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As telehealth grows in popularity, states are trying to decide how much to define or regulate the practice.This has created a sense of confusion, as one state may allow non-synchronous communication between a nurse practitioner and patient, while another may only physicians to communicate synchronously with a patient.To help clear up the confusion, the American Telemedicine Association has released their report “2019 State of the States Report: Coverage and Reimbursement,” detailing the laws in each state, along with what is or isn’t allowed.Here are a few of the key highlights from that report:

Slideshows

The rules and regulations in telehealth you need to know.

4 Facts About the State of Telehealth

Reducing preventable readmissions among Medicare patients has become an important national priority for healthcare policy makers. 

 brought you what you need to know about 

. This month, in part 2 of our ongoing series, we’re taking a look at three other conditions tracked by the Hospital Readmissions Reduction Program (HRRP): acute myocardial infarction (AMI, or heart attack), coronary artery bypass grafting (CABG), and chronic obstructive pulmonary disease (COPD).

The final part will examine hospital readmissions caused by Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA) and pneumonia.

Patients who experience both heart attacks and COPD have a high cost of care, but there are multiple strategies to limit readmissions. The same holds true for those dealing with CABG.

Main causes of heart attack hospital readmissions

Andrew D. Boyd, MD, associate professor in the department of biomedical and health information sciences college at the University of Illinois at Chicago, led a 

recent study that looked at readmission trends for six diseases

, including heart attacks, CABG, and COPD.

By examining data from 14,307 hospital reports from the HRRP from 2012–2015, the authors found that readmission rates for Medicare patients with these diseases were statistically higher among for-profit hospitals compared with nonprofit or government hospitals.

In fact, the findings showed that those with heart attacks and COPD have the highest readmission rate, at 23% to 26%.

Stephen Sinatra, MD, a cardiologist in Manchester, Connecticut, notes the primary causes of re-hospitalization following heart attacks continues to be researched, but in his experience, top causes for re-admission include 

, cardiac arrhythmia, age, and being a female with smaller blood vessels, congestive heart failure, compromised renal function, and diabetes mellitus (which is a risk factor for coronary artery disease).

“For CABG, the main causes of hospital readmissions are complications such as wound infections, and pulmonary compromise like pleural effusions,” he says. “The method with which a CABG/CABS is performed is also important. When arteries are hooked up artery-to-artery, the prognosis is much better. Use of the internal mammary is superior to venous bypass grafts when the vessel is local to the artery needing bypassing, such as the left anterior descending artery (LAD).”

Still, he explains, a lot of these surgical outcomes depend on the individual (patient dependent) as well the experience of the surgeon, technical difficulty, what the surgeon finds once the heart is open, and operative time on bypass pump.

“When a surgeon bypasses vessels with major obstructions but leaves vessels that are only mildly ‘clogged,’ those un-bypassed vessels may still be prone to plaque rupture,” Sinatra says. “Bypassing more vessels, even those that are mildly obstructed, may help to reduce hospital readmissions.”

Main causes of COPD hospital readmissions

The major cause of hospital readmission is COPD because it’s a chronic illness.

“Pneumonia and other infections can also precipitate readmission, which is why antibiotics are used frequently to prevent infections and readmissions,” Sinatra says. “Unfortunately, that’s probably one of the many reasons we have antibiotic resistance today.”

Stephen Schimpff, MD, MACP, an internist in Baltimore, Maryland, and former CEO of the University of Maryland Medical Center, says the primary reason for unexpected 30-day readmission return is communication between hospitalist and primary care physicians.

“In times past, the PCP admitted their patients to the hospital, took care of them in the hospital and discharged them so that the PCP had a clear understanding of the patient’s needs,” he says. “Today two things have changed. PCPs rarely see their patients in the hospital and frequently don’t even know the patient has been admitted. The patient is cared for by hospitalist and at discharge, although a written record is sent to the PCP that may not arrive until sometime much later, there is rarely any verbal communication between the two at the time of discharge.”

Furthermore, the patient is not instructed to obtain an appointment with the PCP or cardiologist within 48-72 hours, so the medications often aren’t reviewed in the context of the patient’s other issues and adjustments. The result is the patient has an exacerbation, goes to the ER, and is readmitted with recurrent heart failure.  

