With nearly one in five Medicare patients returning to the hospital within a month of discharge, the government considers readmissions a leading symptom of a costly and uncoordinated health system.
In order to address this problem, CMS created quality programs that reward healthcare providers and hospitals with incentive payments for using electronic health records in order to promote improved care quality and better care coordination. In the coming years, these incentive "carrots" will soon turn into penalty "sticks." By 2017, CMS will penalize providers and hospitals up to 8 percent of their Medicare payments based on various performance indicators. According to Kaiser Health News, they state that there is a possibility of forfeiting more than $280 million in Medicare funds in 2013, hospitals are looking for innovative and cost effective solutions to reduce readmission rates and provide the highest quality of care.
Legislation history and escalating penalties
In 2010, the Patient Protection and Affordable Care Act charged HHS with creating a program that would reduce the rate of patient readmission to hospitals. This program, called the Readmissions Reduction Program, became effective for all discharges on Oct. 1, 2012. Outlined in the CMS guidelines, the program defines "readmission" as "an admission to a hospital within 30 days of a discharge from the same or another hospital." According to CMS, the rising rate of readmissions points to a decline in of the quality of care in hospitals.
CMS has proposed solutions that could reduce the rate of readmissions by instating penalties for hospitals whose rates of readmission exceed a certain percentage. In October of 2012, hospitals with high rates of readmission were penalized for up to 1 percent of every Medicare payment, and after October 2013, the penalties rose again to 2 percent. By 2017, penalties as high as 8 percent will be in place for high readmission rates, as well as failure to report on certain quality measures and hospital-acquired infections.
CMS has released data (Figure 1) that outlines the number of hospitals projected to be penalized and the percentage of their Medicare reimbursements that they will have to pay as penalties for excessive readmissions. The agency estimates that more than 2,200 hospitals will be penalized in 2013 and 307 hospitals will lose 1 percent of base Medicare payments, the maximum penalty. CMS has also issued predictions for FY 2014 and FY 2015 in terms of the penalties hospitals can expect.
Figure 1: CMS Penalties by Fiscal Year
A study conducted by the Dartmouth Institute lists several reasons why patients are trypically readmitted. The top five reasons found in the study were:
1. Patients may not fully understand what is wrong with them.
2. Patients may be confused over which medications to take and when.
3. Hospitals do not provide patients or doctors with important information or test results.
4. Patients do not schedule a follow up appointment with their doctor.
5. Family members lack proper knowledge to provide adequate care.
With better care coordination and improved patient engagement, during and post discharge, several of these top reasons can be addressed.
HAIs and readmissions
A 2012 study by Emerson et al. titled "Healthcare-associated infections (HAIs) and hospital readmissions" found a clear correlation between HAIs and increasing hospital readmission rates. Hospital patients that had a positive vancomycin-resistant enterococci culture were 67 percent more likely to be readmitted than their uninfected counterparts. In an article published in Infect Control Hosp Epidemiol in June 2012, it states, that the average time until readmission for infected patients was 27 days, compared with an average of 59 days for uninfected patients.
Further, according to HHS, about one in every 20 inpatients has an infection related to hospital care. The most common HAIs are urinary tract, surgical site, bloodstream and pneumonia6. Hospitals can significantly reduce or prevent HAIs with the proper tools for patient surveillance, real-time alerts and monitoring of infectious diseases.
Three-pronged approach
Although these quality programs provide an excellent framework for how hospitals can improve their processes and ensure patient safety and care quality, they sometimes don't account for the whole picture. The main objective for these programs is to improve outcomes for both patients and hospitals. Typically hospitals focus on areas that can positively impact their patients' experience during the time they are actively being treated; however, it may be more beneficial for hospitals to consider a three pronged approach: promote the highest quality of care in the hospital setting with automated patient surveillance and infection control, improve care coordination across multiple personnel, laboratory and hospital information systems and support and maintain patient wellness once they have been discharged and returned back home. If all three are successfully implemented, especially if the patient's care continues post discharge, then the rates of hospital readmissions can be dramatically reduced.
Patient surveillance and infection control
The ultimate goal of these incentive programs is to increase the quality of care by making hospitals more efficient. By streamlining and automating infection control workflows and implementing real-time patient monitoring, hospitals will be able to identify and treat hospital-acquired infections more quickly and effectively.
