Take steps now to reduce readmissions, ED visits within 30 days
Take steps now to reduce readmissions, ED visits within 30 days
CMS is considering incentives to reduce avoidable rehospitalizations
When the Obama administration announced its goals for revamping health care, it proposed cutting reimbursement to hospitals that readmit a large number of patients within 30 days of discharge.
The idea is nothing new.
In its proposed changes to the Medicare Hospital Inpatient Prospective Payment System (IPPS) for 2009, the Centers for Medicare & Medicaid Services (CMS) asked for public comments on the application of incentives to reduce avoidable readmissions to hospitals.
The IPPS proposed rule did not include any specific policy regarding readmissions but said it is considering financial incentives as well as nonfinancial incentives, such as public reporting of hospital admission rates.
CMS noted that almost 18% of Medicare patients are readmitted to the hospital within 30 days of discharge, resulting in approximately 2 million readmissions at a cost of $15 billion annually. The agency cited data from the Medicare Payment Advisory Commission (MedPAC): Potentially preventable readmissions cost more than $12 billion a year.
The president's plan proposes bundled payments to hospitals that would cover their own services as well as any services provided by home health agencies and nursing homes in the 30 days following discharge, a move estimated to save $26 billion over 10 years.
As the idea of cutting reimbursement for readmissions is bandied about, hospitals would be well advised to start tracking their readmission rates and developing initiatives to prevent readmissions, advises Jackie Birmingham, RN, MS, CMAC, vice president of professional services for Curaspan Health Group, a Newton, MA, health care technology and services firm.
"Once Medicare starts mentioning a change in reimbursement procedures, it is likely to happen sooner rather than later. Hospitals are one short episode in patient care. Someone needs to monitor the patient's post-acute care and ensure that there is continuity. A system to bundle hospital payments for post-acute services won't be easy but it has merit," she says.
It's not enough for case managers to come up with a discharge plan. They have a responsibility to make sure that the care plan they set up is working, that the supplies the patient needs at home were delivered, that the home health nurse showed up, and that the patient made a follow-up visit to the doctor, says Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy & Associates LLC, a case management training and consulting company in Huntington, NY.
"With this administration looking at implementing penalties for what is being determined to be 'avoidable' readmissions in less than 30 days, hospital discharge planners and case managers are going to have to do more than just getting [patients] discharged from the hospital. They are going to have to take steps to ensure that the patients stay out of the hospital," she says.
When they are discharged from the hospital, patients may be confused about how to take their medicine and will go home and either not take it or take it incorrectly. A significant number of patients do not leave the hospital with an appointment for a follow-up visit, or if they have one, they don't go to the appointment, says Brian W. Jack, MD, vice chair of Boston University Medical Center's department of family medicine, who led a study that concluded that patients who understand their post-acute instructions are less likely to be readmitted.
Those gaps in the continuum of care often lead to a patient's clinical condition worsening after discharge to the point that he or she ends up going to the emergency department and being readmitted, he adds.
"Taking care of patients in the hospital is a complex process performed by health care professionals. When they go home, we expect patients to take care of themselves, and they are not prepared to do that. If we spend time with them, educating them on what they need to do after hospitalization, they are better prepared to go home, and that makes the difference," Jack explains.
In today's health care environment, as hospitals are under pressure to discharge patients sicker and quicker than ever, there's an increased risk that patients' conditions may worsen and that they'll be readmitted, Mullahy says.
"Something happens between the time people leave and when they come back in a few days. As case managers, we need to identify what is happening and develop a concerted plan to avoid it," she says.
Identify the types of patients who are frequently readmitted and identify any patterns in readmission, Mullahy suggests.
When you analyze your readmission rates, don't look only at diagnoses. Include psychosocial and demographic factors in your analysis, Birmingham suggests.
"Case managers need to go beyond looking at a particular diagnosis for readmission rates and drill down to find the specific population that is being readmitted more frequently," she adds.
Identify patterns in readmissions
Look for patterns in readmissions. Determine if they occur following discharges on a particular day or at a particular time, Birmingham suggests.
"Anecdotally, most readmissions occur among patients who were discharged late in the day on Friday or on Saturdays when staffing is short," she says.
When Birmingham hosted a transitions-in-care seminar for home care agencies and hospital staff, the home care representatives complained that hospitals rush to discharge patients on Friday afternoons to avoid keeping them over the weekend. As a result, home care agencies are challenged to find highly skilled home care staff who are available to care for the patient over the weekend.
Look at the number of readmissions to a specific unit or service line and evaluate the work load of the staff, Birmingham suggests.
For instance, if a medical unit with a patient-to-staff ratio of 25-to-1 has a high rate of avoidable readmissions, this may indicate a need for more staff, she adds.
Compare your readmission length of stay with the length of stay from the previous admission. If the initial hospital stay was lower than the average length of stay, the patient may have been discharged too soon, Birmingham says.
Look at readmissions from specific nursing facilities or home care agencies, as well, to identify any quality issues in post-acute services, she adds.
Lack of patient education can result in a readmission, Birmingham points out.
For instance, a patient may rate his pain as a Level 4 while he is in the hospital, but it may rise to a Level 5 after he gets home, and the family may call the doctor, saying the pain is worse.
"On weekends, there is an on-call physician who may not be familiar with the patient's condition and may send him to the emergency department. They aren't going to send a patient home in the middle of the night, so they'll readmit him," she says.
To avoid such a situation, the hospital case managers should warn the patient what to expect when he or she gets home and what symptoms indicate that he or she should call the doctor.
When you determine which patients are likely to be readmitted, develop a specific plan for following up on them, Mullahy suggests.
Decide when you will call, what questions you will ask, and what signs and symptoms indicate that the patient may be having problems.
Consider making follow-up calls a few days after discharge to the patients who may be likely to have problems that could lead to readmission.
"You don't need to do this with every patient, but every case manager knows which patients and which diagnoses are notorious for having problems after discharge," Mullahy says.
For instance, if a patient with a history of diabetes has surgery and his blood sugar level has been unstable prior to surgery and somewhat difficult to control while he is in the hospital, he is more likely to develop an infection in his wound, Mullahy points out.
In that case, the case manager should educate the patient and family members on symptoms to watch for and follow up with a call to find out if the patient's temperature is elevated, determine the patient's blood sugar levels, and find out if the wound is draining.
"If the patient is having early signs of a wound infection and sees the doctor, it will avoid an emergency room visit and hospital readmission," Mullahy says.
Another example would be to follow up with an elderly patient who is on five or more medications.
"It makes sense for a pharmacist to call after discharge to determine medication compliance, and there are a few hospitals that are utilizing this innovative approach," Mullahy says.
"There are so many opportunities to help patients avoid readmissions. No one is saying that hospitals make a follow-up call to every patient, but it makes sense if you stratify your population and identify who has risks for readmission," she says.
(For more information contact Jackie Birmingham, RN, MS, CMAC, Vice President of Professional Services, Curaspan Health Group, e-mail: [email protected]; Catherine M. Mullahy, RN, BS, CRRN, CCM, President and Founder, Mullahy & Associates, e-mail: [email protected].)When the Obama administration announced its goals for revamping health care, it proposed cutting reimbursement to hospitals that readmit a large number of patients within 30 days of discharge.
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