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Hospitals have been working to reduce readmissions for years, but in the third year of the penalty phase of the Centers for Medicare & Medicaid Services’ readmission reduction program, more hospitals than ever before are losing reimbursement for having more 30-day readmissions than their peers.
According to an analysis by Kaiser Health News (http://kaiserhealthnews.org/news/medicare-readmissions-penalties-2015/), a record 2,610 hospitals are being fined a total of $428 million for excess 30-day readmissions for myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, and total knee and hip arthroplasty.
Beginning Oct. 1, 2014, hospitals with more readmissions than their peers could lose up to 3% of reimbursement for every Medicare admission.
And that’s not the only reason hospitals have to get a handle on readmissions, says Brian Pisarsky, RN, MHA, ACM, senior managing consultant at Berkeley Research Group and Centers for Medicare & Medicaid Services (CMS) alumni faculty for the Community-based Care Transitions Program (CCTP).
"A lot of insurance companies have jumped on the bandwagon and developed their own programs for penalizing hospitals for excess readmissions," he says.
While a lot of facilities are dedicating people and other resources to the issue of readmissions, they aren’t necessarily getting to the root of the problem, says Cheri Bankston, RN, MSN, director of clinical advisory services at Curaspan Health Group, with headquarters in Newton, MA.
"We are just beginning to understand that a lot of what affects readmissions happens outside the four walls of the hospital," Bankston says.
Patients are non-compliant, they don’t get their prescriptions filled, often because they can’t afford to, or they miss their follow-up appointments because they don’t have transportation, Bankston says.
"With more and more hospitals using hospitalists, a lot of information gets lost. Even if patients do show up for their follow-up appointment, their primary care physician doesn’t know what happened in the hospital or what follow-up tests or procedures the patient needs," she says.
Case managers and hospitals can no longer shut their eyes to what happens after patients leave the facility, Pisarsky says. "We have to look at patients throughout the continuum, which includes their homes. It is imperative that hospitals communicate better with post-acute providers so they’re aware of all of the patient’s conditions and comorbidities," he adds.
Handoffs are critical between hospital case managers and those at the next level of care, says Patricia Hines, RN, PhD, an independent healthcare consultant based in Los Angeles.
"Hospitals are still struggling to create a seamless flow as patients transition between levels of care, but pieces of information are still getting lost. We need to continue to work on developing good connections between the acute care facility, the physician offices, and other post-acute providers, and community resources," Hines says.
She recommends sending a written report as well as talking to a clinician at the skilled nursing facility, long-term acute care hospital, or home health agency to make sure they have a good understanding of the patient’s condition and current needs.
Hines tells of situations when a nurse from the acute care hospital has accompanied patients with complex care needs who have been in the hospital for months and are being transferred to a skilled nursing facility. "This is only in extreme situations, but the staff at the receiving facility can get firsthand the information they need and it gives the family a comfort level that the treatment plan is going to be continued in the next level of care," she says.
"When my company, the Berkeley Research Group, consults with hospitals, its experts suggest enhanced collaboration with post-acute providers to find out what information is needed when patients transfer," Pisarsky says. "One of the first steps is developing an explicit form so the information is consistent and in the same order no matter who fills it out and which post-acute provider the patient chooses."
Make sure your discharge information and other communication with post-acute providers includes an updated medication administration record. "There could be readmissions when patients miss a dose of medication or accidentally get it twice," he says.
Some patients refuse home care or a nursing home admission, which makes them at significant risk for hospital readmission, Pisarsky says. "They have a right to make a bad decision but that doesn’t mean you give up. Do everything you can to help them stay safe in the community and make sure they have contact information for post-acute providers if they change their minds," he says.
When Holzer Health System began meeting with representatives of the area skilled nursing facilities, home health agencies, and assisted living centers, the facilities asked for a warm hand-off between the hospital case manager and the charge nurse when patients transfer, says Teresa Remy-Detty, DSC, MHA, LNHA, BSN, RN, vice president of post-acute care services for Holzer Health System, based in Gallipolis, OH. (For details on the health system’s readmission reduction initiatives, see related article on page 7.)
"Most of the time, any discussion that takes place is between the hospital care management team and the receiving provider’s admissions people," she says. "They requested that the care management team or the discharging nurse at the hospital also call the nurse at the facility when the patient is on the way. The hospital team can give the nurse a full picture of the patient’s condition and needs. In addition, the nurse at the facility can tell the patient she talked to the patient’s nurse in the hospital. It makes the patient and family feel much more comfortable."
Develop a relationship with case managers in the community, since that’s where many problems that cause readmissions arise, advises Kathleen Miodonski, RN, BSN, CMAC, vice president of clinical operations for Post-Acute Network Solutions, a company that contracts with managed care organizations to provide care coordination for residents in supportive living facilities, also called assisted living centers.
Patients are in the hospital only a short period of time. The success of their recovery depends on what goes on in the community. That’s why case managers need to pass the baton to someone in the next level of care, Miodonski says.
"We feel like we never get enough information about what happened in the hospital. Some of the things we need to know are what treatments were performed and why, results of diagnostic procedures and labs, why changes were made to the treatment regimen," she says.
Being patient-centered isn’t enough. Hospitals also have to be family-centered, adds Remy-Detty. "Caregivers are an important part of patients’ success in recovering after discharge. The family has to be involved in the discharge planning, and discharge teaching," she says.
Spend time with the patients and family members to get an understanding of patient characteristics, such as culture, language barriers, healthcare literacy, socioeconomic status, and access to social support, and take them into consideration when developing a discharge plan, creating materials for the patient to take home, and educating the patient and family, Hines suggests.
Case managers need to engage the patient and family and help them to see their roles and responsibilities after discharge, she says.
If the patient doesn’t have immediate family or other support, look for other resources, such as community agencies, neighbors, and churches, Bankston adds. "Case managers have got to be creative and connect patients with resources before they leave," she says.
Understand all the disease processes the patients are dealing with, not just the ones that brought them to the hospital, she adds.
Develop a discharge plan that the patient agrees to, and make sure that the patient has the means and the support system to be successful with the plan.
One of the most important pieces is to make sure patients have a way to get their prescriptions and that they fill them and take them as directed, Pisarsky says.
Follow-up telephone calls after patients are discharged are useful but there often isn’t sufficient hospital or case management staff to call every patient, Pisarsky says. He suggests developing a trigger list by diagnosis, insurance, or both.
Above all, patients and caregivers need to know who to contact if they have a problem, Bankston says. "Patients see so many nurses and so many different physicians that they may not be sure who to contact if they have a question or a concern. They do nothing, then end up back in the emergency department when their condition gets worse," she says.