This article appears in the September 2012 issue of HealthLeaders magazine.
When hospital leaders realized they'll endure cuts of up to 1% from their Medicare reimbursement for higher rates of 30-day readmissions starting next month, many complained. What brings discharged patients back to their facilities most often is largely outside their control, they said.
Patients can't get to the doctor, can't afford or don't fill prescriptions, get confused about dosages or forget they must change their routines. Their anxiety or loneliness or an unexpected drug reaction to a pain medication prompts them to dial 911. Oblivious to household hazards, they suffer a fall.
Those are nonmedical issues influenced by social or economic factors and extend far beyond a hospital's discharge planning responsibilities.
So lawmakers addressed those concerns. They wrote into the Patient Protection and Affordable Care Act Section 3026, which sets up a $500 million program not for hospitals, but for community-based organizations that work with discharged patients to avoid these social problems thoughtfully and inexpensively.
Under the Community-Based Care Transitions Program, these CBOs help patients self-manage their care with home visits, counseling, medication reconciliation, financial assistance, transportation, meals and nutrition, legal aid, and follow-up phone calls for 30 days. In other words, these community groups could receive federal funds to do in outpatient settings what hospitals don't and can't. They just had to get hospitals to cooperate with referrals.
"The idea that someone could do home visits—which we knew we didn't have the resources to do—has been reassuring," says Christopher Shearer, MD, chief medical officer for the 266-bed John C. Lincoln North Mountain Hospital, one of two hospitals in the Phoenix-based John C. Lincoln Health System. Shearer has responsibility for readmissions initiatives in the network's hospitals, which are among the first hospitals in the country to sign up. Lincoln is participating in the Phoenix region's Healing@Home program that targets Medicare fee for service beneficiaries who are at high risk for hospital readmission.
After all, he says, "only 25% of readmissions can be directly correlated with what happens during discharge. This has as much if not more to do with patient and outpatient follow-up."
At first, it was challenging to get the program integrated into the day-to-day routine, and make sure the medical providers' efforts dovetailed with those providing social support, he says. But since the Maricopa County program began in March, Shearer says he has heard several stories about readmissions in the works that the CBO was able to prevent.
"It's too early to say whether this has had an overall impact; we'll need to wait another six months," he says. "But we're certainly identifying issues we wouldn't have otherwise."
And in "a worst-case scenario—even if it doesn't work," he adds, "we won't have lost anything."
Shearer says that if there is any cost for the program to the hospital, "it was in getting the program integrated into our day-to-day routine. But we were going to have to do this anyway to deal with readmissions. So we thought the best time to get good at this is now."
Saints Medical Center, a 157- licensed-bed hospital in Lowell, Mass., is one of five hospitals that joined Merrimack Valley Care Transitions program that began Feb. 1. Since then, Helene Thibodeau, the hospital's vice president of outpatient services, says the project "has led us to see that we need to look beyond the four walls that surround our hospital, and make sure that we're including the community-based organizations to facilitate good transitions for our patients."
Janet Liddell, who is quality and patient safety manager for Saints Medical Center, says that other readmission prevention efforts were already under way. But participation in the community care transition program has enabled the medical center to "add a transition coach to our discharge process. It's not something we were able to do before, and it extends the work we were able to do to the patient's home. It offers a softer landing for the patient and improves transitions to the community that way."
The process has helped prevent readmissions from skilled nursing facilities as well, a source of "a good portion" of the medical center's readmissions, Liddell says. "When patients are transferred to skilled nursing homes or long-term care facilities, those patients will be handed off to the transition coach" in those facilities.
For patients discharged to their homes, care transition coaches spread out the patient's medications on the kitchen counter and compare each with the discharge instructions. "Many times they've picked out discrepancies," Liddell says. "Or it may mean that when there's a question, they call the patient's primary care provider right then and get clarification."
The Merrimack Valley program also has a mental health component, with transition coaches who are specifically trained to deal with depression and anxiety in Medicare patients, which Liddell says has frequently led to avoidable readmissions.
Saints was acquired on July 1 by Lowell General Hospital, which plans to continue the program, Thibodeau says.
"There's just not time to deal with all these things while the patient is still in the hospital," says Rosanne DiStefano, executive director of Elder Services of the Merrimack Valley, which has so far completed 1,600 patient assessments under the program. "The patient is not at the point where they're ready to absorb it all; this has to be done over a period of time." Observing the patient in his or her home has also uncovered safety issues that can lead to injuries, she says.
Administered by the Centers for Medicare & Medicaid Services, the CBCTP was supposed to be launched in January 2011. But initially, most hospitals—whose participation is essential—were unenthused.
Hospitals and their trade group representatives were skeptical that regional 501(c)(3) staff had enough medical or polypharmacy expertise to prevent readmissions with transportation, meal programs, and home visits. And why should the CBO receive all the funds when the hospitals get the financial hit from readmissions penalties, they asked.
"The fundamental flaw in this model is that hospitals are the only entity eligible to be penalized for readmissions, yet hospitals are not eligible to directly receive any of the technical assistance funds available," Lisa Grabert, senior associate director for policy with the American Hospital Association, told HealthLeaders Media last fall.
After a slow start, and as readmission penalties loomed closer, more hospitals got on board and by August, more than half of the $500 million had been allocated to CBO collaborations involving 47 organizations, some with multiple hospital sites, across 23 states.
A close relationship between the CBO and the hospital teams is essential.
