, SM. (2012). Contemporary evidence about hospital strategies for reducing 30-day readmissions: A national study. Journal of the American College of Cardiology, 60(7), doi: /j.jacc Coleman, E. A., MD, MPH, Smith, J. D., ND, GNP, Frank, J. C., DrPH, Min, S., AM, Parry, C., PhD, MSW, & Kramer, A. M., MD. (2004). Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. Journal of the American Geriatrics Society, 52(11), doi: /j x 11. Clancy, C. M., MD. (2009). Reengineering hospital discharge: A protocol to improve patient safety, reduce costs, and boost patient satisfaction. American Journal of Medical Quality, 24(4), doi: / Kripalani, S., MD, MSc, LeFevre, F., MD, Phillips, C. O., MD, MPH, Williams, M. V., MD, Basaviah, P., MD, & Baker, D. W., MD, MPH. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. The Journal of the American Medical Association, 297(8), doi: / jama Naylor, M. D., PhD, Brooten, D., PhD, Campbell, R., MSN, Jacobsen, B. S., MS, Mezey, M. D., EdD, Pauly, M. V., PhD, & Schwartz, J. S., MD. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. The Journal of the American Medical Association, 281(7), doi: /pubs.JAMA-ISSN joc Improving health care quality. (2002, September). Agency for Healthcare Research and Quality. Retrieved from ahrq.gov/news/qualfact.pdf 15. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (1999). To err is human: Building a safer health system. National Academy Press. 16. Drugs: Medication error reports. (2009, March 5). U.S. Food and Drug Administration. Retrieved from DrugSafety/MedicationErrors/ucm htm hospital readmission rate reduction: building better interfaces within the community. 9

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