Improving Transitions to Reduce Hospital Readmissions

By Debra Wood, RN, contributor

September 7, 2011 - Patients returning to the hospital in the days after an admission present a vexing problem for hospitals, partly because the Centers for Medicare & Medicaid Services (CMS) is preparing to reduce reimbursements to hospitals with the highest readmission rates. Perhaps more importantly, however, facilities are becoming increasingly aware that readmissions indicate problems for patients, and that improving transitions from acute care to other settings holds the potential to enhance patient outcomes.

“It costs the system money and makes sense from a fiscal health [perspective], but the more compelling reason to do it is the patient,” said Deborah Lambrinos, MSN, RN, executive director of quality management at Holy Cross Hospital in Fort Lauderdale, Fla., which has established a readmission task force to address the issue. However, she added, “This is not just a hospital issue. It’s a community issue. We cannot do it without partners.”

Holy Cross is reaching out to work with nursing homes and home health agencies to facilitate smoother transitions, to overcome language barriers and to ensure patients set follow-up appointments and understand their discharge plan. Holy Cross also has opened a heart failure clinic to assist with education and follow up.

Brian Contos, executive director for strategic research at The Advisory Board Company in Washington, D.C., agreed that preventing readmissions requires a community effort, saying, “Implementing strategies to reduce unplanned readmissions requires that hospitals broaden their accountability beyond the acute-care setting, a theme that applies to larger care delivery and payment reforms underfoot. Efforts must include strategies within the hospital’s four walls and beyond.”

Huntington Memorial Hospital in Pasadena, Calif., also has taken the lead on preventing avoidable readmissions.

“We believe that preventing avoidable admissions not only improves the health status of our patients but also maximizes the limited health resources available to the community,” said Sheryl Rudie, director of business development at Huntington Memorial.

Huntington Memorial has implemented projects that involve alignment with physicians so that patient care can be coordinated across the continuum. The hospital also is in the process of implementing a Health Information Exchange which will create a seamless, virtual community of all providers and significantly improve the information they have to treat their patients, decrease duplicative testing and decrease the cost of care.

Why the focus on readmissions

Preventable readmissions have been a topic of research for many years, Contos said, however, they were accepted as par for the course.

“Perverse financial incentives have hindered efforts to address readmission,” Contos said. “Hospitals generate about 35 percent of their reimbursement from readmissions; generally speaking, all of these cases are fully reimbursed. Moreover, efforts to reduce readmissions can be costly and may not have any associated revenue. Today, however, financial incentives have begun to shift.”

Several groundbreaking studies illuminated the cost associated with readmissions, Contos added. About 20 percent of Medicare patients are readmitted with 30 days of discharge, about three-quarters are avoidable, and those cost Medicare about $15 billion annually.

“It’s not just a cost issue but also a safety issue,” said Alan Spielman, president and CEO of URAC, a nonprofit healthcare quality accrediting body. “Hospital admission means an increased risk of infection and once again, a transition.”

Congress included in the Affordable Care Act a stipulation for penalizing hospitals with excessive readmissions. Contos explained that the penalty begins in fiscal year 2013 with an emphasis on heart failure, heart attack and pneumonia.

“Hospitals will be assessed based on their readmission rate from July 1, 2008 to June 30, 2011; the penalty will be capped at 1 percent of the hospital’s base operating payment from CMS in fiscal year 2013, 2 percent for fiscal year 2014, and 3 percent for fiscal year 2015 and beyond,” he added. “The actual penalty will be the lesser of either the aforementioned cap or one minus a ratio of payments for excess readmissions to payments for all admissions. For fiscal year 2013, the Advisory Board Company estimates that approximately one-quarter of hospitals will have no penalty, three-quarters will face a penalty of between 0.1 percent and 1.0 percent, and 9 percent will face the maximum penalty of 1 percent.”

The issue is broader than CMS incentives. Upcoming accountable care organizations and bundled payments also are driving the interest in preventing readmissions, said David Classen, a senior partner at CSC and an associate professor at the University of Utah.

“A business case [for preventing readmissions] is being created, not just by CMS but by the private payers,” Classen said, adding that hospitals are increasingly trying to leverage information technology to identify and help manage patients at risk for readmission.

Efforts to reduce readmissions

Recognizing that many avoidable admissions occur when coordination of care is lacking and patients are not engaged in their own care, Huntington Memorial launched the Patient Partnership Program, which employs health navigators in a patient-centered medical home model for patients with chronic illnesses, which engages patients as active participants in their own health and provides accessible, continuous and coordinated care.

“By ensuring timely follow-up care after a hospital visit or admission, the program addresses a major cause of avoidable readmissions,” Rudie said.

That necessary follow up with the physician is critical to decreasing the risk of readmission, Spielman said.

However, as Lambrinos indicated, some patients don’t have the resources to follow up with a physician. Some patients are homeless or underinsured.

URAC sets standards that expect case managers to assess transitions between care settings. Medication reconciliation is of prime concern. Poor adherence to diabetes care plans, which includes medications, results in 10 percent of hospital admissions, Spielman said.

“If people don’t get their medication right, the chances of them coming back to the hospital are enhanced,” Spielman said.

The Commonwealth Fund and Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association, published the Health Care Leader Action Guide to Reduce Avoidable Readmissions in January 2010, suggesting that hospitals examine their readmission rates, such as Holy Cross is doing; assess priorities; develop an action plan of strategies to implement; and then monitor progress. The authors cited four interventions that have strong evidence of reducing avoidable readmissions. They include: Boston Medical Center’s Re-Engineered Discharge/RED; Eric Coleman’s Care Transitions Program, with coaches; the Evercare Care Model, a care coordination program for people who have long-term or advanced illnesses; and the Transitional Care Model, developed by Mary Naylor, Ph.D., FAAN, RN, at the University of Pennsylvania School of Nursing, which provides comprehensive in-hospital planning and home follow-up for chronically ill, high-risk older adults hospitalized for common medical and surgical conditions.

“The readmission team is looking at the evidence of what works and can we operationalize it,” Lambrinos said.

Holy Cross nurses are using “teach back,” having the patient repeat the information they have been taught to help ensure they understand. The hospital also is investigating the use of technologies, such as electronic, on-demand education that patients can start to watch as soon as they are admitted.

“Our intent is to make it more patient centered, start it early, and make it more personalized and prescriptive,” Lambrinos said. “It takes a village. It’s not going to be a one-hospital solution. It’s very challenging, and not doing it is not an option.”


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