What a TV Show Can Teach Us About Readmissions

When I recently heard that several state health officials are examining avoidable hospital readmissions with an eye toward detecting regional variation, somehow I thought of Florence Hufnagel.

Smile if you remember this irascible patient.

In the 1980s TV series St. Elsewhere, she was the comical senior who kept returning to the hospital for yet another serious medical issue, frequently stemming from something done to her the last time she was admitted.

Ultimately, the angry Mrs. Hufnagel was victimized one last time when her hospital spring bed snapped shut in a V, trapping and suffocating her inside. Though dismayed, the show's characters conveyed their relief that they no longer would have to deal with her seemingly impossible complaints.

According to a 1985 article in the Los Angeles Times, the show's medical adviser said Hufnagel just couldn't keep developing new illnesses and being readmitted. She either had to get well or die.

In the new health reform bill, readmissions like those Hufnagel suffered are a very serious deal for a number of reasons. For starters, starting in 2012 Medicare isn't going to pay for many of them. And that's potentially a lot of hospital revenue.

We now have numerous studies quantifying that at many as one in five Medicare patients undergo unplanned readmissions to a hospital within 30 days of being discharged, at a cost to the taxpayer of $17.4 billion annually.

According to a 2007 study from the Medicare Payment Advisory Commission (MedPAC), federal funds now pay $5 billion for potentially preventable readmissions within seven days, $8 billion for readmissions within 15 days and $12 billion for those readmitted within 30 days. "In 2005, the average Medicare payment for a potentially preventable readmission totaled approximately $7,200 (almost $1,400 less than the payment for the original stay."

Of course, we're not sure that all these readmissions are preventable, but Amy Boutwell, MD, MPP, director of Health Policy Strategy for the Institute for Healthcare Improvement, and others say as many as 75% of them probably are.

Often it's not because of something the hospital did, such as a misdiagnosis, a hospital acquired infection, or a forgotten instrument in a surgical cavity, (although that those events still happen much too frequently) but because the system failed the patients after they left the hospital.

The hospital perhaps sent the patient home, not realizing—or not trying hard enough to find out—that the patient couldn't make or keep the appointment with her follow-up care physician as she was instructed.

Or, her discharge planners didn't know—or couldn't remedy—that the patient wouldn't get to the drug store to fill the prescription she was given because she didn't have transportation, or that she would fail to take the drugs properly because all those pill bottles are so confusing.

Or perhaps the patient needed in-home support that was never arranged, or hospital dischargers weren't aware that her caregiver-spouse was also increasingly suffering from dementia and incapable of managing the medications.

In short, they didn't care about what happened to Mrs. Hufnagel in her home. Yet, all of these issues put blocks in front of her recovery, and draw a trajectory that leads patients like her right back into the hospital.

That's why officials in Florida, Pennsylvania, and now California are digging into their hospital discharge statistics to see if they can find trends that will reveal flaws in the processes of discharging patients; flaws that result in many such patients coming back repeatedly, each time a little bit sicker.

"We are now starting to look at readmissions not just that faulty or incomplete clinical care was provided, but now we see it as a flawed process of transitions of care," says Boutwell. "This has been a big, pivotal concept."

She adds that through many existing studies, we already know that Medicare patients' 30-day re-hospitalization rates vary between 13% and 24% from state-to-state.

"If hospitals, nursing homes, and ambulatory care providers (home health and MDs) are not motivated and incentivized to discover ways to apply all of what we know in research and best practice to their local setting, isolated efforts to reduce re-hospitalizations may not be as successful as we hope," Boutwell says.

"Providers and patients need to reorient a perspective that providing enhanced services to patients in the home or office—'more care'—is still much more cost effective than sending non-acutely ill patients to the ED for rehospitalization," Boutwell adds.

Four Strategies to Prevent Readmission
Boutwell and IHI offer four strategies hospitals can start employing immediately to prevent readmissions: ( See complete list at www.ihi.org/staar.)

1. Measure your hospital's "all cause 30-day readmission" rate.
2. Form a continuum team of receivers: nursing homes, home health agencies, skilled nursing facilities, hospice, office practice, and include a patient/family representative.
3. Review the stories of five recently readmitted patients.
4. Improve core processes, in collaboration with partners on the cross continuum team. Use the entire hospital stay to educate the patient and family on post discharge care and communicate with post-discharge providers to ensure some follow-up with the patient, such as a home visit or a phone call.

Hospitals are starting to see the potential and are moving to take action, says Boutwell. "We now have dozens of hospitals working with us at IHI. They come to us with these concrete barriers of why the patient's post-discharge care doesn't go well. They say, 'The patient doesn't qualify for home bound status' or 'the patient can't get an appointment to see her doctor in a few days.' "

The work now "is on finding ways to shift services to provide more support at time of transition."

Some of the questions providers should ask when reviewing their readmission rates might be: Are patients in one city or county more likely to be readmitted? Are they likely to be in one socio-economic group or another, or have difficulty getting to a pharmacy to fill a new prescription? Are higher readmission rates associated with certain age groups? Or are they perhaps more likely to occur depending on where they were initially discharged to?

Are readmissions more common when patients are discharged from small hospitals or larger hospitals? Are they more likely to occur at day seven, day 10, or day 29, and at what time are they most preventable?

In the January issue of the journal Health Affairs, researchers at Brown University and Harvard Medical School found that when a hospitalized patient is discharged to a skilled nursing facility instead of to home, they have an even greater chance—one in four versus one in five—of being readmitted or "bouncing back" to the hospital.

These are findings that hospitals would do well to take seriously. They need to do more, even if it means spending considerable sums of money and forging partnerships with doctors and after-care systems and facilities to manage their patients' post-discharge recoveries better.

Quality Care and Money At Stake
Not only is the patient's health at stake, there's money at stake, too.

The Centers for Medicare and Medicaid now penalizes hospitals by denying them reimbursement for care required because of provider mistakes. And, the agency also requires hospitals to "voluntarily" report on a number of quality measures such as readmissions, but reduces reimbursement by 2 percentage points if the hospital fails to report them.

So far, Boutwell and other hospital quality experts acknowledge, those reductions have not presented much of a threat. They haven't been that frequent or that high.

But that is soon to change. "The hospitals realize that very soon they will not be paid for many of these (avoidable) readmissions," Boutwell says. "They know they have to do something."

On Oct. 1, 2012, the new health reform law's Hospital Readmissions Reduction Program takes effect, authorizing a complex formula that will reduce the amount of money paid to hospitals with higher than average readmission rates.

When that happens, and hospitals get serious about keeping patients healthier outside their facilities, Mrs. Hufnagel—wherever she is today—might finally be happy with her care.