For example, at the Charlestown Retirement Community in Catonsville, Maryland, a facility with 2,000 individuals with an average age of 82, the readmission rate has been brought down from the national average of over 25% to just under 10%.

“When a patient is admitted to the hospital, the PCP is aware and receives notification when the patient returns to the community and an appointment is set within 48 hours,” Schimpff says. “If the patient is sent back to the rehab unit, the doctor visits within the same time frame. That simple attention to communication and seeing the patient immediately is the key.”

Nine Ways to Reduce Hospital Readmissions from Hospital Executives

 conducted by Beth Israel Deaconess Medical and Harvard Medical School, which looked at heart attack readmissions, the findings revealed that although reductions in readmissions have been attributed to improvements in discharge planning and care transitions, these declines may instead be due to hospitals and clinicians intensifying efforts to treat patients who return to a hospital within 30 days of discharge in emergency departments and as observation stays.

The study suggested that financial penalties imposed by HRRP may have inadvertently pushed some physicians to avoid readmitting patients who needed hospital care, or potentially diverted hospital resources and efforts away from other quality improvement initiatives.

Based on the results of Boyd’s study, the authors recommend that policy makers may want to consider if readmission penalties are sufficient, examine how patient care can be improved, and make sure that type of ownership does not impact care quality.

 in Zephyrhills, Florida, says the center is seeing a 2.9% net increase in 2019, compared to 2018, for heart attack and CABG. However, for readmissions there is a 3% penalty for excess readmissions for CHF, acute MI, and CABG.

Managing risk factors to drive down 30-Day readmissions

To drive down 30-day readmissions, the Premier Heart and Vascular Center has: increased education around the importance of diet, exercise, and medication compliance at discharge; schedules a follow-up appointment in the office prior to discharge; provides a home health RN to visit the patient after discharge; and calls patients after discharge to ensure they have answers to any questions about medications and symptoms.

“We also assign a nurse navigator to follow up with the patient,” Khamare says. “And we have implemented immediate physician specialty consultation in the emergency department to determine if readmission is necessary.”

This strategy has helped drive down readmissions by as much as 5% this year.

“We have been effective in decreasing readmissions rates; however, more work needs to be done,” he says. “This is a work in progress.”

Sinatra’s biggest personal successes with patients with all these heart issues came with pairing conventional treatments with a “metabolic cardiology” protocol: CoQ10, D-ribose, L-carnitine, and magnesium, as well as omega-3s (fish oils). This combination of nutrients was instrumental in helping to prevent arterial reclosure and plaque rupture in his patients.

In an August 2019 study published in the 

, researchers looked at 41 studies with a total of 134,034 participants to evaluate the effectiveness of omega-3 supplements. What they found is that omega-3 supplement use was correlated with an 8% reduction in heart attack risk and a 7% reduction in coronary artery disease when compared with the non-supplement group.

Another study conducted at Carnegie Mellon University 

showed that optimism is an extremely important healer

. In their conclusion, they found that “Optimism predicts a lower rate of rehospitalization after coronary artery bypass graft surgery [and] fostering positive expectations may promote better recovery.”

“An often hidden risk factor in hospital readmissions is emotions-which can put patients into fight-or-flight mode and precipitate a cardiac event,” Sinatra says. “A lot of my patients needed to be counseled. I would tell them they needed to let the situation go-it’s not worth dying for.”

How Health Systems Use Pharmacists to Reduce Readmissions

Nicholas Hamm is an editor with Managed 

 Executive. Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.

Articles

The ultimate guidebook on everything you need to know about reducing hospital readmissions-the most common risk factors, the reimbursement issues, and how real-world hospitals are solving the problem.

6 Strategies for Your Hospital Readmissions Reduction Program, Part 2

CMS Hospital Readmissions Reduction Program

 (HRRP) in October 2012 thrust readmission reduction into the mind of every health executive.

 an admission to a participating hospital within 30 days of a discharge from the same or another hospital.

six conditions and procedures as part of HRRP

Coronary Artery Bypass Graft (CABG) Surgery

Chronic Obstructive Pulmonary Disease (COPD)

Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA)

Each of these conditions is vital for healthcare organizations to measure-falling behind on only one can still result in penalties.