Although it is possible to perform infectious disease surveillance manually, it can be costly and time-consuming. Implementing an automated infection control and patient surveillance solution can help infection control personnel prevent hospital-acquired infections and also identify those at risk for new infections, thus enabling clinicians to take appropriate action in real-time to reduce adverse events. Automated patient surveillance should also include real-time alerts that can push time-sensitive patient information directly to the treating physician to increase awareness of current medication regimens, renal and hepatic functions, lab results and vital signs.
Improving care coordination with integrated information
By implementing an automated, integrated solution, hospitals can significantly improve care coordination between practitioners, pharmacists and laboratory personnel. If all patient data is interoperable and can be accessed through one integrated system, this could help reduce or eliminate discrepancies that occur with multiple systems and enable more accurate, real-time analytics and reporting.
An integrated system could also assist with reducing readmission rates by providing automated reporting and real-time alerts on several quality parameters outlined by CMS such as:
1. Alerting clinicians to surgical/pneumonia antibiotics follow up
2. Monitoring anticoagulation therapies
3. Reducing hospital-acquired infections
4. Flagging at-risk medication related falls
5. Providing aspirin and/or statins monitoring
6. Improving physician quality reporting
An automated infection control solution can also provide the necessary data needed to identify problem areas, measure the progress of prevention efforts and ultimately reduce or eliminate hospital-associated infections. These electronic reporting systems can enable providers to capture and transmit real-time laboratory results to public health agencies and the Centers for Disease Control and Prevention, saving hospitals countless hours and resources required to track infections manually.
Supporting and maintaining wellness post discharge
While providing hospitals with the necessary tools for reducing readmissions is important, what happens when the patient is discharged and their care is out of the hands of the healthcare provider?
There are effective home monitoring programs that can help patients take control of their own health. By combining personalized solutions with biometric and telephonic monitoring, providers will be able to better assist with a patient's recovery after a hospital stay. Monitoring a patient becomes especially important when managing chronic conditions.
Home monitoring programs have been shown to decrease the number of inpatient admissions when proper follow-ups are integrated into the treatment plan. Biometric and telephonic monitoring have also been proven to be effective in reducing inpatient admissions and readmissions, as well as reducing costs. A 2010 study by Rosenzweig, et al. entitled "Diabetes Disease Management in Medicare Advantage Reduces Hospitalizations and Costs" found that "a disease management program for high-risk patients with diabetes and CAD was effective in reducing hospital inpatient admission and total costs."
Patient interventions included educational pamphlets and newsletters, as well as reminders about vaccinations, eye and foot exams, and medication adherence coaching. Self-reported biometric values, such as A1C and LDL-C, were also collected. Many patients were even found to have continued the program after the study had concluded, showing that this type of positive patient engagement had empowered them to better manage their own care.
Beyond the hospital walls
When it comes to reducing readmission rates, hospitals should consider implementing policies that can go beyond their four walls and across the continuum of care. Data connectivity and information sharing is crucial for interoperability of patient data, but it's also necessary to improve care coordination between hospital personnel and disparate health information systems. When you add on the complexity of patient device data and home monitoring, it is increasingly important to take a more holistic, patient-centered approach to managing care and wellness. If we as healthcare providers can adopt and deploy connectivity technology across the entire healthcare network, from the hospital to the home, then patient health can be better managed and tracked. Further, by monitoring patient wellness post discharge, providers can more effectively communicate with their patients and work together to keep patients healthy, readmission rates low and care quality high.
Dr. Khan currently serves as CMO of Alere Analytics, formerly DiagnosisOne, where she provides direction and leadership to develop practical and scalable technologies that allow clinical decision support and analytic capabilities to be seamlessly incorporated into clinical workflows. She has expertise and passion for algorithm design, knowledge acquisition and engineering as well as data mining and leveraging these capabilities to improve outcomes. Prior to forming DiagnosisOne, Dr. Khan was the director of informatics at UMass Memorial Medical Center with 10 years of experience in the hospital practicing pathology. She is the author, editor, and primary visionary of the "Guide to Diagnostic Medicine", Lippincott Williams & Wilkins, 2002.
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