By Melinda Young
A recent study of Medicare data revealed facilities have many opportunities to improve readmissions — to either a medical or psychiatric hospital — after psychiatric hospitalization.1
The mean 30-day, all cause, unplanned readmission following psychiatric hospitalization rate of 1,343 inpatient psychiatric facilities was 20%, with a mean range of 11% to 36%.
“I am a psychiatric nurse by background, and have worked for many years in hospital quality, looking to improve the quality of inpatient psychiatric units,” says Ivy Benjenk, RN, MPH, a PhD student in health policy and management at the University of Maryland.
The Centers for Medicare & Medicaid Services (CMS) collects and publishes information on 30-day readmission rates for psychiatric hospitals. But, unlike medical hospitals, there are no penalties for poor outcomes at psychiatric hospitals.
“In psychiatry, they put a lot of focus on the public reporting program on hospital compliance, strategies to reduce 30-day readmissions, and what these strategies utilize,” Benjenk explains.
Psychiatric hospitals have been collecting data from the Medicare Inpatient Psychiatric Facility Quality Reporting (IPFQR) program since late 2012. It collects 14 data elements, available at: https://qualitynet.cms.gov/ipf/ipfqr/measures.
The IPFQR program measures include:
- Hours of physical restraint use;
- Hours of seclusion;
- Appropriate justification for patients discharged on multiple antipsychotic medications;
- Screening for metabolic disorders;
- Brief intervention provided or offered for alcohol use;
- Treatment for alcohol and drug use disorder provided or offered at discharge;
- Assistance for smoking cessation offered or provided;
- Smoking cessation treatment provided or offered at discharge;
- Transition record received by discharged patients;
- Timely transmission of transition record;
- Flu shots;
- Follow-up after hospitalization;
- 30-day, all-cause, unplanned readmission following psychiatric hospitalization in an inpatient psychiatric facility;
- Continuing medication after discharge.
CMS publishes benchmarking data from IPFQR online so individual psychiatric hospitals can compare their own performance with other hospitals. (The data are available at: https://data.medicare.gov/Hospital-Compare/Inpatient-Psychiatric-Facility-Quality-Measure-Dat/q9vs-r7wp/data.)
Benjenk’s study highlights wide variation in psychiatric readmission rates, with freestanding psychiatric hospitals performing better than health systems. “That kind of makes sense because that’s [freestanding hospitals’] bread and butter,” Benjenk says. “Hospitals that are more focused on medicine also are focused on creating strategies for reducing readmissions for medical patients. They may use the same strategies on psychiatric units, expecting the same results. Psychiatric hospitals don’t have competing responsibilities.”
But the CMS data are limited in helping hospitals determine which other factors could affect 30-day readmission rates.
Public vs. Nonprofit, For-Profit
Benjenk and colleagues also found nonprofit and for-profit hospitals perform about the same on readmission rates, but public hospitals, such as state-run psychiatric facilities, perform the best. One reason why public hospital readmission rates are lower is their patients stay in those facilities longer than patients at nonprofit and for-profit facilities, Benjenk says.
“They have good, comprehensive services,” she adds. “Most chronically ill patients would stay there for multiple months, which is what these patients need.” By contrast, patients might stay at the typical nonprofit or for-profit psychiatric hospital for a week.
Benjenk’s research showed that while some hospitals are performing well with extremely low readmission rates, others have high readmission rates and are performing poorly.
“You can see unbelievable amounts of variation across the country on psychiatric readmission rates,” she says. “The readmission rates are risk-adjusted.”
The findings were adjusted for demographics, severity of psychiatric illness, and medical illness. There was no perfect way to adjust for social determinants of health, Benjenk says.
The study also revealed the 30-day, all cause, unplanned readmission following psychiatric hospitalization rate was different depending on the state. For instance, the lowest, mean 30-day readmission rate was 16% in Washington, followed by Minnesota and New Hampshire, each with 18%. The highest mean 30-day readmission rate was 24% in Rhode Island and Florida.1
One question was if hospitals that performed well on care coordination measures, including completing the discharge plan, also did better on readmissions. “Not really,” Benjenk says. “Hospitals can be good at doing processes that lead to lower readmissions, but it doesn’t make much of a difference. Our general finding is these measures are probably too broad to make any sort of change in readmission rates.”
The takeaway from the study is that quality measurement is a lot of work for hospitals. It can take a nurse or other staff member looking at 100 or more charts each month, she notes.
“If we make available all of these resources to publicly report it with the idea that what we collect is something we can improve on, then what if it does not lead to improvement?” Benjenk asks. “Is it worth the time? What can we do to get hospitals to reduce readmissions?”
- Benjenk I, Shields M, Chen J. Measures of care coordination at inpatient psychiatric facilities and the Medicare 30-day all-cause readmission rate. Psychiatr Serv 2020;71:1031-1038.