How readmissions penalties are calculated

 hospital data based on hospitals’ performances during a three-year period from July 1, 2015 through June 30, 2018.

The payment adjustment factor (PAF) is the reduction applied to CMS payments. It is calculated using an excess readmission ratio (ERR), which CMS calculates by looking at a hospital’s expected readmission rate (based on other similar hospitals) and comparing it to a hospital’s actual readmission rate.

Hospitals that perform better than average will have an ERR less than 1.0 (and are not penalized), while hospitals performing worse than average will have an ERR of greater than 1.0 (and are penalized). The PAF is generated using ERR and 

. The minimum PAF is 0.97 (which would account for a 3% penalty, the maximum penalty allowed).

Payment reductions are calculated by subtracting the PAF from 1.0 and multiplying by 100. So for example, a hospital with a PAF of 0.975 would have a payment reduction of 2.5%:

1.0 - 0.9750 = 0.025 x 100 = 2.5% reduction

CMS has doled out $2.5 billion in penalties

readmission rates in a variety of condition types are improving

, of the 3,241 hospitals evaluated for readmissions between October 2017 and September 2018, 

The maximum penalty for hospitals is 3%. However, very few hospitals have penalties this high levied against them-in FY 2017, just 

1.8% of hospitals paid the highest penalties

 will be bringing you the ultimate guide on reducing readmissions for each of the six conditions CMS tracks. This first part will take an in-depth look at how hospitals can prevent heart-failure readmissions.

To help your organization successfully reduce heart failure readmissions, here is the complete guide to heart failure, including:

Real-world strategies for reducing readmissions.

The reasons for readmission are multifactorial and it is difficult to predict individual causes for readmission. 

Catherine J. Ryan, PhD, clinical associate professor, college of nursing, University of Illinois at Chicago Department of Biobehavioral Health Science, Chicago, says one way that readmissions have been categorized is simply as preventable or unpreventable. Others have categorized reasons for readmission as clinical, behavioral, and patient-centric, recognizing that the responsibility of readmission may reside with the patient, provider, hospital system, or any combination thereof. 

“Heart failure readmissions have been associated with a variety of factors or characteristics,” she says, adding that the most common include advanced age, history of renal disease, history of diabetes, or a heart failure admission within the past year. Other factors include admission to a teaching hospital, discharge against medical advice or discharge to home, receiving Medicaid, and being of African American ancestry.

The SDOH Factor That Impacts Heart Disease

 (HSPH) found that elderly black patients were more likely to be readmitted to the hospital after a prior hospital stay for heart failure due to disparities related to both race and the hospitals where patients were treated.

The Prevention of Hospital Readmissions in Heart Failure

” by the David Geffen School of Medicine at UCLA, Los Angeles, showed that among readmitted Medicare patients with HF, the five most common primary diagnoses-HF, renal disorders, pneumonia, arrhythmias, and sepsis-account for 56% of the readmissions with no other diagnoses accounting for more than 5%.

“Readmission potentially reflects a failure of the discharge process; thus, discharge planning should start at the time of admission,” says Karen M. Vuckovic, PhD, advanced practice registered nurse, division of cardiology, 

University of Illinois Hospital & Health Sciences System

, Chicago. “Health-related quality of life, or an individual’s perceived physical and mental health over time, predicts readmissions in patients with heart failure.”

“For the past several years, there has been a heightened national focus on reducing readmissions and thus identifying patients with the highest risk for readmission,” Ryan says. “Although there have been reductions, readmission rates remain high.”

In the skilled nursing market, Zachary Palace, MD, medical director of RiverSpring Health 

 at Riverdale in Bronx, New York, says the shift to patient-driven payment model (PDPM) provides facilities with higher reimbursement for more complex Medicare Part A patients, explaining the amount of care needed correlates more directly to the reimbursement received.

The ACA authorized the federal government to penalize hospitals for poor readmission rates for Medicare patients with heart failure, and this has caused many to rethink their strategies.

