The Patient Protection and Affordable Care has forced hospitals to seriously reassess readmissions. Programs specific to preventing readmissions for heart failure, heart attacks and pneumonia are now commonplace in hospitals across the country. However, these programs, while effective at the very start, often begin to plateau, leaving clinicians scrambling to redesign care-reinforcing readmissions programs at a time when penalties are increasing to their highest levels yet.
Eiran Gorodeski, MD, is the former director of Heart Care at Home, a transitional care program established by Cleveland Clinic that helped connect patients to quality care during their moves from hospital to home or a post-acute care facility. However, Heart Care at Home didn't create the post-acute care outcomes Cleveland Clinic had hoped to see, according to Dr. Gorodeski. So in 2013, the health system stopped using the program.
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A programmatic failure isn't necessarily a bad thing, however. "The way we've been looking at readmissions has been evolving," says Dr. Gorodeski, who is also head of the Cleveland Clinic Center for Connected Care
Transitional care is vital. Since 2010, the Cleveland Clinic has put plenty of effort into reducing readmissions according to the sticks and carrots of the Patient Protection and Affordable Care Act. According to Dr. Gorodeski, only when fines were put into place did hospitals begin taking readmission reduction seriously.
Cleveland Clinic created Heart Care at home in response to fines for high readmission rates of heart attack and heart failure patients. The program was driven mostly by telehealth, and it was somewhat effective. But beyond an initial drop in readmission rates, further iterations of the program didn't produce additional improvements in care. "That was when the lightbulb went off: this is probably not the right approach," says Dr. Gorodeski.
"The lessons we will carry forward from the program are not necessarily lessons that have anything to do with heart care," he says. What they do have to do with is improving care coordination.
Dr. Gorodeski cites the example of a particular nurse practitioner's work from Heart Care at Home as being especially eye-opening. "When we sent her into people's homes, it really improved outcomes. She was really coordinating care at a very high level, managing medications and teaching patients in a much more sophisticated way than other providers." The nurse practitioner helped reinforce the idea that, in Dr. Gorodeski's words, "It's not about the disease, it's about the patient."
Dr. Gorodeski believes the answer to readmissions lies in implementing parallel solutions for care coordination. "The focus has been what we should do about single condition readmissions. It's a good thing that is going to go away: it's been a distraction. How to reduce [single] readmissions misses the point." A patient centered, rather than a condition centered, mindset in the midst of care transitions is key, he says.
To keep reducing readmissions, Dr. Gorodeski also suggests partnering with skilled nursing facilties; 17 percent of all patients go to skilled nursing facilities. It's therefore important to consider value and quality when discharging patients to these facilities. "There's more and more data that patients who go to low value SNFs have worse outcomes," he says
Finally, he warns hospitals to be very careful in choosing supplementary technology. Telehealth may produce plenty of data, but whether that data is important, necessary or useful is a vital consideration.
"Essentially, hospitals need to understand Medicare and other payers are going to be moving away from specific admissions. Don't waste your time developing interventions that focus on diseases, or you're going to miss the boat. Instead, come up with ways to improve care coordination in parallel across the continuum," he says. "Cater to the patient population, beware of glittery technology and focus."