Eight clinical strategies to reduce readmissions
Hospital profit margins are at risk. As the Hospital Readmission Reduction Program continues to expand under the Patient Protection and Affordable Care Act, hospital administrators face financial burdens and reorganizational hurdles as they work to reformat themselves to be in compliance with the program's policies. The program requires CMS to reduce payments to Inpatient Prospective Payment System hospitals with excess readmissions. Currently, CMS is only holding hospitals accountable for readmissions related to acute myocardial infarction, heart failure and pneumonia. However, CMS is in the process of finalizing the expansion of the applicable conditions in October 2014 to include: (1) patients admitted for an acute exacerbation of chronic obstructive pulmonary disease and (2) patients admitted for elective total hip and total knee arthroplasty. In order to effectively manage and adopt this policy, hospital administrators are focusing inward and looking to reevaluate current business models. Eight clinical strategies to reduce readmissions include:
1. Manage care transitions effectively
The number one cause of medical errors in the U.S. is the poor transition of clinical care. These errors not only harm patients but account for $25-40 billion per annum in excess care costs, according to a 2013 Health Affairs report. In order to ensure patients are receiving the utmost quality of care during any transition, providers must establish accountability.
Healthcare experts have agreed on certain "minimal" consensus principles and standards that are necessary to properly manage care transitions. These principles include: accountability, care coordination and family involvement, communication that is effective and timely, and adherence to national standards.
- Accountability. When all care transitions include medical records that meet certain minimum standards, accountability is enhanced. The patient's primary diagnosis and problem list must be transferred to the appropriate parties during the care process. Medication lists derived from appropriate medication reconciliation functions are also necessary. Proper identification of the primary care coordinating physician is imperative. Description of the patient's cognitive status and primary language is necessary, as is a detailed elaboration of critical and pending test results. While mitigating health and financial risk, instituting provider accountability also creates guidelines for future practices.
- Care coordination and family involvement. At every point in the patient's care, both the patient and family should know who is primarily responsible for the care of the patient. Care coordination best occurs via a provider who serves as the "hub" of care. This provider must be ready to supply timely communication to all other care providers.
- Communication. Patients and families should have clear, concise and straightforward access to a communication infrastructure that includes all medical records across the care continuum, as well as treatment and follow-up plans. Furthermore, timely communication, especially around changes in health status, is one of the many keys to managing care transitions.
- Adherence to national standards. Adherence to national standards of continuous quality measurement and improvement, as well as standardized clinical care treatment plans, also result in the most efficient, effective care possible. Care quality is markedly improved when such measures are put into place.
2. Employ IT effectively, including clinical decision support
Electronic medical records not only afford physicians streamlined workflow, but can also provide clinical decision support with references to the latest industry updates surrounding specific treatment routines. During any hospital admission, the utilization of clinical practice guidelines and computerized physician order entry are known to facilitate care. EMRs that provide clinical decision support to physicians using technology, such as info buttons linking physicians to the latest internet-based guidelines, are important in improving clinical outcomes during the hospital stay. In addition, the use of pharmacy software such as Micromedex that is designed to monitor and conduct real-time clinical surveillance to identify at risk-patients can aid physicians in their clinical treatment plans.
3. Stratify readmission risk for each patient
Patient assessment with regard to readmission risk can help identify which patients will require the most monitoring. Multiple risk factors for avoidable readmissions have been defined, including patients who are discharged without a follow-up primary care appointment or altered mentation/dementia.
Segmenting patients into diagnostic coding groups can help better identify patients at risk of admission or readmission. Effective risk stratification will help to predict which patients need to be monitored more closely with early primary care follow up, transition coaches, telemedicine and the other clinical interventions discussed within this article. Risk factors for readmission typically fall into one of three categories:
- Patient factors. A number of patient risk factors, which can be remodeled by education and intervention, include patients with a history of depression who are more susceptible to readmission, usually due to noncompliance. Similarly, patients with five or more chronic illnesses are at great risk, while the highest risk diagnostic-related groups seem to be heart failure, acute myocardial infarction and chronic obstructive pulmonary disease. Finally, patients older than age 80 are also at increased early readmission risk.
- Event factors. Other factors that predispose patients to be admitted include a past history of readmission before 30 days post-discharge, poor patient education prior to discharge, lack of a primary care follow-up appointment and an acute hospitalization length of stay of greater than two-fold above the mean for the admission DRG.
- Medication-related issues. The presence of adverse drug effects related to certain high-risk medications, such as warfarin, is extremely high. Patients who receive more than five routine medications upon discharge are also at increased risk. The increased possibility of patients being readmitted due to medication-related issues can often be attributed to medication discrepancies, unexplored adverse drug-drug interactions, as well as medication noncompliance.
4. Employ a transition coach or discharge advocate
Patients at high risk for readmission should be assigned a coach who conducts a comprehensive assessment and develops a care transition plan. A care transition plan should include key information from the hospitalization and guide the patient with post-discharge instructions.
