Health care providers need to think outside the box to reduce readmissions

Look at community, payers for answers

Health care systems that lack quality improvement projects to reduce their readmission rates or fail to discuss utilization issues with private payers, third-party administrators (TPAs), and others already are stuck in 20th-century thinking and habits, experts say.

The future is here, and it involves hospitals, physicians, employers, insurers, TPAs, and governmental or nonprofit groups working together to keep their region's populace healthier and out of the hospital. One of the crucial parts of this objective is the goal of reducing hospital readmission rates, experts say.

"Historically, health care centers have rewarded doctors for volume, and hospitals got paid again when patients were readmitted," says Guy D'Andrea, president of Discern Consulting in Baltimore. D'Andrea was scheduled to speak about transitions of care and pay-for-performance at the National Business Coalition on Health's annual conference, held Nov. 14-16, 2010, in Washington, DC.

"It's not that they were actively seeking to have patients readmitted, but they didn't focus on building systems that would reduce readmission rates," he says. "This is particularly true in transitions of care, where the doctor and hospital are separate entities and get paid separately, leading to a system that is fragmented."

The future can be found in what a few health care leaders are doing: building coalitions that address health care transitions from a holistic, community perspective, he says.

Evidence suggests that preventable readmissions are frequent, and readmitting patients is far more expensive than investing the time and effort into preventing readmissions, says Jeremy Nobel, MD, MPH, adjunct lecturer on health policy and management at Harvard School of Public Health in Boston.

This is why the Centers for Medicare & Medicaid Services (CMS) and corporations are beginning to pay more attention to health care transitions.

For instance, the Affordable Care Act of 2010 includes cost-containment strategies that address reducing hospital readmissions. The act states that it will reward hospitals that successfully reduce avoidable readmissions. The regulations are expected to be issued in 2011. Also, the government website Hospital Compare (www.hospitalcompare.gov) will report readmission rates.

Corporations are following suit and seeking ways to align financial incentives for providers to reduce readmissions, D'Andrea says.

There are a number of different models being proposed that will promote integration and coordination of care across multiple health care settings, he explains.

One model is pay-for-performance, which is also called P4P, he adds.

"That's where the business tells the provider, 'Here's what we expect you to do when the patient is discharged,'" D'Andrea says.

Employers will expect providers to take these steps at discharge:

• Review patients' medications to make sure patients are on the right medicines and won't take any that lead to adverse health events.

• Follow-up with them periodically post-discharge to make sure they do what they need to do.

• If they have a health need, build that into the plan.

• Lower the readmission rate as an end goal.

In exchange, the payer will provide physicians and hospitals with financial incentives for positive outcomes and quality performance.

With the health care reform bill, it is more likely that discharge planning strategies and tools will become widely used by health care systems.

"There are different models and payment mechanisms out there for people to try," says Michael Ong, MD, PhD, assistant professor at the University of California — Los Angeles (UCLA) David Geffen School of Medicine.

UCLA has led the formation of a consortium of UCLA's medical schools, plus Cedars-Sinai Medical Center in Los Angeles to research the use of wireless and telephone care management to reduce readmissions of heart failure patients. Ong is the principal investigator of the research.

"As evidence becomes clear that these methods are effective, there might be some means of making sure people are compensated for the services they provide," Ong says. "If these approaches are demonstrated to be effective and can reduce costs further, then people will look to implement them."

The current system's methods for handling discharge do not work, so it will take changes and different incentives to improve the process nationwide, Ong adds.

"Under any payment structure, if you can provide effective services at a low cost, then those are the things that will be adopted," he says.

Payers will check readmission rates and other quality indicators to see how hospitals are progressing with the necessary changes.

"When we talk about hospitals, the readmission rate is the key outcome indicator," D'Andrea says. "In other clinical areas, there might be other outcomes we will look at."

Hospitals will need to put more resources and staff in discharge and care transition planning, if they expect to achieve the results that will help them make the grade with Medicare and payers, experts say.

One recent study found that hospital nurses and other staff spend too little time with patients at discharge, says Mark V. Williams, MD, FACP, FHM, chief of the division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago.

Williams was one of the researchers who worked on a project that evolved into Project BOOST, a national project that promotes better quality care transition planning. Dozens of health care systems have adopted Project BOOST initiatives and have used BOOST tools.

"The study found that less than 10 minutes was spent at discharge process," he adds. "This didn't surprise me, because this [is] how it's typically managed: Patients are told what to do and then asked if they have questions, and then the discharge process stops."

When hospitals give discharge planners time to make certain patients truly understand their instructions, it can pay off in multiple ways, Williams says.

"Patients are really pleased when someone takes the time to confirm they understand, because too often the discharge process is rushed," he says. "Also, nurses are pleased by this; one nurse told us after we implemented Project BOOST in her hospital that this is why she went into nursing."

The discharge process can be confusing with inadequate patient education — even for patients who have advanced health literacy skills, says Terry Davis, PhD, professor of medicine and pediatrics at the Louisiana State University Health Sciences Center at Shreveport, LA.

Davis saw firsthand how difficult it is to interpret medication instructions and other directions on the discharge form sent home with patients after she had mitral valve surgery, followed by a hospitalization.

"When I was discharged, I was overwhelmed," Davis says. "I was being discharged with so many medicines [that] I didn't know the indications for the medicines, and why I was taking them, or how long I'd be taking them."

Discharge planning tools that provide templates with clear written instructions for patients could help prevent this type of confusion. While these have not been widely implemented to date, experts expect that will change.

Now that the health care reform bill clearly promotes better discharge planning and is expected to result in financial rewards for reduced readmissions or penalties for frequent-flier patients, many hospitals are scrambling to implement discharge tools, Williams says.

"Prior to this, there was no financial incentive and even a disincentive to manage discharge properly," he says. "If a patient was discharged, and bounced back in one to four weeks, that was another payment to the hospital."

From the non-Medicare payer perspective, it will be difficult to focus on financial incentives that address only the hospital piece of the care transition process, Nobel notes.

"If you expect commercial payers to have fees available to reward discharge planners, then you have to think about how it will help the whole patient population," he explains. "You would have to focus on not just the discharge planning process, but the environment in which you are discharging patients."

The receiving environment needs to be prepared and coordinated, he adds.

"There is no better example than preventable readmissions to illustrate how health care delivery is a system with care established between groups," Nobel says.

Sources

• Guy D'Andrea, President, Discern Consulting, 1501 Sulgrave Ave., Suite 302, Baltimore, MD 21209. Telephone: (410) 452-4470.

• Terry Davis, PhD, Professor of Medicine and Pediatrics, Louisiana State University Health Sciences Center at Shreveport. Email: tdavis1@lsuhsc.edu.

• Jeremy Nobel, MD, MPH, Adjunct Lecturer on Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115.

• Michael Ong, MD, PhD, Assistant Professor, University of California – Los Angeles School of Medicine, Box 951736, 911 Broxton, Los Angeles, CA 90095-1736. Email: michael.ong@ucla.edu.

• Mark V. Williams, MD, FACP, FHM, Chief, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 750 N. Lakeshore Drive, 11th Floor, Suite 187, Chicago, IL 60611. Telephone: (312) 503-2388.