Managing heart failure risk factors: Successful strategies

David Majure, MD, medical director, mechanical circulatory support program, 

 at North Shore University Hospital in Manhasset, New York, says reducing readmissions is about a strong system approach and doing good heart failure care.

At his hospital, a group known as Health Solutions targets patients subject to the Heart Failure HRRP umbrella and efforts are made to connect with them at home.

The way it works, he explains, involves calling the patients at home and ensuring they have adequate resources at home and following up appropriately. By doing this, it helps reduce readmissions and the hospital’s decreasing numbers have shown it’s a success.

“If they become readmitted, they help them identify factors to help minimize their readmission,” Majure says.

 program is a hospital-based quality improvement program that provides assistance for providers to maintain current practice guidelines.

The guidelines noted that scheduling an early follow-up visit (within seven to 14 days) and early telephone follow-up (within three days) of hospital discharge are reasonable. In response to this recommendation, most HF programs include a discharge follow-up phone call though data in response to this recommendation is mixed. Therefore, Vuckovic notes each program needs to evaluate what works for their population.

“Studies which have included follow-up phone calls usually include other interventions,” she says. “There is a handout for TARGET-HF which guides the process and scripts the call.”

For example, a clinician-initiated discharge phone call is a simple and cost-effective method that allows clinicians to connect to the patients after their hospital discharge to check on their well-being, review or reinforce discharge instructions, and address issues that may potentially lead to adverse outcomes.

“Dealing with heart failure patient’s basic needs is essential in helping them manage their disease,” Vuckovic says. “For example, one inner-city teaching hospital recognized that providing housing for those who are homeless during the transition phase led to patients being more likely to attend follow-up appointments.”

Hebrew Home utilizes the AMDA’s (The Society for Post-Acute and Long-Term Care Medicine) 

 as its protocol for treating CHF patients. Palace explains the guidelines are in a small handbook, easy to read, and provide clinicians with key points to identify heart failure, assess it, and treat and monitor achievements. This keeps everyone on the same page with best practices and ensuring they are practicing the most current medicine.

“We also have full-time physicians on staff and provide comprehensive training to all of our clinical teams on what to look for and what steps to take,” he says. “Through these efforts, we are able to manage the majority of patients in our facility and thus have a low number of readmissions.”

Anecdotally, he shares families often talk about how their mom or dad when at different facilities, would end up in ER every few weeks with heart failure, but since coming to Hebrew House, they haven’t gone out at all. It’s a credit, Palace says, to managing these patients in-house.

Hebrew Home has also invested in technology, such as contact-free continuous vital sign monitoring, to help it identify patients at risk for CHF exacerbation. This is a trend that others are following and Palace says it’s important because it acts as the eyes and ears when the nurse is not in the room, which is a large part of the time.

“In CHF patients, a key risk to look for is an increase in fluids. Fluid builds up and when patients lie down, this fluid moves from their legs and collects in their lungs. An indicator we look for is shortness of breath,” Palace says. “We also monitor weight, a quick increase in weight is another way to monitor for fluid retention. We are also seeing a lot of new technology coming to the market specifically designed to help identify changes.”

, a recently-approved technology. The technology is a vest a nurse applies a patient which has a built-in sensor that reads across the chest from front to back and can quantify total lung water volume. That is also significant in helping to identify heart failure patients.

Hospitals successful at reducing readmissions that were enrolled in the American College of Cardiology’s 

, a resource for hospitals and cardiovascular care providers committed to improving transitions from hospital to home and reduce their risk of federal penalties associated with high readmission rates, created a summary of 10 key practices. Of the 10 practices, three centered on medication management.

“Education about the purposes of each medication, changes in doses/frequency, which to stop, which are new, and how to take them correctly were identified as essential to self-management. Medication reconciliation is essential,” Vuckovic says.

Palace says medication compliance is much easier to manage in a skilled nursing facility where physicians are keeping a close eye, and the clinical staff is helping to ensure adherence.

