National health care reform makes discharge planning a higher priority

Think: readmissions, readmissions, readmissions

Health professionals who have worked hard to improve the discharge process might see change occur more quickly in the coming decade as the changes envisioned in national health care reform begin to take effect.

The Patient Protection and Affordable Care Act (H.R. 3590) was signed by President Barack Obama in March 2010. The new legislation appears to be nudging health care providers in the direction of improving quality, reducing lengths of stay and readmissions, and achieving optimal outcomes at a lower cost.

"For those of us in the case management and care coordination, transitions of care world, we're pretty excited about health care reform," says Margaret Leonard, MS, RN-BC, FNP, senior vice president for clinical services at Hudson Health Plan in Tarrytown, NY. Leonard also is the president of the Case Management Society of America (CMSA) in Little Rock, AR.

The new legislation provides funding for pilot programs that will improve care transitions and emphasize case management, care coordination, disease management, and reducing readmissions, Leonard says.

There are specific parts of the bill that address hospital readmissions, she adds.

"There's a focus on preventing the preventable hospital readmission as a key initiative in health care reform," says Scott Flanders, MD, SFHM, director of hospital medicine at the University of Michigan in Ann Arbor.Flanders also is the president of the Society of Hospital Medicine in Philadelphia.

Hospital medicine has grown in recent years, and communication among providers during care transitions is a particularly vulnerable area for hospitals, Flanders says.

"By necessity, there are patient hand-offs, so if there is a lack of information in the transfer or poor communication, it has potential risk for the patient," Flanders explains. "Adverse events and readmissions are among those risks."

The new health care bill will result in hospitals putting more emphasis on discharge planning and care coordination with post-acute care providers, predicts Caroline Steinberg, vice president for trends analysis for the American Hospital Association in Washington, DC.

"Hospitals will need to make sure patients are receiving more appropriate follow-up care," Steinberg says.

"In the future, hospitals will be eligible to receive higher payments if they have better performance or show improved performance on quality measures," Steinberg says. "It will result in an increased focus on patient safety and care coordination."

This shift in priority might also result in hospitals hiring more clinical pharmacists, social workers, and case managers, she adds.

Hospital leaders will need to follow the bill's regulations to determine which conditions will be the initial focus for readmission rate reduction strategies, says Jason A. Scull, program officer for clinical affairs at the Infectious Diseases Society of America in Arlington, VA.

Also, hospitals with abnormally high readmission rates might have their payment adjusted, he adds.

The health care reform bill likely will bring both opportunities and challenges, says Carol Frazier Maxwell, LCSW, ACSW, director of social work, family services, and interpreter services at the Arkansas Children's Hospital in Little Rock, AR. Maxwell is president of the Society for Social Work Leadership in Health Care in Philadelphia.

"Potentially, more people will have health care coverage, which is a good thing," Maxwell says. "But this also could mean our taxed health care systems will not be able to handle the higher volume."

And the bill will result in hospitals receiving lower reimbursement rates for some procedures, which may or may not be offset by higher volumes, she adds.

"If they're not able to increase their hiring to meet higher demand, then people will have longer waits getting into clinics, specialty programs, and that sort of thing," Maxwell says.

On the positive side, hospitals will see their charity care cases decline, as more people who previously had entered hospitals without insurance now will have health care coverage.

From a care transitions perspective, it is possible discharge planners will have an easier time finding placement for patients, since just about everyone will have some type of coverage.

Social workers and discharge planners need to convince their hospital leadership to be proactive and station someone in the emergency department to help with care transitions to non-acute care options, including long-term care facilities and other settings, Maxwell suggests.

"This is an opportunity for hospitals to look at cost-shifting," she adds. "A lot more hospitals are doing discharge planning in the ER."

The key is to have someone in place who can develop liaisons with community agencies, long-term care organizations, and other post-acute care entities.

Health care reform had been taking place even before the bill was signed in March, and hospital readmission rates have been a particular focus, Leonard notes.

"I was appointed to a CMS [Centers for Medicare & Medicaid Services] technical expert panel that was looking at readmissions within 30 days, and that's something near and dear to my heart," Leonard says.

CMS is focusing on a handful of conditions to determine whether a patient's visit with a primary care provider during that 30-day post-discharge time frame can make a difference in a hospital's readmission rate, she explains.

The AHA is concerned about the federal government's policies that could result in payment cuts to hospitals that have high readmission rates, Steinberg says.

Hospitals soon will find that they'll have to collect data about their readmission rates, and those that have unnecessary 30-day readmissions will be compared with peers. Those that are among the top 25% in having the most preventable 30-day readmissions will be penalized with reimbursement cuts.

"We're concerned that those measures may not pick up on the readmissions that are planned or unrelated to the initial admission," she says. "We're concerned that hospitals will be penalized for having readmissions that are actually appropriate, so we're advocating on behalf of our members for a fair readmissions policy."

Still, hospitals can use their discharge planning process to improve their preventable readmission rates.

"There are a lot of opportunities for care coordinators to work within a hospital system to put together a plan that shows what will keep patients from being readmitted to the hospital," Leonard says.

For example, the National Transitions of Care Coalition has developed tools that are being adopted by hospitals to help them with medication reconciliation and other aspects of discharge planning, she adds.

The new legislation puts money into care transition demonstration projects, and this also could provide opportunities for case managers and care coordinators, Leonard notes.

Also, the health reform bill establishes a national pilot program on payment bundling. The program will involve an episode of care around a hospitalization with the goal of improving coordination, quality, and efficiency of health care services.

One factor will be the number of readmissions for any of eight conditions to be selected by the Secretary of the U.S. Department of Health and Human Services.

The pilot program's goals include providing transitional care interventions that focus on a hospital inpatient episode and targeting post-discharge patient care to reduce unnecessary health complications and readmissions, according to the bill's Subtitle C - Provisions, at H.R. 3590 - 330.

In some ways, the very language of discharge planning is changing to show that all providers, including hospitals, are responsible for the patient's transition from one episode of care to another, Leonard notes.

The right questions for hospital providers to ask are whether a patient is returning to his primary care provider after leaving the hospital and whether there is some coordination of care, she says.

"The thought is that this will prevent the patient's readmission," Leonard adds.

As the health care legislation plays out, hospital discharge planners will need to focus on transitioning patients to a safe and appropriate level of care, Maxwell says.

It will be difficult to determine all the ways the legislation will impact discharge planning until the bill's regulations are written.

"The bill is here whether you liked it or didn't like it, and it's historic," Leonard says. "And now regulators need to define what the bill means, and they'll write the guidelines for what happens next."


For more information, contact:

• Scott Flanders, MD, SFHM, Director of Hospital Medicine, University of Michigan, Ann Arbor, MI. President, Society of Hospital Medicine. Email:

• Margaret Leonard, MS, RN-BC, FNP, Senior Vice President for Clinical Services, Hudson Health Plan, 303 South Broadway, Tarrytown, NY 10591. Telephone: (914) 610-0721. email:

• Carol Frazier Maxwell, LCSW, ACSW, Director of Social Work, Family Services, and Interpreter Services, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR 72202. Telephone: (501) 364-6531.

• Jason A. Scull, Program Officer for Clinical Affairs, Infectious Diseases Society of America, 1300 Wilson Blvd., Suite 300, Arlington, VA 22209.

• Caroline Steinberg, Vice President for Trends Analysis, American Hospital Association, Washington, DC. Telephone: (202) 638-1100.