“We can’t force patients to be compliant, and sometimes there are socioeconomic factors beyond our control; however, there is a lot that we can do for them while they are in the hospital as well as when they leave the hospital. We owe it to our patients to do the very best we can in those areas.” -Gina Anderson, Ascension Health
In the new normal of Medicare-reimbursed healthcare, hospitals are finding themselves on the front lines of preventing what some in the industry refer to as “frequent flyer” patients.
The term refers to patients who are readmitted within 30 days of being discharged from a hospital. Medicare reimbursements place prime importance on improved patient outcomes, while spending as little as possible to achieve that outcome.
And to Medicare’s way of thinking, if a patient is readmitted within 30 days of being discharged, then the provider did not do his or her job.
The scenario has forced hospitals to redefine the point of care. It no longer ends with hospital discharge paperwork and an answering service number to call in case of emergency. The care continuum must now include patient education and various patient touch points during those first critical 30 days post-discharge.
Hanging in the balance are the hospital’s Medicare reimbursement for that care, and the hospital’s reputation.
Of course, the business of managing readmission rates is hardly an exact science. For one thing, you have social factors such as low income and limited education that contribute to a substantial percentage of hospital readmissions.
How can a hospital accurately gauge the true cost of these types of readmits? Can a hospital ever expect to impact readmits caused by these social drivers, or are they unavoidable, to be considered a cost of doing business? Which readmits stem from other causes, and how can the hospital address these?
Like so many aspects of U.S. healthcare in today’s post Affordable Care Act environment, this issue brings with it more questions than answers. Still, thought leaders are emerging. While their approaches vary, the common theme is to focus on what they can impact.
St. Vincent’s Health System is one hospital leading the charge. In August 2012, the hospital’s parent company, Ascension Health, which operates 1,400 locations across 21 states and the District of Columbia, selected it, along with five other Ascension sites, to test, measure and report effective, replicable methodologies for readmission reduction.
In response, St. Vincent’s, which operates five locations throughout Alabama, developed and implemented a six-point strategy to address unnecessary readmissions across the DRGs of congestive heart failure, acute myocardial infarction, and pneumonia. From its November 2012 implementation to second quarter 2014, St. Vincent’s Birmingham experienced a 29 percent improvement from their baseline in 30-day observed all cause readmissions from its baseline with a current 12-month average of 6.59% and a current 3-month average of 5.54%.
Through six distinct processes, St. Vincent’s Hospital began to move the readmission reduction dial in their favor. So how did they do it? While your hospital bed size and patient population may vary from theirs, review the below and consider which tactics could work for you:
1. Understand your readmission risks
Identify contributing factors:
“As early in the admission as possible, patients are assigned a risk for readmission score,” said Anderson. “There are many risk scoring tools that have been created by content experts. We utilize the LACE score. This stands for Length of Stay, Acute or Observation Status, Comorbidities and ED visits made in the last six months. Research has shown that these are the common drivers leading a patient to return to the hospital.”
2. Provide consistent discharge instructions
Build patient understanding of their diagnosis:
“We’ve taken a multi-disciplinary approach,” said Anderson. “We began with looking at our current processes and data to determine where our opportunities were for these patients. The second part was to align messaging with the various staff interacting with a single patient. We consolidated our literature into one consistent educational booklet and utilized the content expert to provide the education that includes the care transition nurse, dietician, case manager, social worker, physician, pharmacist, and the chaplain. Each discipline meets with that patient individually and attempts to include the family, prior to discharge, to review the information in a clear, consistent way.”
3. Involve primary care earlier
Initiate care transition:
“Whenever a patient of ours is at high risk for readmission, we utilize nurses to engage the patient’s primary care physician both to make them aware and to arrange for that patient to be seen within seven days of hospital discharge,” said Anderson. “In reviewing the readmission data, we were seeing trends of readmission occur around Day 11. So we knew it was vital for these patients to be seen by their doctor prior to Day 11 so any changes in their conditions could be addressed as soon as possible.”
4. Assess the home environment
Learn the patient’s reality:
“We now have nurse practitioners going into the patient’s home 48 to 72 hours after discharge,” said Anderson. “That initial visit includes a physical assessment, a medication reconciliation, a high level depression screening and a high level socioeconomic assessment. All of this information results in the development of a 30-day care plan that can be a combination of phone calls and visits with a range of care specialists that may include nurse practitioners, registered nurses, social workers, and EMTs. The plan evolves based on the patient’s needs and changes in health status throughout those 30 days. But we are giving them a consistent and effective support system to make sure they are receiving the care they need where and when they need it.”
5. Manage the big picture
Coordinate transitional care:
“Our staff would pass home health staff in the patient’s driveway,” said Anderson. “It made no sense. We quickly realized we had to align with post-acute care providers and payers to share resources and to prevent patient confusion. We now have a dedicated patient resource tech with the primary responsibility of communicating pertinent information about our shared patients to post-acute care providers and payers and vice versa. We each have a role to play, but if it’s not communicated across the care continuum and it causes patient confusion, we risk disengaging the patient all together.”
6. Put the patient first
Provide person-centered care:
“Our readmission program is not patient-centered care,” said Anderson. “This is person-centered care. Yes we’re working hard to reduce unnecessary readmissions, but you can’t take a cookie cutter approach to prevent these bounce-backs. It really has taken a multi-pronged effort to move the dial. We know we are on the right path because of the reduction we are seeing in our readmission rates and we are pleased with that. But when we see an individual patient’s quality of life being impacted positively by what our team is doing, that is when it matters most to us. We have a lot of patient stories to tell. But when you see patients that are able to stay out of the hospital for more than 30 days and they haven’t done that in several months, that is when we know it is person-centered care.”