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Readmissions and Community-Based Support

Cheryl Clark, for HealthLeaders Media, September 13, 2012
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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."

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