Executive Summary

Initiatives from the Centers for Medicare & Medicaid Services (CMS) and commercial payers that penalize hospitals when patients are readmitted make it necessary for providers throughout the continuum to collaborate and ensure that patients get the care they need.

  • Create discharge plans that go beyond the hospital walls and coordinate with the post-acute providers to ensure that they have the information they need to help the patient follow the plan.
  • Develop close relationships with post-acute providers by meeting with them face to face and discussing ways to improve transitions and solve problems.
  • Track quality metrics, such as readmission rates, and share them with the providers. When patterns occur, alert the group to work on solutions.

The stakes are rising in the quest to base hospital reimbursement on quality.

Initiatives from the Centers for Medicare & Medicaid Services (CMS) and commercial insurers mean that case managers no longer can create a discharge plan that ends when patients leave the hospital. Instead, they must look beyond the hospital walls and work closely with post-acute providers to ensure that the discharge plan will succeed.

“New initiatives mandated by the Affordable Care Act make it imperative for hospitals to coordinate care throughout the continuum and avoid penalties. Hospitals need to develop strong relationships with their post-acute providers and work together to improve care and ensure smooth transitions,” says Marcia Colone, PhD, ACM, LCSW, system director for care coordination at UCLA Health with headquarters in Los Angeles. UCLA Health’s readmission prevention programs include leasing beds at skilled nursing facilities to ensure that hard-to-place patients have a bed, and partnering with home health agencies to increase the number of contacts patients receive.

In a way, hospitals are being penalized twice for Medicare readmissions within 30 days of discharge — once in the readmission reduction program, where they can lose up to 3% of their Medicare reimbursement, and again in the Medicare Value-based Purchasing Program, since stays for patients who are readmitted to the hospital typically cost more than the initial hospital stay.

Commercial payers are also developing readmission reduction programs, according to Karen Zander, RN, MS, CMAC, FAAN, president and co-owner of the Center for Case Management.

When hospitals participate in accountable care organizations or bundled payment programs, they also bear risk for what happens to patients after discharge, Zander says.

“Hospitals have to get to know the post-acute providers in their network, whether they own them or not, and be willing to partner with them to discuss critical issues and to share information,” Zander says.

The problem hospitals face with all of CMS’ quality initiatives is that the healthcare infrastructure was built for volume and not value, points out Brian Pisarsky, RN, MHA, ACM, associate director at Berkeley Research Group, with headquarters in Emeryville, CA.

“We have to make a fundamental change in the day-to-day work of case managers. It’s no longer just utilization review and discharge planning. Care across the continuum is what needs to happen and it takes a different approach from what we’ve done in the past,” he says.

Information that clinicians at the next level of care need often falls through the cracks when patients transition, says Toni Cesta, RN, PhD, FAAN, partner and consultant in New York-based Case Management Concepts.

“There’s only so much the hospital side can do. Hospitals have to improve communication during handoffs to post-acute providers to ensure that patients get the care they need in order to avoid readmissions,” she said.

“Unfortunately, some hospitals have said that they can’t control what goes on after a patient is discharged. This may well be true, but all the providers throughout the continuum are engaged in care of very sick people and to do this, you need collaboration between the various settings,” Cesta says.

Case managers need to shift their strategies and develop a detailed discharge plan that can be accomplished outside the four walls of the hospital, says Mindy Owen, RN, CRRN,CCM, principal owner of Phoenix Healthcare Associates, a Coral Springs, FL, consulting firm, and senior consultant for the Center for Case Management.

Care plans no longer can be implemented and completed in the hospital setting, Owen points out. “That is why it’s critical to have collaboration and communication across the entire continuum of care,” Owen says.

Care plans for joint replacement patients are a prime example, she adds.

“The length of stay for joint replacement patients has shortened so drastically that hospitals no longer have the ability to provide intensive rehabilitation in the inpatient setting. Therefore, the transitional plan of care must include rehabilitation in order to avoid a readmission when the patient experiences complications or is not able to perform some of the activities of daily living,” Owen says.

At the same time, now that hospitalists treat many of the patients in the hospital, outpatient clinics and primary physician practices often don’t have the detailed information they need to help their patients transition from the hospital to the community, she says.

“One of the biggest problems with transitions is that nobody follows up on the results of tests patients have before they leave the hospital. The primary care physicians don’t know that the patients have had the tests and orders them again,” Cesta says.

Hospital case managers have got to improve their communication with their counterparts at post-acute providers, including primary care physician practices, she adds.

As hospitals have begun to participate in accountable care organizations and bundled payment agreements, they have started to develop relationships with local skilled nursing facilities and home health agencies, but few have built a comprehensive program that truly looks at patients along the entire continuum of care, Pisarsky says.