The transition coach or care manager's responsibilities include notifying the appropriate insurance payer and the patient's case management service. Should in-home care be required, the transition coach is tasked with initiating such services. After discharge, the transition coach should interact with the family caregiver, the primary care provider and the hospital's discharge care manager, as well as a number of other ancillary medical providers, such as pharmacy and nutrition services. The transition coach can also arrange for population health messaging via email or text that is customized to the patient's diagnosis. Interventions — including follow-up appointments — should also be coordinated by the hospital-based transition coach.
Approximately 30 days after hospitalization, assuming that the patient has not been readmitted, the patient can be placed in an ongoing surveillance program for intermittent follow-up. The importance of the role of the transition coach or care manager cannot be emphasized enough in contributing to the success of a readmission prevention program. If a hospital is participating in an accountable care organization, preventing one admission or a readmission to a hospital can save a five-figure expenditure of dollars.
5. Consider using telemedicine, especially for the sickest patients
Telemedicine can serve as an early warning sign by alerting physicians to changes in patients' conditions. Using telemedicine, physicians can monitor changing patient status and can alter and/or develop treatment plans before the patients require readmission. For the sickest patients, the use telemetric monitoring is an attractive strategy to combat this scenario. Encouraging readmission data is currently being reported for multiple diagnoses. For example, the use of telemetric scales can let a physician or nurse know when a patient with congestive heart failure is gaining weight and thus retaining fluid. This early alert is then used to make medication changes on an outpatient basis prior to clinical deterioration and the need for readmission to an inpatient unit.
6. Affiliate with a patient-centered medical home
Some evidence shows that patients who receive their care through a patient-centered medical home have fewer admissions and readmissions. Research also suggests that patient-centered medical homes can decrease the cost of providing care to groups of patients by as much as five percent. A medical practice must meet several criteria to be considered a PCMH:
- The patient has a personal physician
- The practice is physician directed
- Patient care is oriented toward the whole person, not the symptom or disease
- Subspecialty or ancillary services are coordinated by the primary care practice, or the practice integrates the services into the primary care practice
- Quality and safety drive patient care
- The medical home provides enhanced access (e.g., evening and weekend hours)
- Evidence-based medicine, clinical pathways, protocols and EMRs are used
- Disease management and automatic reminders are employed warning both patients and providers of required preventative care
- Disease-based patient registries are in use
- Patient self-management tools, such as an Internet portal and electronic prescribing are in place
- Team orientation is evident with the use of physician extenders and team incentives
Hospitals interested in preventing readmissions should consider developing PCMH practices of their own or partnering with presently extant PCMHs.
7. Educate patients about readmission risk
Physicians should consider devising special programs for patients who fall into the highest risk categories for readmission. It is clear that patient education is important in preventing readmissions, and clinicians interested in having the greatest impact should consider implementing this practice. Any patient who falls into the categories noted in section three (patient factors, event factors and medication-related issues) should be given special attention and education prior to discharge. These patients should also be the ones most closely considered for special attention from patient navigators. A number of standardized programs are available to address issues such as the routine use of multiple medications without adverse effects. Standardized discharge instructions for heart failure, acute myocardial infarction and chronic obstructive pulmonary disease are routinely available and effective.
8. Devise a formal plan to communicate a final checklist before discharge
Physicians who create a plan to monitor a patient's health after discharge will help establish stronger communication lines and ensure all involved parties are committed to the best quality treatment plan. The process of discharge planning begins on day one of admission. It is strongly advised that in-hospital case managers prepare a patient checklist that encompasses the areas described throughout this article. Specifically, no patient should be discharged without a follow-up primary care appointment. High-risk patients should be seen within two to five days of discharge. Lower-risk patients should be seen seven to ten days after discharge. The medication checklist and medication reconciliation should be reviewed with the patient and preferably by clinical decision support software to prevent adverse drug events.
A detailed plan for home health visitation, rehabilitation and nursing care should be included in the discharge summaries provided by physicians and nurses. Checklists should include exercises of patient "teach-back" where a patient describes how he or she will continue the agreed upon care at home. This teach-back should focus on high-risk medication utilization, new or recently altered medical therapies, and especially complex or difficult to understand treatment concepts. Physicians who take responsibility for their patients' care once they've left the hospital setting not only set precedence for future care models, but greatly reduce any confusion the patient may have about his or her continued treatment plan.
These eight guidelines for preventing avoidable hospital readmissions present opportunities for hospitals and physicians alike to alter existing care structures in ways that will have minimal impact to the system. In order to continue to provide the best services for patient care, hospital staff should refocus their efforts on this care structure. Ultimately, it is the communication and the follow-through of such complex multifactorial therapies that result in improved patient safety and decreased readmissions.
Dr. Bill Bithoney serves as chief physician executive and managing director at BDO Consulting, where he co-leads clinical strategy for the firm's National Healthcare Advisory Practice within BDO's Center for Healthcare Excellence & Innovation. He can be reached at bbithoney@bdo.com