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Readmissions costly, impact quality of life
Collaborate to ensure smooth transitions
In today's healthcare environment, as patients are being discharged from the hospital sicker and quicker than ever before, some patients are in and out of the hospital as if they are going through a revolving door, says Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy & Associates, a case management training and consulting company based in Huntington, NY.
"Something happens between the time people leave the hospital and when they are readmitted within a short period of time. As case managers, we need to identify what is happening and develop a concerted plan to avoid it," Mullahy says.
The problem is especially acute among Medicare recipients who often are frail with multiple comorbidities and polypharmacy issues. They might be socially isolated with little family support and have hearing and eyesight problems that impair their ability to understand and carry out their post-discharge plan, she adds.
According to a study in The New England Journal of Medicine, nearly 20% (19.6%) of all Medicare beneficiaries discharged from the hospital are readmitted within 30 days, and 35% are rehospitalized within 90 days.1
Data posted on the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov) in July 2010 shows the 30-day readmission rates were 19.9% for heart attack patients, 24.7% for patients with heart failure, and 18.3% for patients hospitalized with pneumonia from July 1, 2006, to June 30, 2009. These rates were essentially the same as the 2005-2008 rates. The average stay of rehospitalized patients was .6 days longer than patients in the same diagnosis-related group who had not been hospitalized for at least six months, The New England Journal of Medicine study reports.
When she spoke at a seminar for case managers several years ago, Mullahy was startled to find that many hospital case managers were doing little to prevent readmissions because they believed that when patients were readmitted, that meant more revenue for the hospital. "We're supposed to be doing what is best for patients. As long as payers were reimbursing for it, nobody did anything differently to prevent readmissions," she says.
That's going to change since CMS has announced its intentions to penalize hospitals when patients with pneumonia, heart failure, or heart attack are readmitted within 30 days, beginning with discharges on Oct. 1, 2012. The agency has declared that it is likely to add other conditions to the list in the future. In addition, an explicit provision in the Patient Protection and Accountable Care Act mandates that in fiscal 2014, hospitals in the highest quartile for hospital-acquired conditions receive a 1% reduction in total Medicare reimbursement, and CMS has proposed using hospital readmissions as one of the processes of care measures used to determine hospital reimbursement in its value-based purchasing system.
Readmissions are expensive, says Cory Sevin, RN, MSN, NP, director with the Institute for Healthcare Improvement (IHI), an independent, not-for-profit organization in Cambridge, MA, that works with providers to achieve safe and effective healthcare. "In a report to Congress in 2007, MedPac estimated that readmissions within 30 days account for $12 billion in Medicare spending each year,"2 Sevin says. "In addition, when patients go in and out of the hospital and are very sick, it impacts their quality of life. In the hospital, they are at risk for infections, falls, and medical errors."
The best way to prevent hospital readmissions is to make sure the patients are better managed and receive the care they need after they leave the hospital, says Donna Zazworsky, RN, MS, CCM, FAAN, vice president of Community Health and Continuum Care for Carondelet Health Network in Tucson, AZ. "Many patients are readmitted to the hospital because they don't have what they need to stay stable once discharged back into the community. If patients don't have the basic things they need to take care of themselves, it can derail a discharge," Zazworsky says.
About half of patients discharged from the hospital don't understand what to do when they get home, Sevin says. Hospital stays are very short, and inpatient education activities often do not ensure that patients and their caregivers understand the key information needed for the patient to stay stable, she adds. "When the discharge instructions are complicated and the patient is ill and frail, it's even harder to make sure they understand. Many times family members, primary care physicians, and post-acute providers don't have the information they need to help the patient remain stable," Sevin says.
Patients and family members need to understand how to take their medication, any dietary restrictions, signs and symptoms that indicate they should seek medical care, and who to call. Sevin advises using the "teach-back" method, which involves having patients or caregivers repeat their discharge instructions to ensure that they understand them. Post-actute providers need complete and accurate information about what happened during the hospital stay, medication regimen, details of the patient's post-discharge treatment plan as ordered by the physician in the hospital, and any psycho-social issues or other issues that could impact the patient's post-acute stay.
Case managers should make sure patients understand their treatment plan and their medications, that they have support at home, that they have a follow-up visit with a physician, and that caregivers and providers at the next level of care have the information they need to ensure a smooth transition, Zazworsky says. Sevin says, "A huge part of reducing readmissions is designing the care process across the continuum of care. Hospital case managers need to work with home health agencies, nursing homes, primary care physicians and specialists, and their counterparts at health plans to ensure that care is coordinated and that everyone is giving the patient consistent information."
Patients are at highest risk for readmissions during the first week after discharge, Zazworsky points out. For that reason, it's critical to make sure that patients have a follow-up visit with a primary care physician or a specialist within a week of being discharged from the hospital. "Case managers can do a wonderful job of educating patients, but if they don't get that follow-up visit, they are likely to have problems after discharge that could result in a rehospitalization or emergency room visit," Zazworsky says. "The linkage to the community beyond the hospital walls is critical."
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, Mullahy says.
Case managers need to identify the causes of readmissions before they can begin to make changes in the discharge and follow-up processes to keep patients from coming back, Mullahy says.
"Providers and payers need to look backward before they start to look forward and to analyze each readmission to find out the root causes. Then they can start to address the issues that contribute to readmissions," Mullahy says.
For example, if patients are being readmitted to the acute care hospital after a stay in a skilled nursing facility, it might be that the transition to post-acute care wasn't smooth and gaps in care occurred, or it might be that the nursing home is providing less than optimal care, she says. If patients aren't seeing their physicians in a timely manner, it might be that they didn't understand the need to make the appointment within a week of hospital discharge rather than accepting the next available physician appointment, which might have been a month away, Mullahy adds.
"Find out what caused each readmission, identify trends, and go back and start chipping away at barriers and reasons for readmissions," she says. For example, many patients are readmitted because they don't get their prescriptions filled. Find out if it's because they can't afford the medication, they don't have transportation to the pharmacy, or another reason, Mullahy says.