Readmissions are on more shoulders now

Reports looks at how all players impact data

You know that you are going to get dinged for any unplanned readmissions related to a patient’s original hospitalization. You have probably felt the heat about that for some time and have worked on how to make sure no one bounces back unless it’s part of the plan. Well, now you can feel less alone. The National Committee for Quality Assurance (NCQA) released its Insights For Improvement: Reducing Readmissions: Health Plan Performance report in November and it includes a good deal of emphasis on how hospitals aren’t alone in this (to see the entire report, go to http://www.ncqa.org/Portals/0/Publications/2012%20BI_NCQA%20ReAdMi%20_Pub.pdf).

The report, which includes a detailed look at the Plan All Cause Readmissions measure from development through initial data, includes commentary about the multiple factors in the in- and outpatient settings that can impact readmission, and how a strategy that keeps both elements in mind is required. “From a system perspective, a safe transition from a hospital to the community or a nursing home requires care that centers on the patient and transcends organizational boundaries,” the report states.

The NCQA has the Plan All Cause Readmissions measure to “complement hospital-based measures,” the report notes, and put some emphasis on how well plans as a whole manage the care members receive in the wider community. Together, the authors hope that hospital readmissions data and the plan all-cause readmission data will provide more fodder for improvement in the delivery of care and the outcomes for patients.

The issue has to be addressed: NCQA says that up to a fifth of Medicare patients are readmitted within 30 days, and a lot of those could be prevented.

“One of the main things we wanted to do was call attention to the importance of readmissions as an issue and to highlight the fact that hospital readmissions are not strictly a hospital problem,” explains Robert Saunders, PhD, assistant vice president of research and analysis at NCQA and one of the main authors of the report. “Many factors go on in the lives of patients, particularly once they leave the hospital. While other measures have been focused on the hospital, we know that there are other actors and factors. We believe as a matter of philosophy that a health plan has a role in shaping the coordination activities.” He hopes the report will help hospitals develop strategies and the impetus to connect to those other parts of the continuum and work on issues of care coordination. “We wanted to highlight the fact that measurement in the area of readmission has to also take into account the health plan focus.”

This is not necessarily something new, says Mary Barton, MD, vice president of performance measurement. “But we are putting this all in one place and cementing the idea of those connections. You should look at where your interests are lined up with others in the community and think about how if you worked more together, how much more effective you would be.”

Saunders says looking at the history of the plan measure might be interesting to some, too. “When we developed the measure, much of the work was focused on hospital-based measures on congestive heart failure, pneumonia, and myocardial infarction — and with good reasons,” he says. “But the process of the care, the issue of handoff problems, the issue of patients coming back, well that all spans diseases. We wanted to focus on the totality of the problem, even if people are looking for actionability on specific causes of it. There are some issues of commonality, even if there are also some intervention opportunities that are related to specific causes.”

The first data on the Plan All-Cause Readmissions shows that some areas are doing better than others. Seattle region had the best performance, for both commercial and Medicare plans. In the commercial sector, there was about 15% less readmission than expected. Kansas City region had the worst performance in both commercial and Medicare, with about half a percent more readmissions than expected in commercial plans.

But overall for both Medicare and commercial plans, there were slightly fewer readmissions than expected.

To continue on this path, hospitals should be looking for problem areas in care transitions, improve transition planning with the receiving care setting, and letting the patient’s usual doctor know of the transition. They can improve communications with patients about the pending transition of care, and their health status and plan of care. For high-risk patients, the report suggests hospitals work on creating systems that proactively coordinate services and educate patients and caregivers about how to prevent bouncing back to the hospital.

“This is an issue of equity and disparity,” Barton says of the effort made on the measure and data collection. “When you don’t measure all-cause readmission, you don’t have information on people who have COPD and CHF. You have one or the other. This is meant to be an instigator for system thinking, for a broad look that will help patients make successful and safe transitions.”

For more information on this topic, contact:

  • Robert Saunders, PhD, Assistant Vice President, Research and Analysis, NCQA, Washington, DC. Telephone: (202) 955-1746.
  • Mary Barton, MD, Vice President Performance Measurement, NCQA, Washington, DC. Telephone: (202) 955-3500.