Rethinking the Process

Editor’s note: In April, the Journal of Healthcare Contracting examined the Hospital Readmissions Reduction Program’s impact on hospitals, skilled nursing facilities and home health agencies. This month, JHC examines its impact on physicians.

Hospital Readmissions Reduction Program could affect how doctors care for patients

The federal government is trying to change the rules of the game of U.S. healthcare.
Traditionally, those rules have called for providers to get paid for doing more procedures and providing more care. But spurred on by the Patient Protection and Affordable Care Act, the feds are trying to turn that formula around. One vehicle they are using to do so is the Hospital Readmissions Reduction Program.

Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the United States, according to the Institute for Healthcare Improvement. In the majority of cases, hospitalization is necessary and appropriate. However, a substantial fraction of all hospitalizations are patients returning to the hospital soon after their previous stay, says IHI. These rehospitalizations can be costly and harmful, and are often avoidable, according to the organization. And the feds apparently agree.

The readmission-reduction program calls for the Centers for Medicare & Medicaid Services to reduce payments to hospitals that have excess readmissions, effective for discharges beginning Oct. 1, 2012. “Readmission” refers to a patient being readmitted to a hospital within 30 days of discharge. Though Year 1 penalties are reportedly relatively small (ranging from 0.01 percent to 1 percent of a hospital’s Medicare revenue), they are scheduled to increase in following years.

In its final rule for FY2012, CMS finalized the readmission measures for acute myocardial infarction, heart failure and pneumonia, and wrote in adjustments for factors considered to be clinically relevant, including patient demographic characteristics, comorbidities and patient frailty.

The bottom line? The feds hope the readmission-reduction program will reward new activities among healthcare providers, including:

  • Increased communication and, it is hoped, coordination of care, among hospitals, doctors’ offices, long-term-care facilities and home care providers.
  • A growing emphasis on patient education, so that patients and their caregivers fully understand post-hospital instructions, particularly for medication management and diet.
  • Prompt and frequent monitoring of the patient’s post-discharge condition by medical professionals, such as a doctor, nurse, nurse practitioner, etc.

Though not directly tied to the readmissions-reduction program, two newly created Current Procedural Terminology (CPT) codes for “transitional care management services” may encourage physicians to get onboard.

Rethinking processes
“[The readmission-reduction program] is causing us to look at our processes,” says C. Michael Valentine, MD, FACC, Cardiovascular Group of Centra, Lynchburg, Va., and treasurer of the American College of Cardiology. “The first thing we have to do is ramp up training of the patient and staff,” he says. “No. 2, we have to think about, ‘What avenues are we going to take that will prevent the patient from coming back to the hospital?’”

The process begins during the patient’s hospital stay, but it has implications in the outpatient setting as well, including the doctor’s office or clinic.

In the traditional heart failure clinic, for example, the cardiologist might not see his or her patient for two, three or even four weeks after discharge, says Valentine. But many readmissions occur within a week after discharge, due to a lack of planning or teaching. The patient may not understand instructions and hence won’t be in compliance with them.

That’s why the new heart failure clinic is taking a new approach, starting with its internal team, says Valentine. “Rather than just the physician planning to see the patient two or three weeks after discharge, now we need an entire team to help manage the patient – nurses, nurse practitioners, dietitians, social workers and physicians. In the future, a physician may not even be the leader of that team. It most likely will be a nurse or nurse practitioner, pairing with a physician.”

At Centra Health, mid-level providers meet with discharged patients no later than three to five days after discharge. “That provider is looking for dietary compliance and understanding; medication compliance and understanding; setup of food and understanding of the sodium restrictions at home,” says Valentine. Centra practitioners look at barriers to compliance, such as a person’s inability to read, lack of money to buy medicine, or social problems in the home. “The team goes from being a physician to a nurse, nurse practitioner, social worker and dietitian,” he says.

The key is education and breaking down the barriers to success, he continues. And the payoff? “Keeping the patient at home and healthy is the primary goal,” says Valentine. “The secondary goal is reducing [financial] losses for the healthcare system as a whole.”

Some physicians may resist forming the kinds of healthcare teams that Valentine believes are necessary to reduce readmissions and improve patients’ well-being. “But heart failure, like many things we face today, is a chronic disease. It calls for partnering with nurses, nurse practitioners, managers, pharmacists,” he says. “When you look at accountable care organizations, it’s the people who partner best and create the most efficient ways of working together who will be the winners.” So will their patients.

Medical homes
Some practices already have experience forming the kinds of teams necessary to reduce hospital readmissions. Coastal Medical in Cranston, R.I., for example, has been a patient-centered medical home for two years, and, for the past six months, has been a Medicare accountable care organization, says Yul D. Ejnes, MD, MACP, a practicing internist and immediate past chair of the American College of Physicians’ board of regents.

The fact that Coastal Medical is a patient-centered medical home and ACO “aligns everything,” says Ejnes. Being a medical home means that payment is based not just on the number of patient visits, but on the practice’s success in improving quality of care and on managing patients’ long-term health. That’s why the practice employs a nurse care manager, who stays in close touch with patients with chronic conditions, such as diabetes. “Those patients may need more time, or they may need to be called regularly or seen,” says Ejnes. The nurse care manager makes those phone calls and coordinates that care.

Coastal Medical also stays in close touch with the staff at Rhode Island Hospital – where Ejnes is on staff – about patient admits and discharges. “[The hospital staff] alert us when the patient is discharged, and that allows us to do a better job of making sure his or her meds are reconciled and the patient gets timely access to our office.”

