Guest Column

Reduce your hospital's preventable readmissions

Target premature discharge, outpatient management

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Reducing readmissions has become an increasingly important goal for hospitals. Medicare is evaluating various payment incentives to encourage lower rates of preventable readmissions. This may include withholding payments and offering incentive payments, as well as public reporting of hospital-specific readmission rates. Although today, hospitals have little incentive to invest in managing post-hospital care, many already are positioning themselves for this new imperative by implementing outpatient case management programs for elderly patients, those with chronic diseases, and other "revolving door" patients. These programs include home visits by nurse practitioners and other caregivers and regular phone calls to answer questions and encourage patient compliance with follow-up instructions.

These post-hospital patient management strategies do not replace an effective inpatient case management program. In addition to traditional care coordination activities, hospital case managers can be instrumental in identifying preventable hospitalizations. It is important to work closely with primary care physicians, home health agencies, and other out-of-hospital providers to identify inpatient admissions that might represent inadequacies in outpatient management practices or premature discharges. Evaluation of these cases can help pinpoint where changes are needed to reduce readmission rates.

Taking the first step

The first step is to identify the magnitude of potentially preventable readmissions. Use your clinical/financial information system to find patients admitted to the hospital with "ambulatory care sensitive conditions" (ACSCs). These are conditions for which the probability of hospitalization could be reduced by adequate primary care. ACSCs have been endorsed by the Agency for Healthcare Research and Quality as a measure of access to health care and can also be used to screen readmissions for potential problems. To select these conditions, researchers conducted a literature review and obtained clinical guidance from practicing physicians.

In Figure 1 is a list of ACSCs for pediatric and adult patients. All admissions could be evaluated or just those that fall into the category of a readmission (within a specified time period — usually up to 30 days).

The circumstances surrounding each hospitalization for an ACSC condition should be analyzed to determine what, if anything, could have been done to prevent the admission. Ideally, this analysis is undertaken by a multidisciplinary group, such as the utilization management committee or a group with similar case review responsibilities. To determine whether the hospitalization could have been prevented and how it could have been prevented will often require review of outpatient records (clinic, home health, etc.) as well as the inpatient chart.

Some patient hospitalizations are due to the natural course of their chronic disease. Some of the hospitalizations might be related to premature discharge during the last hospital stay or ineffective or inadequate outpatient services — for example, the patient may not have had adequate access to primary care services, which resulted in an exacerbation of their condition. A patient's access to adequate ambulatory health care services can be influenced by many factors, including:

  • transportation to facilities;
  • availability of child care;
  • clinic hours of operation;
  • linguistic or cultural barriers;
  • health literacy barriers;
  • patients' health care beliefs;
  • patients' living conditions/environmental concerns.

The committee should always look for system problems that affect the incidence of preventable hospitalizations (e.g., unavailable community resources, inadequate quality of care, lack of care coordination among providers, integrated delivery system inefficiencies). The form shown in Figure 2 can be used by the committee to document review findings and suggestions for improving the system of care.

Reducing the level of preventable rehospitalizations will require implementation of several different action plans. To effect changes in lifestyle and health behaviors, consumers must have an interaction with the primary care system — meaning that access problems must be overcome. If quality of care is found to be a problem, the committee may need to develop and disseminate practice guidelines to caregivers or encourage continuing education. If there is a question about a practitioner's compliance with the standard of care, the case should be referred for peer review by the appropriate group. The utilization management committee should not be involved in judging individual competence.

Two cases reviewed

Following are two summaries of readmission cases reviewed by a hospital's utilization management committee. Through evaluation of inpatient and outpatient records, as well as input from caregivers, the committee discovered some opportunities for improvement. Often the tactics needed to reduce preventable hospitalizations require action by outpatient providers. Thus, it is important that these providers are supportive of the readmission review process and invited to be involved in the case discussions.

Readmission for hypertension: Home health record shows that the patient reportedly experienced symptoms possibly associated with hypertension. Despite nurses' recommendations, patient did not seek treatment. Action: Evaluate patient's access to care and reduce barriers. Initiate more intensive patient and family education through home health agency or outpatient case manager.

Readmission for uncontrolled diabetes: Clinic records show that appropriate lab tests were done but abnormal results were not followed up. Action: Evaluate continuity of care between nurse practitioner and primary care physician. Identify where the communication system broke down and implement improvements.

Medicare's payment policies are changing. Hospitals will increasingly be rewarded for efficient use of resources across the continuum of care. One way to stay ahead of these changes is to involve case managers in identifying and analyzing preventable hospitalizations. By working closely with post-hospital providers, case managers can assist in examining the causes of readmissions and begin now to minimize the influence of controllable factors.