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Better management on several fronts should be able to reduce a hospital’s readmissions, but it requires commitment and attention to detail.
Back in October 2012, Medicare began penalizing hospitals for excessive readmission rates, with the penalties rising annually through 2014. In that initial phase, more than 2,000 hospitals were hit with payment penalties.
Nearly one in five Medicare patients is readmitted within 30 days of hospitalization, often for preventable causes, and the nationwide cost of preventable readmissions under Medicare alone has been pegged at $17 billion, according to the Centers for Medicare and Medicaid Services.
Preventable hospital readmissions remain a challenge for the healthcare system, as does the fact that patient characteristics significantly affect readmission risk. A November 2015 report in JAMA Internal Medicine concluded, “Hospitals with high readmission rates may be penalized to a large extent based on the patients they serve.” The study identified more chronic conditions, less education, more depressive symptoms, worse cognition and more difficulties with activities of daily living as among more than a dozen problematic patient characteristics.
So the current system of Medicare penalties, and indeed expectations regarding readmissions more broadly, might well be unfair to a substantial degree. But unless and until that changes, hospitals will remain under pressure to reduce readmissions.
Given that, and for ample other reasons, it makes sense to examine management approaches that can minimize preventable readmissions.
“One issue,” says Kip Piper, president of Health Results Group, “is just data and the lack of it.”
The healthcare system needs “a much more robust system of data and analytics,” instead of relying on a billing system or CMS, he contends. “You can’t wait for that. You need that actionable, decision-relevant information day to day.”
Such timely (if not necessarily real-time) information, Piper says, increases the likelihood of identifying patients who are at risk of readmission, based, for example, on the source of admission.
“Certain populations are far more likely to be readmitted,” he says. “We know that certain nonclinical characteristics are highly influential on whether they’re at risk of readmission.”
One warning characteristic is payer status, because, for example, a Medicaid or dual-eligible patient is less likely to speak English well and more likely to have a behavioral health issue.
“It’s not about blaming the patient,” Piper says, but rather about recognizing that some patients have to contend with an abusive living environment, a low level of education, substance use/abuse or even homelessness.
Medical complexity, such as chronic health conditions, behavioral health issues or multiple medications, is an issue with many patients at high risk for readmission, says Anita Morris, director of practice transformation in the Office of Healthcare Innovation and Quality, University of Massachusetts Medical School.
She adds that parallel to medical complexity there is “social complexity.” A high-risk patient might, for example, lack transportation to get home from the hospital or to pick up prescription medications. A lack of transport, Morris notes, could, for example, delay a patient starting on antibiotics for two or three days, compromising a clinical outcome.
A common mistake, says Don Hall, president of DeltaSigma LLC, is to treat people from different cultures the same or to ignore socioeconomic disadvantage. A patient with diabetes might not have something as simple as ready access to orange juice after being discharged.
Finally, Piper points out, factors that had nothing to do with a patient’s admission, such as behavioral or mental health issues, might strongly increase the patient's risk of readmission.
Discharge planning should begin as soon as possible during a hospitalization and if necessary continue after discharge, Piper says.
Not seeing a physician within a week of discharge worsens readmission risk, he says, so the hospital should consider actually making the after-discharge physician appointment and following up to remind the patient, rather than just telling the patient to make an appointment.
Similarly, he says, don’t just hand the patient prescriptions. Instead, forward prescriptions to a pharmacy that’s convenient for the patient, coordinate with the next provider, and give the patient a supply of the medication(s) at discharge.
Discharge checklists can be a big help, says Hall, and there are plenty of them to be found.
Key issues include:
• Whether the patient is ready to be discharged;
• Whether the patient has been informed about self-care;
• Whether the patient has been provided with at least a short-term supply of needed medications and bandages;
• Whether the patient knows whom to contact if there’s a problem; and
• Whether the patient knows when or under what circumstances to call someone.
Hall also suggests that including a home assessment as part of discharge planning might catch an issue like the lack of a refrigerator in the home, which could compromise medication and/or nutrition.
Coordination between hospital and out-of-hospital processes, particularly primary-care providers, constitutes “a large umbrella issue,” says Morris, who adds, “Primary care is the hub.” Communication is therefore crucial when a patient transfers out of a hospital and back to primary care, she says, recommending, for example, that hospital personnel communicate directly with the primary-care physician, especially for high-risk patients.
More can be done in this area, she says, because sending one follow-up fax might not be enough, though often that’s all that happens.
“The first line of defense is for the patient to have clear information about what medications they’re taking,” says Morris. Just as medication reconciliation takes place at hospital admission, it needs to happen again at discharge, and, she stresses, the primary care provider needs to reconcile also. Otherwise, there’s a major risk of a patient simply taking only the previous medications or the previous meds plus the new ones.
Another problem area is immediately following discharge, says Hall: “People leave the hospital, and they fall off the radar.”
Managing this phase better is simply a matter of actually applying what’s already available, he says, with tools like caregiver follow-up at home and more outbound communications from the hospital.
“Hospitals need to think, and act, about what goes on beyond their four walls,” agrees Piper.
New technologies open possibilities for better post-discharge monitoring, he says, including wearable devices with accelerometers; devices that dispense medications and can, for example, remind a patient to take a given medication with food; and digestible tags on medications, to help track compliance.
In all, better management on several fronts should be able to reduce a hospital’s readmissions, but it requires commitment and attention to detail.
“It takes time and effort to build up those processes and that communication,” Morris concludes. “It doesn’t happen by itself.”