With the financial consequences associated with hospital readmissions gradually mounting, providers are focusing on improving transitions from inpatient to outpatient status.
As the Centers for Medicare & Medicaid Services continues to ramp up payment penalties for hospitals with high 30-day readmission rates, it's becoming more important than ever for hospitals and health systems to get a handle on this key quality measure.
Launched in October 2012, CMS's Hospital Readmission Reductions Program began by penalizing hospitals up to 1% of their Medicare reimbursements for excessive readmissions of patients with heart attack, heart failure, and pneumonia.
The financial consequences are gradually mounting, and by fiscal year 2015, CMS will expand the program to include a maximum penalty to 3%. Chronic obstructive pulmonary disorder and total hip and knee replacements will also be added to the list of medical conditions factored into the calculation.
Hospital leaders are well aware of the dollars that are now at risk. In the HealthLeaders Media September 2013 Readmissions Buzz Survey, 85% of respondents indicated that CMS's readmissions penalty is addressed in their organization's current business plan.
Improving Transitions to the Outpatient Setting
Roughly one in five Medicare patients is readmitted to a hospital less than a month after discharge. One strategy for reducing this number is to improve the transition from the hospital to the post-acute care setting, says Marc Berliant, MD, associate chair of medicine at the University of Rochester (NY) Medical Center.
In January 2011, URMC, a healthcare delivery network anchored by the 800-bed Strong Memorial Hospital, started its Safe Transitions program to focus its attention on successfully moving patients out of the hospital to their next site of care, whether it be to a skilled nursing facility, a rehab center, or their own home.
The program's goal is to drive down 30-day readmissions by 15%. "It's a multidisciplinary program focused on areas like medication reconciliation and management and early discharge follow-up," Berliant says.
"Our idea is that for high-risk patients, the minute they are admitted to the hospital, they need intensive attention. We are planning their discharge on that day of admission. We are rounding on them with a pharmacist, a social worker, a case manager from their patient-centered medical home… We are trying to see if micromanaging these patients might result in better outcomes."
Before patients are discharged, nurses and case managers cover a checklist of items with them, such as making sure they can access their medications and that they understand how to take them and what the potential side effects may be. Staff use teach back techniques to confirm that patients fully comprehend their care instructions and also set up a follow-up appointment with a primary care doctor.
After discharge, case managers continue to support patients through telephone consultations in which they address the medical and social barriers that may prevent patients from recovering their health.
Taking a Population Health Approach
The Safe Transitions program represents a shift in healthcare. Hospitals are realizing that they are responsible for the patient even after discharge, says Kelly Luther, URMC's director of social work and patient and family services.
"The biggest challenge is actually shifting the culture from one focused on episodes of care to one based on population management," she says. "We are so used to taking care of what is in front of us at this very moment and then faxing that piece of paper and hoping all goes well at the next place where that patient is received."
Redesigning the care continuum around new ways to care for populations is critical to URMC's ability to prevent readmissions and to make gains on other quality measures, Berliant says.
"One of the markers of quality of care is readmissions, but that is just one marker. We are also looking at overall admission rates, ED visits, and other areas," he says. "What is clear is we are trying to evolve toward a population health model of care delivery… It all goes hand-in-hand if we are going to be paid for quality and not just for volume."
Identifying High-Risk Patients
URMC has embedded a risk stratification tool in its electronic health record to identify patients with the highest risk of readmission so that these patients can receive additional attention after discharge, Luther says.
"You can capture some real success this way in terms of preventing a readmission," she says. "For example, during a follow-up phone call, if a patient says they are not going to take their meds until they see their own doctor, then that is an opportunity where the case manager can offer some clarification about how and why to take their meds."
Smarter use of the EHR has also helped URMC work more effectively with its local skilled nursing facilities to prevent readmissions, Luther adds.
"It has transformed our relationship with nursing homes," she says. "We always struggled with that because our system of communicating with them was archaic. With the EHR we were able to launch open access to medical records for their patients in addition to what we were doing with verbal handoffs, either nurse to nurse, or physician to physician."
Its enhanced relationship with nursing homes has helped URMC keep people from returning to the hospital, Berliant agrees. "There have been several cases with nursing homes where we have been able to empower them to take care of people who have complex diseases and help them manage those people onsite instead of in the hospital."
Still More Work to Do
So far, URMC has seen about a 5% drop in readmissions, which is an indication that there is more work to be done and that the program needs to be refined, Berliant says.
"One example is we thought early discharge follow-up would be tremendously advantageous, but only 60% to 70% of patients are able to be seen by their primary care doctor before being readmitted," he says.
"We have to keep putting these processes in place and getting people ready for discharge. We are also working on establishing a real willingness on the part of the primary care practice to see the patient quickly and on adequately communicating with the primary care physician so they can be prepared for the visit."
Berliant says being realistic about preventing readmissions is also necessary given the medical realities that many patients face.
"Some patients are going to come back no matter what you do," he says. "They just are not going to be kept out of the hospital due to multiple comorbidities. That is recognized nationally, and we wish CMS would recognize that as well."
A HealthLeaders Media webcast, A Comprehensive Readmissions Solution—Getting Process and Data Right, will be broadcast on Wednesday, June 25, 2014, from 1:00–2:30PM ET. Join leaders from Baylor Heart and Vascular Hospital and Southwest General as they reveal how adopting a hospital-wide culture of end-to-end care can reduce readmissions rates, improve patient experience, and foster physician engagement.