Providers’ Focus: Reducing Readmissions December, 2013 BLOG POST
Overview Under the changes mandated by recent healthcare regulations and burden of increasing costs, the United States healthcare industry is going through a transformation to create high quality and low cost care for patients. As payors and providers, both, try to seek better coordination, lower costs, and greater quality of care, one of the focus areas is reducing patient readmissions, especially Medicare patients. A readmission is defined as a hospitalization that occurs after a discharge, often measured as 30 days but it could be shorter or longer. Some of these readmissions are planned, and others may be part of the natural course of treatment for specific conditions. But some hospital readmissions are being thought of as avoidable and as indicators of poor care or missed opportunities to better coordinate care. Many Medicare patients discharged from an inpatient stay find themselves back in the hospital within 30 days. Hospitalizations are costly, accounting for approximately 30 percent of total health care expenditures1. In Medicare, inpatient care accounts for almost 35 percent of spending, and readmissions contribute significantly to that cost – 18 percent of Medicare patients discharged from the hospital have a readmission within 30 days of discharge, accounting for $15 billion in spending1. Until recently, the cost of readmissions was borne entirely by those who paid the bills – health plans, employers, consumers, and government agencies. However, payers have begun to limit the amount they will pay by denying payment for readmissions deemed preventable. Medicare, for example, contracts with quality reviewers to investigate readmissions and may deny payments if discharge planning was deemed to be inadequate. Hospital readmissions may adversely impact payer and provider costs and patient morale. Therefore, interventions to reduce readmissions target both inpatient care, through efforts to improve the quality and safety of care, and the transition to outpatient care, through efforts to ensure continuity and coordination between providers and timely access to needed follow-up services. Drivers of Hospital Readmission Several factors lead to readmissions including patients not understanding hospital instructions for post-discharge care as well as patients been discharged too early by hospitals. Below are some key reasons for readmissions: Communication breakdown: This occurs during the hospital stay and at the discharge stage. Lack of clear instructions, incomplete information, and questions not asked, and poor recall of the details leads to lack of compliance. Another problem is when patients get confused about a change in their medications and providers don’t sufficiently explain the change. Patients discharged early: Financial pressure from administrators to discharge patients as soon as possible, especially under the current terms for reimbursement has been a factor. A number of patients are discharged too soon and health care providers also agree this happens frequently. Also, some patients want to leave as soon as possible. 1
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Staff shortages: Several providers, across the nation, are facing shortage of skilled nurses and doctors. This is very relevant due to the additional number of newly insured people entering the system because of the Affordable Care Act, the problem of short staffed hospitals is expected to worsen. Reducing Hospital Readmissions Identifying best practices and policy levers to reduce avoidable readmissions would likely improve quality, reduce unnecessary health care utilization and costs, promote patient-centered care, and increase value in the health care system. 30-Day Readmission Rates among Hospitals with Lowest Readmission Rates (2010)2 Heart Attack (2,427 hospitals reporting)
Heart Failure (3,935 hospitals reporting)
Pneumonia (4,095 hospitals reporting)
McKay-Dee Hospital Center
17.70%
19.30%
13.70%
Memorial Hermann Memorial City Medical Center
18.00%
24.60%
14.30%
Mercy Medical Center – Cedar Rapids
17.20%
20.10%
14.90%
St. John’s Regional Health Center
17.10%
21.30%
15.60%
National Average
19.97%
24.73%
18.34%
Best Practice Initiatives to Reduce Readmissions
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Quality
Health Information Technology
Care Management
Care for patients correctly and readmission rates fall, performance on quality measures improves, and savings are realized as byproducts
Use health information technology (e.g., electronic health records, patient registries, and risk stratification software) to improve quality and integrate care across settings
Begin care management and discharge planning early, target high-risk patients, and ensure frequent communication across the care team
Patient Education
Customer Service
Provider Alignment
Educate patients and their families in managing conditions. Teach at a level appropriate to patients and ensure they understand and can teach back key instructions
Maintain a “lifeline” with high-risk patients after discharge through telephone calls, telemonitoring, or other practices
Align hospitals’ efforts with those of community providers to provide a continuum of care. While this may be best achieved in integrated systems, such cooperation can be facilitated through collaborative relationships among hospital and community providers
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Apart from individual hospitals, providers are also using a collaborative quality improvement approach to reduce readmissions. The Cleveland Alliance, known as Better Health Greater Cleveland has developed a network of 11 local and regional hospitals that are working together to improve care for heart failure, diabetes and stroke patients in Cleveland. The Alliance has been particularly successful in engaging hospitals to collaborate in a way that they were not accustomed to doing in the past. The Oregon AF4Q Alliance, known as the Oregon Health Care Quality Corporation (Quality Corp), is involved in several initiatives to reduce readmissions related to congestive heart failure and chronic obstructive pulmonary disease. The AF4Q Hospital Quality Network comprises of twelve hospitals in Oregon engaged in Reducing Readmissions collaborative. Six Florida hospitals have joined together to focus on reducing potentially preventable readmissions to hospitals within 15 days and 30 days. Members of the Collaborative meet quarterly and participate in monthly conference calls to discuss issues surrounding readmissions. Conclusion Reducing hospital readmissions within a fragmented health care system requires stakeholders to challenge aspects of the current system by breaking silos of treatment, improving relationships between all providers, and working to develop the future system and workforce. Although, reducing hospital readmissions is a substantial task given the financial, regulatory, and systemic constraints, continued dialogue between stakeholders, study, and experimentation can provide ways to reduce the number of avoidable readmissions and increase the value of health care.
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