[The following article was written by Patricia Hines, PhD, RN and Kathleen Miodonski, BSN, CMAC for The Camden Group.]
The Hospital Readmissions Reduction Program levels penalties against hospitals with “excessive readmissions” after risk adjustments have been applied. The penalties will apply to all Medicare payments, not just payments associated with excessive readmissions. Hospitals with higher than expected 30-day readmission rates will incur penalties against their total Medicare payments beginning in the federal fiscal year 2013. To meet these challenges, hospitals need to take a structured approach to reducing readmissions. Here are ten ways to reduce avoidable readmissions:
1. Manage chronic diseases effectively in the outpatient setting. High admissions equal high readmissions. According to a recent article in the New England Journal of Medicine, there is a substantial association between regional rates of rehospitalization and overall admission rates. In addition to improving the quality of transitional care processes, the authors suggest that aligning incentives through shared savings programs may be effective in lowering readmission rates. Such programs should be designed to encourage the development of strategies and programs to manage chronic diseases effectively in the outpatient setting.
2. Stratify patients to align the appropriate clinical care. Patients with chronic diseases should be stratified into high, medium, and low risk categories based on their age, socioeconomic level, education, co-morbidities, dependence on medication management, the frequency of their use of the emergency room, and recent hospital admissions. Clinical care strategies include self-management, telephonic case management, nurse-led disease management programs and clinics, complex case management, home care management, and ultimately, end-of life, palliative care programs. The goal is apply the most appropriate intervention based on the patient’s needs and condition to optimize clinical outcomes and quality of life.
3. Encourage interdisciplinary collaboration. Collaboration among clinical disciplines is vital in the prevention of readmissions and to avoid fragmentation of care. The role of the Medical Social Worker (“MSW”) is especially valuable in the prevention of readmissions. MSWs assess patients at high risk for readmission, using standardized tools to determine the patient’s ability to understand and adhere to self-management/discharge instructions and their readiness for change. Armed with this information, and in collaboration with the patient, the multidisciplinary team can design a transition plan that is most likely to succeed. In addition, collaboration with the care team in post-discharge venues of care is essential to avoid fragmentation of care.
4. Leverage technology innovation to improve team communication. A simple recent innovation impacting patient care coordination is the ability of multidisciplinary members to text each other. Other innovations include Carebook, an online networking platform which connects care providers to form multidisciplinary care teams, collaborate on safe transition plans for their patients, coordinate care, and engage patients and caregivers with a patient-centered after-care map.
5. Ensure smooth transitions with a strong transition plan. A key component in transitions of care for a patient returning home is the transition plan. Develop the transition plan on admission with the family. The plan should consider issues such as the home environment, whether the patient is physically and cognitively able to care for themselves, availability of support systems, and whether palliative or hospice support is appropriate. It should ensure that there is a timely follow up visit with the primary care provider or case manager. Also, the patient and family need to be educated at a level that considers language, educational level, and cultural preferences.
6. Emphasize medication reconciliation and management in the home. Medication reconciliation, particularly during the transition from hospital discharge to the next level of care or home, is an important step to avoid potentially costly errors. Patients should be encouraged to participate in medication reconciliation to learn the medications they should continue and the over the counter medications they should avoid, as well as when to contact their primary care provider. For those patients at the highest risk, transition management should be provided through complex care management or telephonic management, provided by a registered nurse or registered pharmacist in the home environment.
7. Strengthen relationships with Skilled Nursing Facilities (“SNF”). The role of a SNF-ist (e.g., nursing home physician specialist or long-term specialist) has begun to emerge as a way to improve the care of SNF residents. The SNF-ist is responsible for the provision of physician services and coordinates the care transitions. They ensure patients are moving from the acute care setting to the SNF to home at the appropriate time and with the appropriate support. The SNF-ist works with those patients with multiple co-morbidities who are at high risk of readmission. By managing them for a full 30 days after the acute care stay, the SNF-ist can, with the physicians, address issues that commonly contribute to unnecessary readmits, particularly the coordination of care. Additionally, MedPAC’s most recent report to Congress outlined several factors impacting acute readmits that are within a SNF’s operational control and should be addressed. These include staffing levels, skill mix, staff turnover, drug mis-management, medication reconciliation, patient education, and the presence of advanced directives.
8. Manage health of population. In this era of accountability and value-based purchasing, patient registries create a realistic view of clinical practice, patient outcomes, and provider performance. To be effective, those responsible for population health need to provide high-quality, effective care at the lowest possible cost, and engage patients in staying well and managing their health. This requires an integrated, behavior-driven, patient-centric model tailored to a specific patient population that looks at the disease as part of the patient’s care. Health coaching programs deploy a variety of techniques aimed at behavior changes and include the stages of change, motivational interviewing, self-management techniques, positive psychology, and social cognitive theory.
9. Engage patient through telehealth tools. An increasing number of organizations are taking advantage of patient portals and personal health records, and even more are using other approaches to engage patients in their care, including e-mailing, texting, and social media channels. Such engagement efforts will increase over time, and these technologies will be used in a variety of ways to provide patients with access to their data so they understand their current health status, allow them to communicate with their care providers directly, enable patients to enter their own data, and provide patients access to management tools. A system that allows patients to communicate with caregivers, perform self-care activities, and participate in health screenings, for example, can improve quality of care and outcomes, especially for patients with chronic diseases.
10. Monitor progress with metrics. Development of a scorecard that allows the healthcare team to evaluate the success of their interventions, track trends, and identify opportunities for program improvement is a fundamental component of any readmission reduction program. The scorecard should include process and outcomes metrics that reflect the goals of the program, provide an overview of program effectiveness, and have relevance to the various disciplines on the team. The scorecard should include data that reflects clinical, quality, and
financial considerations. Clinical metrics such as numbers of patients hospitalized in each risk category and/or DRG with readmission rates, length-of-stay, emergency department visits, PCP/specialist visits, etc. can be reported at 30, 60, 90, and/or 180 day intervals after discharge. Process measures (e.g., discharges to home care and skilled nursing, follow-up phone calls, and ancillary involvement) may correlate to the clinical data. Patient satisfaction scores and average scores from self-reported wellness surveys are quality measures that round out the scorecard and help to tell the story.
See more at The Camden Group.