Over the past few years, the Centers for Medicare and Medicaid Services (CMS) has focused on reducing avoidable hospital readmissions to decrease unnecessary healthcare spending. Those efforts are beginning to pay dividends.
According to data from the CMS Office of Information Products and Data Analytics, Medicare 30-day, all-cause fee for service readmissions during 2007-2011 held steady at 19.5 percent. But in 2012, after CMS incentives and penalties were introduced, they fell to 18.5 percent — a figure that was further reduced to 17.5 percent in 2013.
That rate is still too high, especially since it only takes into account readmissions. Emergency department visits and overnight observation stays can be just as costly and disruptive to the lives of elderly Americans. Long-term post-acute care communities (LTPACs) have an active role to play in reducing avoidable re-hospitalizations.
The April passage of the Protecting Access to Medicare Act of 2014 included a provision for a new CMS reimbursement plan that, starting October 2018, could tie a portion of skilled nursing facilities' reimbursements to their hospital readmission rates. Essentially, the government would withhold 2 percent of SNFs' Medicare payments, and about 70 percent of those dollars would then be distributed to high-performing providers with reduced hospital readmissions. In addition, the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 includes goals for LTPAC providers to facilitate care coordination and improve Medicare beneficiary outcomes.
Here are five more ways LTPACs can contribute to reducing readmissions:
1. Collaborate and communicate. According to The Joint Commission, 80 percent of serious medical errors involve miscommunication during the hand-off between caregivers as patients are transferred from one setting to another. To avoid an error that leads to a readmission, as an LTPAC communicates with the patient's physician(s) to report an acute change in condition, it is important to have all the necessary information about the resident – including observations by the staff – readily available at the point of care. Otherwise, most physicians will instruct the clinical professional on the phone to send the patient to the hospital. Had more detailed, salient information been available, that's a hospitalization that potentially could have been avoided.
When communicating changes in patient condition with hospitals, quality improvement programs such as Interventions to Reduce Acute Care Transfers (INTERACT) can be very valuable in creating clean, concise dialogues designed to ensure only those residents who are in the throes of an acute change in condition are sent to hospitals. Another valuable step is for representatives from throughout the care transition spectrum to engage in monthly collaborative discussions on topics about transfers that occurred, such as communication protocols used and whether they were effective, whether the documentation that accompanied the resident to and from non-acute settings was useful and reached its intended destination, and other key areas to determine if they need improvement.
2. Embrace interoperability. Creating interoperability between LTPACs and other providers can greatly reduce medical errors. Nursing homes and home health agencies – even those without an electronic health record – can transmit patient assessment data to a health information exchange.
One solution is offered by KeyHIE Transform, an innovative, accessible and cost-effective tool developed through the Keystone Beacon Community. KeyHIE Transform is a software solution that converts the minimum data set (MDS) of patient assessments that nursing homes transmit to CMS for billing to a clinical care document that is sent to the health information exchange using the same standards endorsed by ONC for MU2 requirements. Through this service, KeyHIE receives the MDS or OASIS patient assessments, transforms them into interoperable, standards-compliant LTPAC Summary Documents and returns the LTPAC Summary document to the authorized recipient.
3. Improve information/documentation sharing. This strategy goes hand-in-hand with enabling interoperability, but really refers to the quality of shared information. Specifically, it's about the concerned parties working together to ensure all the needed information about a patient, such as baselines for critical health measures and recent status change observations, is available to all — whether in the form of an EHR, digitized paper records or a hybrid of the two. The goal here is to make any communication or transitions between locations and/or providers seamless.
For example, suppose a patient with a history of urinary tract infections exhibits confusion, fever and a decrease in appetite. A call to the physician with limited information will likely lead to a trip to the hospital to ensure that the patient isn't experiencing a life-threatening event. But if the LTPAC nurse can provide detailed medical history and current symptoms, the physician may be able to recommend a treatment approach that delivers the same outcomes the patient would receive after visiting a hospital, minus the battery of tests — for a lower cost, and more importantly, without the disruption and long wait at the ER. If hospitalization is unavoidable, the documentation should be so easily shared that it beats the ambulance to the hospital.
4. Incorporate remote patient monitoring and telehealth. Taking physical vital signs through traditional means, no matter how diligently performed, is only a snapshot in time. If a problem develops 10 minutes after the last visit, it could get out of hand before the next one, leading to a hospital readmission. The use of remote patient monitoring avoids this issue by delivering data alerts about the patient to the caregivers so they can respond immediately. Virtual house calls or e-visits take the frustration out of seeking care for common medical issues. Telehealth providers offer a personalized, timely and efficient consultation and diagnosis.
5. Build an all-inclusive team approach to care. There is a famous story about John F. Kennedy visiting NASA in the early 1960s and stopping to speak with a janitor who was sweeping the floor. When JFK asked the man what he was doing the man replied, "Sending a man to the moon." That is the mindset LTPACs need to build among their staff – all staff, not just nursing professionals. Patient care isn't just the responsibility of nurses or the care staff. It needs to be everyone's priority. The administrative, dietary and environmental support staff see residents every day and get to know them well. If they notice something that seems wrong about a resident one day, they should feel comfortable speaking up and bringing it to the attention of a nurse, who should then feel empowered to investigate the report and take action, if necessary. A server in the dining area who notices and quickly alerts of a change in Mrs. Johnson's mood, for example, might have just taken action to save that resident a trip to the hospital, or even her life.
Long-term and post acute care centers all over the country are adopting these and similarly enhanced processes, along with new ways of thinking, to bring down readmissions and costs. With improved collaboration and communication, interoperability, information sharing, telehealth and a team approach to care, LTPACs will become a leading contributor to the almost complete elimination of avoidable readmissions.
Maria D. Moen is Vice President of Care Innovation for VorroHealth (formerly BlueStep/BridgeGate Health), a company that delivers technology solutions to LTPAC communities and across the healthcare continuum to improve the quality of care for residents and patients. Prior to joining VorroHealth, she served in various healthcare leadership positions in the provider as well as vendor markets, most recently at Brookdale Senior Living. She can be reached at mmoen@vorrohealth.com.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.