“We can no longer feel we’ve done our job if we provide excellent care between the four walls of the hospital but ignore what happens to patients when they leave. The solution is to build comprehensive care coordination and collaboration across the entire continuum, but there are obstacles to overcome,” he adds. One of the biggest obstacles is lack of access to medical records across the continuum, says.

“Now each individual entity has a different piece of the record. The problem is that the hospital uses a different system from the skilled nursing facility, and the pharmacy and the home health agency have other systems and none of them interact with each other. This has to change,” he says.

In order to take a comprehensive approach to readmissions, hospitals have to collaborate and communicate with all of the providers along the healthcare continuum in the community, Pisarsky says. This includes primary care providers, skilled nursing facilities, long-term acute care hospitals, rehabilitation facilities, home health agencies, Area Agencies on the Aging, and anyone else who may participate in the healthcare of patients.

The best way to forge a good relationship is for hospital staff to meet once a month with the post-acute providers in their area to share data and brainstorm on solutions to problems, Zander adds.

“It’s harder to know somebody on the other end of the phone than if you see them in person. It’s better to work on building relationships along the way rather than trying to establish a relationship when you need someone’s help,” Zander says.

Post-acute providers that are a part of the hospital system are a natural place to start collaborating across the continuum, Owen says. Also involve providers that are not part of the health system, starting with the ones to which you transfer the most patients, Owen suggests.

It’s helpful to cement relationships with providers who will give your patients quality care, Zander says, but be careful not to alienate other providers, she says.

While some hospitals try to work with any post-acute provider that will take their patients, other hospitals are trying to develop narrow networks of preferred providers and collaborate with a few carefully chosen providers, Zander says. However, Medicare patients still must have a choice of providers and if they choose providers who are not in the network, the hospital has no choice but to discharge them to that provider, she adds.

One way to narrow the field is to give preference to those who use the INTERACT (Interventions to Reduce Acute Care Transfers), a quality improvement set of activities designed to help facilities reduce potentially avoidable transfers by early identification and assessment of changes in patient conditions, Zander suggests.

Look at the CMS Home Health Compare (https://www.medicare.gov/homehealthcompare) and Nursing Home Compare (https://www.medicare.gov/nursinghomecompare/search.html) websites for information on post-acute providers. “CMS doesn’t tell you everything, but the information on those websites along with data hospitals have compiled will help identify providers who provide quality care,” she says.

Every hospital should convene a monthly meeting of community-based providers, advises Amy Boutwell, MD, MPP, president of Lexington, MA-based Collaborative Healthcare Strategies, and one of the original co-developers of The Institute for Healthcare Improvement’s STAAR (State Action on Avoidable Rehospitalizations) initiative.

She suggests that the meeting include representatives from home health agencies, skilled nursing facilities, hospice providers, physicians, representatives from federally qualified health centers, elder service agencies, behavioral health clinics, and the larger community health clinics.

“It sounds like a big undertaking but it’s in the best interests of post-acute providers to collaborate with hospitals. This does not need to be a first step to developing a network. It’s simply a meeting where all the parties can discuss how to work better together,” she says.

Some hospitals have invited 80 or more providers to the meeting. Set up a regular time and date for the monthly meeting and issue an open invitation, Boutwell suggests.

“People who come to the meeting consistently will demonstrate their commitment to improving patient transitions and will show the hospital that they are the best partners,” Boutwell says.

Zander recommends that the hospital’s director of case management chair the meetings and keep them running smoothly and bring up topics and data for discussion.

Develop a to-do list and keep working on it, she advises.

Owen tells of working with a hospital that brought together representatives from skilled nursing facilities and home health agencies to look at problems that were causing readmissions.

“The first problem they identified was medication reconciliation. The issue was that the forms the hospital used were different from the forms used by the other providers and the electronic communication tools did not sync. This resulted in medication errors that sent patients back to the emergency department. Once all the providers started using the same communication tool, we saw a huge drop in readmissions,” she says.

Colone advises other hospitals to invest in relationships with post-acute providers over the long term, and share quality metrics with them.

Develop a process to address issues such as referral denials and readmissions and constantly review the referral process and handoffs, she says.

When you see a pattern of problems, work with the group to develop a strategy. Keep the conversation about topics of concern general and don’t single out individual providers, Zander advises.

Share your statistics on readmission rates with the post-acute providers but meet with each individual provider to discuss the data, Zander says. “It’s important to keep each provider’s data separate and confidential from the other providers. You don’t want to embarrass them,” she says.

When patients are readmitted, in addition to finding out the discharge destination listed in the medical record, find out where the patients were when their conditions brought them back to the hospital, Zander says. “There are so many steps along the way that it’s sometimes hard to know exactly where patients came back from. Case managers should interview patients and families and drill down to find out where the patient was before being readmitted,” she says.