Realizing Reductions

Editor’s note: 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. The Journal of Healthcare Contracting examines its impact on hospitals, skilled nursing facilities and home health agencies. Next month, JHC will look at its impact on physicians.

Reducing avoidable readmissions to the hospital is doable, but will demand increased commitment, communication.

Piecework. It sounds damning, but that’s how some healthcare providers describe the way their profession has approached patient care. Patient presents, diagnosis is made, treatment is prescribed, patient is discharged, provider gets paid. Then the whole process starts over the next time the patient gets ill…which might be just a week or two hence.

What has piecework bought us? Not much. The patient and his family members feel alone, warning signs go unnoticed, tests and treatments are duplicated, the patient is often readmitted to the hospital just days after discharge…and the cost to the system climbs.

It’s tough to change years of habit and flawed reimbursement methodologies. But change can occur, and it is. Today’s healthcare providers are making strides in focusing on the patient as he or she moves among inpatient and outpatient settings, and even to the home. These efforts are resulting in new alliances and avenues of communication.

Readmissions reduction program
The Hospital Readmissions 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 feds hope the readmission-reduction program will lead to:

  • 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.

What’s the problem?
Hospitalizations account for nearly one-third of the total $2 trillion spent on healthcare 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 are patients returning to the hospital soon after their previous stay, says IHI. These rehospitalizations can be costly and harmful, and are often avoidable.

Skilled nursing facilities get about 2.5 million admissions a year from hospitals under Medicare Part A, says David Gifford, MD, MPH, senior vice president of quality and regulatory affairs for the American Health Care Association and the National Center for Assisted Living. Of those, about one in four end up back in the hospital within 30 days. The situation isn’t unique to skilled nursing facilities either, he points out. Roughly the same percentage of patients discharged to their homes end up back in the hospital within the same time period.

“A readmission isn’t always a negative thing,” points out Peg Bradke, RN, MA, director of heart care services at St. Luke’s Hospital in Cedar Rapids, Iowa. Sometimes it’s merely a concession to reality – the patient and her caregiver simply aren’t capable of tending to her needs at home, for example. “They’ve gone home and tried it, and they find they really can’t take care of things themselves.”

But unnecessary hospitalizations can be harmful to the patient – as well as expensive to him and the healthcare system.

“Things can be challenging in healthcare,” says Gail Nielsen, BSHCA, FAHRA, RTR, director of learning and innovation at Iowa Health System, Des Moines, Iowa. Hospitals are full of sick people, meaning patients are susceptible to picking up influenza or infection; in some cases, they can be the victim of a mistake in medication. “Hospitals are complex places,” she says. Hospitalization is also disruptive, not just to the patient, but to his or her family, she adds.

Part of the disruption is handling all the bills that are associated with hospital stays, says Bradke. “We hear from our patients that it’s difficult to get all these bills from the hospital and doctors. They haven’t even figured that out, then they’re readmitted, and get more bills. It’s difficult to sort through all that.”

“The healthcare system has tended to be designed around people getting pretty severely ill before going to the doctor or the hospital,” says Gifford. “We didn’t see them early enough to prevent them from going back to the hospital. But there are a lot of ways to detect [warning signs] earlier, and that’s something we’re focusing on.”

Communication shortfalls
It’s difficult to pinpoint the top two or three reasons for avoidable rehospitalizations, continues Gifford. “It’s usually a combination of a lot of different factors.” Even the top diagnoses for Medicare patient discharges – heart failure and pneumonia – comprise only a relatively small fraction of all discharges.

That said, he points to several factors – some avoidable, some not – that can contribute to rehospitalization:

  • The patient’s underlying medical illness.
  • Flaws or quirks in the healthcare delivery system, especially poor communication among providers.
  • Unwillingness on the part of the patient or doctor to have a frank end-of-life dialogue.

Patients discharged to skilled nursing facilities often have underlying medical illnesses, Gifford points out. “You have to remember that these are people who were too sick to go home after discharge from the hospital,” he says. “They may be impaired in their ability to feed themselves, walk, dress and toilet themselves. They may need assistance in physical and occupational therapy.” Illnesses that might not affect healthier individuals may be enough to send such patients back to the hospital.

