Study Highlights Hospital Readmission Rates from Post-Acute Care Facilities

By Jennifer Larson, contributor

February 20, 2013 - By now, everyone in healthcare is aware of the need to reduce hospital readmissions. But how many are focused on the issue of reducing hospital readmission rates from post-acute care facilities?

Kenneth Ottenbacher: Cooperation can reduce hospital readmissions from post-acute care.
Kenneth Ottenbacher, PhD, who studied hospital readmissions from rehabilitation facilities, hopes bundle payment incentives will increase cooperation between acute care and post-acute care facilities.

A team of researchers led by Kenneth Ottenbacher, PhD, hopes that more will take notice of this issue soon.

The team analyzed records for almost 737,000 Medicare beneficiaries who were discharged from 1,365 inpatient rehabilitation facilities to the community between 2006 and 2011, and their results were published in the February 12, 2014 issue of JAMA. The researchers discovered that the patients’ likelihood of returning to the hospital depended, in part, on their particular impairments, with 30-day readmission rates ranging between 5.8 percent and 18.8 percent. The overall 30-day readmission rate was 11.8 percent.

This study is one of the first to examine readmission rates among people who are discharged to rehabilitation facilities and other post-acute care settings, which Ottenbacher sees as a good step forward.

“The patient population that goes to inpatient rehabilitation facilities is almost by definition [susceptible] for readmission,” said Ottenbacher, professor and director of the division of rehabilitation science and the director for the Center for Rehabilitation Sciences at the University of Texas Medical Branch, Galveston.

Many of these patients are older, and many have had strokes or fractured hips, which are two of the largest categories of impairment. Those types of impairments are likely to have an impact that will last far beyond their hospital stay, putting them at increased risk for readmission, he explained.

Readmission rates: Not a perfect quality indicator

CMS recently announced that it will consider 30-day readmission as a national quality indicator for inpatient rehabilitation centers.

“Although readmission is an imperfect quality indicator, it has the potential to serve as a platform for efforts to improve patient transitions and care continuity associated with bundling and other initiatives proposed by the Affordable Care Act to reduce cost and improve health outcomes,” the researchers wrote.

Ottenbacher notes that there has been some controversy over the years about using readmission as a quality indicator.  “But on the other hand, it’s a very simple measure,” he said. “Readmission is like mortality, in that it’s straightforward. They’re either readmitted, or they’re not readmitted. So, it’s a place to start, for you how you look at outcomes across all these settings.”

And this particular study in JAMA is a start.

“When you look at where the focus has been, it hasn’t been on post-acute care. The focus has all been on acute care,” he said. “So our first goal was just to make people aware of the issue of readmission within a post-acute care setting.”

Highlights from the study

The researchers examined readmission rates for patients with one of the six most common reasons for receiving inpatient rehabilitation: stroke, lower extremity fracture, lower extremity join replacement, neurologic disorders, brain dysfunction and debility.

The lowest 30-day readmission rate was among patients with lower extremity joint replacement, at 5.8 percent, and the highest was for patients with debility, at 18.8 percent. Readmission rates tended to be higher among non-Hispanic blacks, men, and people with longer lengths of stay.

Factors that contributed most often to readmission in this study were heart failure, UTI, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis and digestive disorders.

More efforts to reduce hospital readmissions

Indeed, there are a growing number of programs that have been launched with the goal of reducing hospital readmissions, including:

Project BOOST. The Society of Hospital Medicine oversees the national initiative Project BOOST, which works to improve the care of patients as they transition from hospital to home, using evidence-based interventions. The goals include reducing 30-day readmissions, especially among older adults, and identifying high risk patients and tailoring specific interventions to them.  There are mentoring programs in place in more than 100 sites around the nation.

Community-based Care Transitions Program (CCTP). This program is part of the nationwide Partnership for Patients; one goal of this public–private partnership is to reduce hospital readmissions by 20 percent. It was created by the Affordable Care Act to test models for reducing readmissions for high-risk Medicare recipients and improving the transition of care from the inpatient setting to home or other post-acute setting--all while saving money for Medicare. Launched in 2011, there are 102 participating sites.

Ottenbacher would like to see specific programs to address the readmission rates among the patient population that he and his team studied, and feels that recent incentives may make that possible.

The study’s authors wrote, “CMS has proposed bundled payment models (acute and postacute care) to align performance incentives and contain costs. Understanding the ramifications of bundling requires accurate information regarding readmission rates for patients receiving postacute services.”

Additionally, there will have to be a common mechanism in place to provide that information. Ottenbacher noted that Medicare has been working on the development of the Continuity Assessment Record and Evaluation (CARE) Item Set, which is a standardized set of measurements that would enable providers to examine and compare the status of Medicare patients across a spectrum of settings.

“You have to be able to measure people across these different settings to see how well they’re doing and to see if [interventions] are working,” he said.

Ultimately, hospitals will have to partner with post-acute care facilities if they want to achieve meaningful reductions in readmission.

“Some form of bundling, even if it’s not mandated by CMS, will probably happen,” said Ottenbacher.

For more information:

The JAMA study: Thirty-Day Hospital Readmission Following Discharge from Postacute Rehabilitation in Fee-for-Service Medicare Patients

Related articles:
Better Nurse Staffing Shown to Reduce Readmission Penalties
Study: Hospital Performance Can’t Be Fully Measured by Readmission Rates

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