Vuckovic says that culturally appropriate multidisciplinary discharge planning and education has been shown to facilitate compliance and decrease readmissions. 

 that self-care (e.g., diet, medication, and symptom management) is largely insufficient in ethnic minority populations, indicating an area where more emphasis is needed-especially as self-care can be a 

“We need to shift our approach from hospital care to providing self-care at home since the majority of the patients’ care takes place in the home, not the hospital,” she says. “Providers should seize every opportunity to reinforce self-care principles and education.”

Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.

6 Strategies for Your Hospital Readmissions Reduction Program

Artificial intelligence (AI) has largely dominated conversations about the future of healthcare. From improving diagnoses to analyzing EHR data, AI is often touted as the cure for many of healthcare’s technological woes. But there are currently huge barriers to that future.

, which seeks to temper expectations about AI.

The titular truth in “The ‘inconvenient truth’ about AI in healthcare,” is “that at present the algorithms that feature prominently in research literature are in fact not, for the most part, executable at the frontlines of clinical practice.”

The authors say that while AI has the potential to help fix many of healthcare’s biggest problems, the hype of AI is just that-at least in the current state of healthcare.

“We are so far away from artificial intelligence becoming a tool to improve the way we deliver care despite all the sensational research publications,” co-author Leo Anthony Celi tells 

The biggest problem? Celi says “An algorithm that was developed using data from another hospital or clinic cannot be used immediately by another hospital or clinic …There is practically no healthcare organization that has the data infrastructure and skillset to oversee the validation, deployment, and continuous re-calibration of AI algorithms.”

The editorial points out what most in the healthcare industry know all too well: that healthcare data is compartmentalized and often inaccessible across organizations-or often, even within an organization. Without a stable structure with which to gather data, the authors argue, there is little point in bringing in systems to analyze those data-i.e., poor data beget poor analysis. “Simply adding AI applications to a fragmented system will not create sustainable change,” the authors conclude.

The State of Healthcare Data and Technology

This becomes a problem for organizations with an infrastructure too small to optimally train algorithms. If sharing data is impossible, smaller organizations’ use of AI will suffer because they will lack the ability to gain access to adequate amounts of data.  This means the algorithms used and trained on those smaller data sets won’t “‘fit’ the local population and/or the local practice patterns, a requirement prior to deployment that is rarely highlighted by current AI publications.”

A lack of resources could also lead to AI bias-for instance, the authors point out that an algorithm fed a sample of primarily Caucasian patients wouldn’t perform the same for minority patients.

The key to healthcare’s data problem, the authors say, requires a broad look at who that data actually belongs to-"who owns health data, who is responsible for it, and who can use it?”

Public discourse and policy intervention, the authors say, are necessary to help answer those questions and move the state of healthcare data forward. Before AI can begin to revolutionize healthcare, healthcare data must be in a state where it can be shared-and controlled-in a way that the public and government sectors approve of.

The authors point to two possible solutions. The first would involve the creation of “generalized data infrastructure by building on existing impactful successes in the research domain,” citing examples like the Science and Technology Research Infrastructure for Discovery, Experimentation and Sustainability (STRIDES) initiative from the National Institutes of Health or MIMIC from the MIT Laboratory for Computational Physiology.

Another, more radical solution would be for the government to require all healthcare organizations to store their data in commercially-available clouds.

Even those solutions, the authors admit, would require solving several complex problems, from how to protect confidentiality to how to handle consent of data.

“The potential of AI is well described,” the authors conclude, “however in reality health systems are faced with a choice: to significantly downgrade the enthusiasm regarding the potential of AI in everyday clinical practice, or to resolve issues of data ownership and trust and invest in the data infrastructure to realize it.”

For healthcare executives, Celi says the biggest takeaway from the editorial should be a cautionary tale, that before AI can succeed, the challenges to its adoption must be fully grasped and dealt with, saying that “most healthcare executives have no grasp of what is entailed and what investments are necessary to realize the promise of AI in medicine.”

Only when those challenges are met can the true promise of AI be realized.

Artificial intelligence is poised to take over healthcare-or is it?

Nicholas Hamm

Articles

4 Facts About the State of Telehealth

6 Strategies for Your Hospital Readmissions Reduction Program, Part 2

6 Strategies for Your Hospital Readmissions Reduction Program

The Limits of AI in Healthcare