Though rehospitalization is often unavoidable, SNFs and other providers can institute management protocols to reduce its incidence, he says. “We can identify changes in people’s status early on, so small changes can be addressed earlier. The same thing holds true for patients discharged into the community.”

Poor communication among providers is a big contributor to rehospitalization, says Gifford. Too often, the healthcare provider examining a patient – either on an outpatient or inpatient basis – lacks information about the patient generated by another provider in another setting. “It’s frustrating to everyone.”

In the skilled nursing facility, medication reconciliation can be a big issue, adds Gifford, who paints the following scenario from the skilled nursing facility’s perspective: Nursing home patient is on one set of medications. She receives medications in the hospital, and is discharged back to the SNF. “Often, the orders don’t match, and it’s not clear why,” he says. Did the hospital forget to give one of the medications to the patient in the hospital? Did the physician in the hospital intend to stop administering the particular medication? And if the patient was taking a particular medication in the hospital, but that medication is not on the discharge orders, why not?

Sometimes patients discharged to the nursing home require an immediate dressing change or treatment, but the hospital doesn’t communicate that to the SNF in a timely manner. Say, for example, the patient needs medication every six hours, but the SNF doesn’t know that until he or she is admitted to the nursing home. “It may be hard to get them on that medication within six hours of the time they arrive,” says Gifford. What’s more, approximately one-fourth of patients discharged from the hospital have a pending lab test. “If the results come back abnormal, and that result doesn’t get back to the skilled nursing facility or home, you may miss things.”

Poor communication among providers within a given setting can also lead to unnecessary rehospitalizations, he adds. Lacking good information on a resident, for example, the physician in the SNF may readmit a patient simply as a default measure.

End-of-life dialogue
Sometimes patients are readmitted to the hospital simply for lack of an honest dialogue about end-of-life care with his or her family and caregivers, says Gifford. “No one likes to talk about this. But if you’re elderly, with several chronic conditions, and you’re going in and out of the hospital, that’s probably a bad prognostic sign.”

Absent end-of-life-counseling, patients may receive care from which they don’t benefit, he adds. “They suffer through it in the last couple of months of their lives.” Frank discussions – difficult as they may be – can lead to a reduction in readmissions and a better quality of life for the patient.

Nielsen believes that difficulties in taking medications at home is a leading contributor to avoidable readmissions. Patients and family members may not understand medication instructions, or medications may lead to unwanted side effects, leading the patient to simply stop taking them. They may be unable to afford the medications that have been prescribed, so they don’t fill their prescription.

“There has to be enough trust between the patient and providers of care, the physicians and nursing staff, the social workers, and all the people touching the patient, for them to really share their biggest concerns,” says Bradke.

“If they don’t trust us, they won’t tell us they don’t have money to buy medications, or they lack heat at home, or their diet contains a lot of salty foods. Many times, it’s when people come back to the hospital that we find these things out. So having those trusting relationships is important.”

Healthcare’s traditional silo mentality is another cause of avoidable readmissions, continues Bradke. “Handovers are a big contributor to readmissions. We send information, but are we sending timely information and appropriate information to provide for that smooth transition to that level of care?”

Providers around the country are working on improving the quality of information exchanges, adds Nielsen. “Here’s where it all comes together – creating a community-based team.”

Teresa Toland, RN, BBA, in western Michigan couldn’t agree more.

Western Michigan collaborative effort
Toland is vice president of business development and quality, Porter Hills Retirement Communities and Services, Grand Rapids, Mich. She and other providers in the area – including a local EMS provider – have formed collaborative teams to tackle rehospitalization as well as inappropriate use of the emergency department. “Our task force has recognized that there are many community resources that should be included in the plan to keep someone at home, while ensuring adherence to medication regimes and health programs,” she says.

“Our certified [home health] agency is most focused on readmissions because CMS has been holding us accountable for this outcome for many years,” says Toland. “We have done a great deal of work related to education, structure, and resource utilization in order to affect the percentage readmitted each month. We began tracking 30-day readmissions manually before automation was available.”