The hospitals must pick the right patients at highest risk, because the program must produce a 20% reduction of a hospital's baseline 30-day all-cause readmission rate among Medicare patients in the first two years. If that's not achieved, CMS can reject funding for the rest of the five-year program. The CBO can't provide these services for all discharged patients, so hospitals must refer just those high-risk patients most likely to be readmitted.
The rules also say the CBO must assure that its costs to keep patients from unnecessarily returning to the hospital within 30 days are less than the cost of an average hospital readmission, or about $9,600.
The programs are structured in a variety of ways. But in general the federally funded CBO may hire care managers to work inside the hospital with physicians and nurses to assess high-risk patients at the point of their index admission. Hospital and CBO teams develop a structured, formal protocol for how they will address each issue the patient might have after discharge and get the patient's consent.
At discharge, the patient's needs are reassessed, and care transition coaches, such as those trained under the Coleman model, are assigned to each patient. That may mean one or more home visits, making sure the patient sees a physician within the first two weeks and has the means to get to the appointment, and instructions and teach-backs to ensure the patient understands his or her medications and care plan. Cultural and language issues must be addressed with multilingual personnel.
It's still too early to tell whether the programs are working. But success stories are starting to come in.
The Southern Maine Area Agency on Aging, working with the 150-licensed-bed Southern Maine Medical Center in Biddeford, has been able to help patients proactively manage chronic illness in the community rather than in the hospital setting during crisis, says Helen Troy, SMMC's director of quality and case management.
The agency has helped patients and their families plan for inevitable structured custodial care settings so that such crucial decisions are not made urgently in yet another trip to the emergency department.
It used to be, Troy says, that it was "only after crisis after crisis, and re-admission after readmission, would it be decided that a patient could no longer return to their home. Now, we have a better opportunity in partnering with the CBO to prevent this from happening in crisis mode."
Troy says that procedurally, the hospital has made some important shifts to weave the program into daily operations. For example, staff are now guided by tools for better communication to community providers to assess patients' readmission risk, looking at key issues such as the number of drugs they're taking, past history of readmissions, psychosocial issues, and conditions that may categorize patients as "end-stage."
"It's in our patients best interest that hospitals be aware of services in the community and make all attempts to connect our patients to those resources as appropriate," she says.
In Southern Maine, as well as many other areas of the country, hospitals and their Area Agencies on Aging or other CBOs already had some informal working relationships to manage care transitions. But the dollars from this federal program enabled more formal routines to become standardized and accountable for outcomes, Troy and others say. Additionally, CMS will be monitoring each program's readmission success.
In Phoenix, Melissa Benfield, director of Healing@Home, which is working with four hospitals including John C. Lincoln, tells how psychosocial issues too often result in avoidable readmissions. Recently, a Medicare patient arrived home, only to become agitated over what she thought was a high-priced ambulance bill from the city. The transition coach talked with the patient for an hour in her home, reassuring her that the paperwork was a Medicare coverage notice, not a bill.
Shearer and Benfield describe another patient with a breathing condition who was supposed to get a nebulizer and oxygen, but the equipment had not arrived. When the transition coach showed up, she arranged to get what the patient needed in a couple of hours, avoiding what would surely have resulted in a readmission.
Benfield says that since Healing@Home began Feb. 1, coaches have helped 420 patients identified as high risk for readmissions.
One of the biggest challenges, explains Benfield, is to convince patients and care providers why this extra service may be needed in addition to, say, a visiting nurse or home health program.
The answer is that this program specifically targets avoidable readmissions. "We focus on medication reconciliation, getting patients connected with primary care physicians, and identify those red flags that will send them back to the hospital."
The programs use a variety of models. UniNet, an Omaha, Neb.–based, nonprofit physician hospital organization that provides managed care services to area metropolitan hospitals, has expanded its operation to qualify for the program. UniNet is working with the Eastern Nebraska Office on Aging and five hospitals within Alegent Health to help 8,000 discharged patients a year avoid a readmission. The program in June.
Richard A. Hachten II, Alegent president and CEO, says that apart from the readmissions penalty, preventing readmissions under current fee-for-service payment structures means hospitals will lose money. Nonetheless, he says, Alegent decided to participate "to prepare ourselves and learn everything we can to most effectively manage the health of populations as reimbursement models change. Each of these experiences adds to our knowledge base in effectively managing patients' health."
UniNet uses nurses in the hospital to meet with Medicare patients to evaluate which ones are at highest risk. Depending on their needs, either the nurse follows up with the patients at home after discharge, or if the patients have home health needs, they are referred to the Office on Aging.
The important thing, Hachten says, "is that now it's all a coordinated effort to provide a number of resources" in a way neither the patients nor the hospitals had before.
With the Supreme Court's decision in June, and looming readmission penalties (up to 1% of Medicare DRGs for the first year starting with Oct. 1 discharges, up to 2% in 2013, and up to 3% in 2014), some skeptical hospital organizations are now reconsidering their participation in Section 3026, says Bruce Siegel, CEO of the 170-member National Association of Public Hospitals and Health Systems. In particular, leaders of safety-net hospitals, some of whom are more worried about readmissions penalties than others, "see the train is coming. And I think a lot has changed in the last year, with people more willing to think about models like this that they weren't willing to think about a year ago."
Reprint HLR0912-9
This article appears in the September 2012 issue of HealthLeaders magazine.