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By Jaimie Oh for Becker’s Hospital Review
The reasons hospital and health system leaders should be concerned with driving down preventable readmissions are clear. Under healthcare reform, healthcare providers with high levels of preventable readmissions face the potential of losing a portion of their federal payments. The Hospital Readmissions Reduction Program, which is part of CMS’ Inpatient Prospective Payment System, will reduce Medicare reimbursements to hospitals with high levels of preventable 30-day readmissions for three high-volume conditions: acute myocardial infarction, heart failure and pneumonia. Additionally, CMS’ proposed Hospital Value-Based Purchasing Program includes measures for readmissions, which will further penalize hospitals for high rates of preventable readmissions. Both programs take effect fiscal year 2013.
In addition to the high costs associated with preventable readmissions, preventable readmissions rates are increasingly being used as a quality indicator subject to scrutiny by commercial payors and consumers alike, which can affect your hospital’s bottom line. Here are 10 proven ways to reduce preventable hospital readmissions, based on a combination of research and successful hospital initiatives.
1. Understand which patient populations are at greatest risk of readmissions. It is critical hospitals identify which patient populations are at increased risk of hospital readmissions to target specific patients. Research from the Healthcare Cost and Utilization Project suggests, for instance, that Medicaid patients and uninsured patients are at increased risk of preventable hospital readmissions, compared to privately insured patients. Specifically, HCUP’s research showed maternal readmission rates were approximately 50 percent higher for uninsured and Medicaid patients than for privately insured patients.
What’s more, among non-maternal adults (aged 45-64), Medicaid patients were readmitted to hospitals approximately 60 percent more often than uninsured patients. Similarly, they were readmitted to hospitals twice as often as privately insured patients.
2. Target patients with limited English proficiency. Healthcare experts agree patients with limited English proficiency are at increased risk of readmission. In fact, The Joint Commission recently established new requirements for hospitals delivering care to limited English proficiency patients. These regulations require proof of interpreter training and fluency competence for interpreters in spoken languages, as well as American Sign Language for deaf and hard of hearing patients. The standards are already in place as of this year but do not impact accreditation during the initial year-long pilot phase.
3. Participate in incentive programs with payors. Hospital and health systems across the country have been enrolling or partnering in incentive programs with payors designed to incentivize providers who effectively drive down unnecessary hospital admissions. Abington (Pa.) Health, for instance, and other Pennsylvania healthcare providers agreed in July to partner with Philadelphia-based Independence Blue Cross in a hospital-physician incentive program. The pay-for-performance model, aligned with federal accountable care guidelines, is designed to incentivize hospitals and physicians to collaborate in efforts to reduce hospital-acquired infections and readmissions and follow evidence-based guidelines for surgical care and the treatment of heart attacks, heart failure and pneumonia.
Similarly, the Maryland Health Services Cost Review Commission launched a voluntary program in March that caps payments for inpatient care over three years. Maryland hospitals could realize substantial savings if they reduced readmissions and lose money if readmissions rose. To meet the goal, participating hospitals would work with physicians and other providers in the community to ensure that patients receive the necessary care, preferably in lower-cost settings.
4. Join a readmission prevention-focused collaborative. Although they do not involve financial incentives, collaboratives can provide a way for health systems and hospitals to team together and share best practices and strategies for preventing hospital readmissions. The New Jersey Hospital Association, for instance, launched a year-long collaborative last June involving 50 hospitals, nursing homes and home health agencies to reduce hospital readmissions for heart failure. The goals of the collaborative included understanding why patients are readmitted; identifying best practices to reduce the rate; developing resources to improve care for heart failure patients and creating resources for patients to better manager their condition.
5. Ensure patients schedule a seven-day follow-up. Medical studies have suggested that patients who followed up with their physician within seven days of discharge were less likely to be readmitted to the hospital. CMS launched a pilot program from 2008-2010 in which hospital participants aimed to lower hospital readmissions within 30 days of discharge by 2 percent. Valley Baptist Medical Centers in Brownsville, Texas, and Harlingen, Texas, surpassed that goal, achieving 2.8 percent and 4.2 percent reductions in readmissions, respectively, by working with physicians to ensure patients were being scheduled for follow-up visits within seven days.
6. Implement a robust home healthcare program. Post-discharge care can also be a powerful mechanism for preventing readmissions. Research conducted by Avalere Health showed home healthcare, such as medical social services or home health aides, can be effective. According to Avalere’s study, home healthcare for chronically ill patients resulted in an estimated 20,426 fewer hospital readmissions than chronically ill patients receiving other post-acute services, such as long-term acute-care hospital services.
7. Ensure smooth transitional care. In addition to home healthcare, transitional care has also been shown to reduce hospital readmissions. Transitional care could feature a transitional care team or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge. One study conducted at Baylor Medical Center at Garland (Texas) found a nurse-led transitional program reduced adjusted 30-day readmission rates by 48 percent.
Another study, published in the Archives of Internal Medicine, compared 30-day readmission rates between a control group and fee-for-service Medicare patients who received transitional care coaching. Results showed the group that received transitional coaching experienced a 12.8 percent 30-day readmission rate, compared to the group who did not receive coaching and experienced a 20 percent 30-day readmission rate.
Also, the nurse’s role in transitional care should not be overlooked. Researchers conducted a systematic review of literature and analyzed 21 randomized clinical trials of transitional care interventions involving chronically ill adults. They discovered nine common interventions that helped drastically lower readmissions 30 days post-discharge, many of which included some variation of nurse involvement. Hospital should position nurses in leadership roles, such as clinical managers or in-person home visitors for discharged patients.
8. Clearly communicate post-discharge instructions. Patient communication and education is a critical component of readmission prevention. At UCSF Medical Center, a team of multidisciplinary heart failure experts monitored heart failure patients after discharge. These experts target preventable readmissions by educating patients about their disease and utilizing the “Teach Back” method. This method requires the patient to repeat the information they have been taught to ensure full understanding. UCSF Medical Center’s multidisciplinary-expert approach helped reduce 30-day and 90-day readmissions for heart failure patients 65 and older by 30 percent.
9. Install telemonitoring technology in the homes of chronically ill patients. Hospitals could also prevent unnecessary hospital readmissions by utilizing telemonitoring technology. A Horizon Blue Cross Blue Shield pilot program in New Jersey is closely monitoring congestive heart failure patients in their own homes in an effort to drive down hospital readmissions. Patients participating in the pilot program are equipped with a small transmitter that sends readings to Horizon BCBS. Anytime the transmitter senses a risk, such as weight gain, a Horizon BCBS medical professional is alerted to check on the patient without requiring an expensive hospital visit.
10. Effectively staff nurses during patient care. Yet another study showed effective and proper nurse staffing while the patients are still in the hospital could decrease preventable readmissions. A study published in Health Services Research examined data on nearly 1,900 patients at four hospitals from Jan.-July 2008. Notably, the researchers found higher RN overtime staffing increased readmissions as well as ED visits. Meanwhile, higher non-overtime RN staffing was found to decrease ED visits indirectly due to improved discharge teaching quality and discharge readiness