Toland and the Porter Hills team began working with a local hospital one and a half years ago. “At that time, the hospital was working with individual organizations related to readmissions. Due to the amount of time that was taking, they asked that we combine all the meetings into one. Although collaborating as competitors was not the norm for this group, we began to work together and compare notes on practice standards within home health and skilled nursing. Over time, the boundaries have become blurred, and we almost always represent one group of providers with common goals.”

Local providers with whom Porter Hills is collaborating include Clark Retirement Community, Holland Home, Pilgrim Manor, St. Ann’s, the Alliance for Health (Aligning Forces for Quality), and Life EMS. “We have had participation from the hospital’s process excellence department with regard to the LEAN process, which we believe brings success to the departments implementing change,” she says.

The collaborative effort has led to changes in how Porter Hills helps reduce readmissions among its patient population.

“We perform a root-cause analysis on all readmissions that occur in 30 days or less,” explains Toland. “These are reviewed internally with our quality staff and medical director in an effort to address trends or practices that may be a factor in the readmission. We have a falls program that utilizes a personal response system as well as telehealth on at-risk patients. Our professional staff receive their own individualized readmission reports on their caseload every quarter along with the agency percentage comparison.”

The Western Michigan group includes providers who are in the community every day delivering services, including EMS providers, meal delivery services and DME providers, says Toland. Many of these individuals are trained or could be trained to perform patient-specific tasks identified in a health improvement plan, or HIP, she says. The HIP would be established by a case manager/health coach/transition coordinator. “A notification would be sent to a community team member to provide either a routine check or perhaps a needed visit based on data gathered on a phone call, telehealth report, or family member. The community member utilizes the HIP as a guide to establish compliance or further assistance from a professional.”

Improving collaboration among providers is a key element in reducing readmissions, but the Porter Hills group has found other areas for improvement as well. “Our biggest challenges have been in the area of making changes in our skilled nursing centers,” says Toland. “This is not uncommon across the industry. Most staff serving in these areas were very accustomed to taking care of seniors who were in their last years of life; their main goal was to keep them comfortable. When nursing homes changed to skilled nursing and rehab centers, the staff didn’t change as quickly.

“A skilled nursing/rehab unit today looks like what a medical surgical floor in a hospital did a few years ago. It is a drastic change for them, and one they weren’t prepared to make. We are focused on elevating the expertise of all staff as well as preparing to take a much sicker population that may either enter our units from acute care or bypass the acute care setting and enter skilled nursing as an alternative. We have established criteria for having gold standards of excellence, which are above and beyond regulatory requirements.”

Information co-design
Healthcare partners – clinics, home care agencies, SNFs and hospitals – that are serious about reducing readmissions are co-designing the communication that takes place among them, particularly during the crucial handoff period, says Bradke. “It’s not just a matter of me in the hospital deciding what they need to know. Instead, it’s sitting down with [other providers] and asking, ‘What’s the most important information you need, and what is the best way to present it?’” For high-risk patients, Bradke talks about the “warm handover,” that is, a conversation – not just a paper exchange – among the various providers.

“A chart isn’t enough,” adds Nielsen. So-called “cross-continuum teams” need to make sure patients and healthcare providers know upfront whom to call when questions arise, she adds.

Cause for hope
Positive change is already occurring among home care providers, but more is needed, says Mary St. Pierre, RN, BSN, MGA, vice president for regulatory affairs, National Association for Home Care & Hospice.

“Many agencies have always taken a comprehensive approach to patient care,” she says. “Others have looked on home health services in a task-oriented fashion, as opposed to looking at the total patient, with all of his or her health needs, and prescribed treatments and medications. Agencies will ensure success in the future if they are a part of the healthcare team – the physician, the pharmacy, the community – working together to ensure that all the patient’s health needs are met.”

Agencies that are part of integrated delivery networks may be in a better position to put into action this holistic approach, she says. But many freestanding, independent agencies have already done the same. “Not only do they see the patient after he or she leaves the hospital, but they’re sending one of their nurses to the hospital to introduce themselves to patients, assess their needs and help them prepare for discharge,” she says.