For the most part, communication between hospital and medical practice has always been pretty good, says Ejnes. “But overall, things have gotten even better,” he says. “Five years ago, we might find out that our patient had been in the hospital only after they came in for a routine visit months after they were discharged,” he says. “But we’re seeing less of that now, because of the various tools we have in place, as well as greater sensitivity to the issue.”

The state of Rhode Island has instituted measures to keep all providers aware of patients’ status, says Ejnes. For example, when patients leave one institution for another, or go from a healthcare institution to their home, a form is sent to the patient’s physician containing diagnoses, medications, changes in medications and management instructions.

One of the keys to reducing hospital readmissions is seeing patients as soon as possible after their discharge from the hospital, says Ejnes. Perhaps changes to the patient’s medication regimen were made in the hospital. Following the patient’s discharge, the practice wants to ensure that his or her meds are reconciled. Often, the patient who has been discharged from the hospital needs to be monitored for whatever condition or incident brought him or her to the hospital. Often that monitoring can be done in the patient’s home, he says. Telemedicine offers other possibilities for remote monitoring.

CPT codes
Physicians in all practices – not just those that qualify as medical homes or accountable care organizations – should benefit from two new CPT codes covering transitional care management. Codes 99495 and 99496 are intended to reimburse physicians for the management of patients who have recently been discharged from a hospital or skilled nursing facility. The codes allow for efficient reporting of time spent discussing a care plan, connecting patients to community services, transitioning them from inpatient settings and preventing readmissions, according to the American Medical Association.

“There has been a longstanding concern that the evaluation-and-management (E&M) codes do not fully account for the services that are not provided in a face-to-face office visit,” says Peter Hollmann, MD, chair of the CPT Editorial Panel and associate chief medical officer for clinical affairs, Blue Cross & Blue Shield of Rhode Island. That has been problematic, because reducing readmissions calls not only for face-to-face visits, but phone contact, as well as coordination between the physician’s office and home care agencies, social service agencies, pharmacy benefit management companies and others. That’s particularly true for the older Medicare population, he says.

“A lot of doctors are doing these things now, and not getting paid for it,” says Hollmann. “So with the CPT codes, they are finally getting paid and recognized for the work they’re doing.” And it might encourage others, who might have been unable to afford to engage in these activities, to do them as well. “That’s the fundamental principle behind them,” he says.

STAAR initiative
Better education, handoffs key to reducing readmissions

Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the United States, according to the Institute for Healthcare Improvement (IHI). In the majority of cases, hospitalization is necessary and appropriate. However, a substantial fraction of all hospitalizations are patients returning to the hospital soon after their previous stay. These rehospitalizations are costly, potentially harmful, and often avoidable.

In May 2009, the Institute for Healthcare Improvement launched the STate Action on Avoidable Rehospitalizations (STAAR) initiative to reduce rehospitalizations. STAAR participants work across organizational boundaries by engaging 1) payers, 2) stakeholders at the state, regional and national level, 3) patients and families, and 4) caregivers at multiple care sites. Participating states to date are Massachusetts, Michigan and Washington.
The STAAR initiative is grounded in a two-part strategy for reducing rates of rehospitalization.

  1. Improve transitions of care.
  2. Engage state-level leadership to understand and mitigate barriers to change.

Improve transitions of care
Delivering high-quality healthcare requires contributions from many parts of the care continuum, and effective coordination and transitions between providers and between care settings, according to IHI. The best transition out of the hospital is only as effective as an activated reception into the next setting of care.

STAAR participants are required to engage partners from across the continuum of care to problem-solve and co-design improvements in the day-to-day work of providers. STAAR provides content reviews, process recommendations, inventory and celebration of best practices, and suggested measurement strategies. Best practices and experienced faculty are drawn from successful teams that have worked with IHI in prior engagements.

Prioritizing longitudinal care and reducing avoidable rehospitalizations involves new behaviors, norms, relationships, and partnerships to communicate and coordinate care between disciplines, settings, and organizations. State-level leadership is essential to understand and act on the barriers that front-line teams encounter. Similar in many respects to the cross-continuum team at the provider-level, STAAR engages with multi-stakeholder state leaders and steering committees to lead and coordinate this initiative at the state level.

At the patient level
STAAR hospital teams focus on the implementation of four key process-level improvements, which require collaboration between the hospitals and their community partners.
1. Perform an enhanced assessment of post-hospital needs.

  • Involve family caregivers and community providers in completing a needs assessment of patients’ home-going needs.
  • Reconcile medications upon admission.
  • Create a customized discharge plan based on the assessment.

2. Provide effective teaching and facilitate enhanced learning.

  • Customize the patient education materials and processes for patients and caregivers.
  • Identify all learners on admission.
  • Use “Teach Back” regularly throughout the hospital stay to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care.

3. Provide real-time handover communications

  • Reconcile medications at discharge.
  • Provide customized, real-time critical information to next clinical care provider(s).
  • Give patients and family members a patient-friendly discharge plan.
  • For high-risk patients, call the individual listed as the patient’s emergency contact to discuss the patient’s status and plan of care.

4. Ensure timely post-hospital care follow-up

  • Identify each patient’s risk for readmission.
  • Prior to discharge, schedule timely follow-up care and initiate clinical and social services based upon the risk assessment.

To learn more about STAAR, go to