Successful agencies are also “front-loading” home health visits, she adds. “They’re seeing the patient as soon as possible after receiving the referral.” Though regulations may call for that patient to be seen within 48 hours of discharge, St. Pierre urges agencies to act in half that time or sooner. “In my mind, a person can get into a lot of trouble in 48 hours.”

Home care professionals may have had a jump start on addressing avoidable hospital readmission. That’s because for a number of years, Quality Improvement Organizations, or QIOs, have been assigned to work with home health agencies in every state on quality improvement. QIOs are private, primarily non-profit organizations staffed by healthcare professionals, who are contracted by CMS to review medical care, handle beneficiaries’ complaints about quality of care, and implement improvements.

QIOs work with agencies on better coordinating care with other providers, communicating with physicians, managing medications and coaching patients. “You can tell someone, ‘Here are your medications,’ but unless you effectively coach them or get their buy-in that they will comply, or adopt the goal, it’s not going to be effective,” says St. Pierre.

Some home health agencies are already working with hospital emergency departments to identify patients who could in fact be treated at home instead of going to the ER or being admitted, for example, through prompt initiation of IV therapy, or prompt response and therapy for patients who fall at home.

Other home health agencies are working with hospitals in a nationwide effort to improve the transition of patients from inpatient status (in the hospital or nursing home) to the home, says St. Pierre. They are working to ensure that the patient sees his or her doctor in a timely manner after discharge, that they have medications and understand how to take them. “Home health agencies can play a tremendous role in ensuring that the person coming home gets off on the right foot, that they understand their diet, their medications, their disease process and warning signs that they should report immediately,” she says.

“Having been in home health and working with an agency for 20-plus years, I know this is very doable,” says St. Pierre, referring to such policies as making sure every patient is seen within 24 hours of referral. “You can do it as long as you staff up. But it is a commitment. And the agency has to equip their staff not only with coaching help, but with additional clinical skills, such as knowledge of medication interventions and side effects.” Staff may need to be trained on infusion therapy, she adds.

“It calls for job redesign,” says Nielsen, who points out that in Des Moines, a home care liaison – whose salary is jointly paid by the hospital and the home care agency – helps assess patients being prepared for discharge to ensure the transition is successful. Also in Des Moines, caregivers from the hospital and the community – including skilled nursing facilities and home care agencies – visit each other’s place of work, so they get to know each other and the steps each must take in order to ensure a smooth transition for patients.

“You won’t get readmissions down to zero,” says Bradke. “These are very complex patients,” she says. Mental illness can further complicate matters. “But that’s why it takes a team. You need to look at what’s going on with that patient and decide as a team what the best plan of care is. It takes some time.” Eighteen months is not an unreasonable amount of time in which local providers can expect to see improvements in readmissions.

The good news is, progress is being made, and the work being done to reduce avoidable readmissions is laying the groundwork for accountable care organizations, she says. “Hospitals haven’t necessarily always thought about outpatient social workers. But now they’re asking, ‘How do we get social workers into the community to keep patients safe at home?’” It is the direction in which healthcare reform is leading us, she says.

Improving care transitions

Hospitalists’ program is designed to reduce readmissions caused by poor patient handoffs

Want to make sure patients understand how to manage their care after discharge from the hospital, and hence reduce the likelihood of a readmission? It’s simple: Ask them. That’s what the team at Sherman Health in Elgin, Ill., found out. But the way you ask them, and the questions you ask, have to be well-thought-out. In turn, the answers to their questions have to be simple and communicated clearly.
One of the trickiest parts of patient care occurs during the so-called transition periods, that is, when the patient is discharged from the hospital to the home or outpatient setting; or when the patient is transferred from, say, a long-term-care facility to the hospital – and then back again.

Poor transitions can lead to multiple negative consequences, according to the Society of Hospital Medicine, the national association of hospitalists, that is, physicians who specialize in the practice of hospital medicine. Those consequences include decreased patient understanding, medication errors, increased stress on caregivers, increased readmission rates, and an increase in care costs.

Project BOOST offers an online toolkit and year-long mentoring program designed to help hospitals improve their care-transition process. Developed through a $1.4 million grant from the John A.

Hartford Foundation, the Society of Hospital Medicine continues to fund the collaborative with the aid of Blue Cross Blue Shield of Michigan, California Health Care Foundation, and tuition-based sites. Sherman Health began implementing BOOST three years ago. And it’s working.

Key elements
Project BOOST comprises five key elements:

  • A comprehensive intervention developed by a panel of experts based on the best available evidence.
  • Implementation guide, which provides step-by-step instructions and project management tools, such as the TeachBack Training Curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
  • A year of mentoring and coaching to implement BOOST interventions and build a culture that supports safe and complete transitions. The mentoring program provides a train-the-trainer DVD and curriculum for nurses and case managers on using the TeachBack process, and webinars targeting the educational needs of other team members, including administrators, data analysts, physicians, nurses and others.
  • The BOOST Collaboration, which allows sites to communicate with and learn from each other via the BOOST Listserv, BOOST Community site, and quarterly all-site teleconferences and webinars.
  • The BOOST Data Center, an online resource center, which allows sites to store and benchmark data against control units and other sites, and generate reports.

All about patient engagement
The Sherman Health team started examining the literature on preventable readmissions three years ago, says Kelly Tarpey, M.S., R.N., CPHQ, director of clinical excellence. “What we found was, no one understood how to [address readmissions].” But they did find Project BOOST, and were lucky enough to secure as a mentor one of the nation’s pioneers in studying and reducing preventable readmissions – Mark Williams, MD, FHM, professor and chief, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago.

“Through our journey with the BOOST program and through our mentoring with Dr. Williams, the thing we learned – and it has been key to our success – is that it’s all about patient engagement and family engagement,” says Tarpey. Teach-Back is one way to do that.

“It’s a deeper methodology of really making sure our patients understand what their instructions are,” says Tarpey. To illustrate, she says that Sherman traditionally gave heart failure patients 20-some pages of discharge instructions. “It’s a lot of information, but it doesn’t engage our patients,” she points out. Today, patients get fewer, but more targeted, instructions.

“We learned to simplify our message, and to pick our battles,” says Tarpey. For example, what’s most important to heart failure patients is knowledge of proper diet, medication regimen and red flags to watch out for. “So we’ve learned to simplify the message. We say, ‘Sir, this is what medications you will take, and when, and here’s a grid. Now, tell me what you are going to take tomorrow when you go home.’ They’re open-ended questions. It sounds way too simple, but it has made a significant difference.”

When taking patient histories, Sherman is beginning to focus on streamlining the process, eliminating some of the information-gathering redundancies, and instead collecting only information that adds value for the patient. The minutes saved can be better spent talking to patients and caregivers about the discharge and post-discharge process.

Prior to discharge, Sherman makes sure that patients have made follow-up appointments with their doctor. “This was a key learning challenge,” says Tarpey, who has been in the nursing profession for years. “I used to think that if patients were told to make an appointment after discharge, they would go to see their doctor.” But it doesn’t always happen. With an appointment locked in prior to discharge, the physician’s office can call that patient if the patient fails to show up for the appointment. “The doctor has a hook on [the patient],” she says.
Sherman has also centralized post-discharge follow-up phone calls. Now, one group of nurses makes the calls, exercising Teach-Back principles with key populations. For example, the phoning nurse may ask a heart failure patient, “I see you were sent home with these medications. Tell me what you took this morning.”

“It’s another way of connecting with patients,” says Tarpey, adding that “in healthcare, engagement is the key concept.”

BOOST numbers
To date, the BOOST toolkit had been downloaded by approximately 3,900 sites. More than 150 hospitals have implemented the year-long mentoring program. The BOOST listserv has more than 700 subscribers.

Early data from six sites that implemented Project BOOST reveals a reduction in their 30-day readmission rates, from 14.2 percent before BOOST to 11.2 percent after implementation, according to the Society of Hospital Medicine. Thirty-day readmission rates among the sites dropped 21 percent.

For more information on Project BOOST, go to

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