Reducing Hospital Readmissions - it takes a community

Readmissions appear to be one of the hottest topics in healthcare this year.  There are numerous symposiums, education sessions, articles and interviews about readmissions everywhere you turn.  Each of these venues provides a different perceptive on the subject, but few I’ve read or attended addresses the ultimate challenge: getting all the participants throughout the continuum of care on the same page.

The big disincentive looming before the hospital industry is that CMS will begin reducing reimbursement for re-admissions by diagnoses starting in 2013.  Every two years after the initial set of diagnoses are reduced, an additional set of diagnoses will be added to the list.  CMS will determine these moving forward through the mining of their claims data to determine the number and cost associated with the re-admissions.  So far, the episodes of care targeted for 2013 include congestive heart failure, acute myocardial infarction and pneumonia.  In 2015, COPD, coronary artery bypass grafts, percutaneous coronary interventions and a few vascular surgeries will be added.

Anyone who is in healthcare knows that this list is complicated because few patients admitted rarely have a single condition and usually have many complicating factors associated with their original admission.  Most have hypertension, diabetes, obesity, HIV or other complicating factor associated with their admission.  And, many (if not most) have been admitted because they are not compliant with the plan of care prescribed by their primary care or specialty physician.  So the conundrum: how do hospitals motivate or incentivize care teams to focus on patients’ long term stabilization after discharge.  And more importantly, how to get the patient engaged in managing their own health risks and conditions.  Unfortunately, the current hospital system has little impact on the cause for readmission yet they must absorb all the financial disincentives associated with their occurrence.

Hospitals have made great strides in keeping patients alive and well until discharge.  Many quality initiatives, the proliferation of hospitalists and technological advances, have improved mortality rates and reduced length of stay over the past ten or more years.  However, hospitals lose control over the patient and their care once they are discharged.  And, like many changes that invoke quality and cost effectiveness, reducing readmissions, ED visits, diagnostic tests, etc., all impact the hospital bottom line revenue negatively.  The quandary hospitals face is how to enter a paradigm of cost avoidance and quality and still survive financially using their assets to manage patients over which they have little or no control.

Because hospitals have the most to lose (in fact they may be the only stakeholder with a negative incentive), they must take a leadership position within a multi-stakeholder group that includes everything from primary care physicians, specialists, post-acute facilities, long term care, home care agencies, social services and hospices to address the problem.  The impetus for these players to participate in these efforts is much more positive on the revenue front, engaging them in revenue producing activities. Keeping these players involved in the process takes data and regular communication about the overall progress and individual patient encounters.

Ultimately, a health information technology infrastructure that allows a healthcare community to work together is essential.  The system must provide patient-specific data for determining the varying reasons for readmissions; identify patients at risk of readmission based on evidence-based, predictive modeling technology and real-time clinical analysis; and allow all members of the care management team to have access to both data and communications about the patient at risk for a readmission. Using technology to identify, target and plan at the patient level is imperative to managing the readmission process. This infrastructure must also be patient-centric while integrating and engaging the patient or care giver in the process. The patient, physician, post-acute care providers and their personal support system are important participants in managing the readmission reduction process so they all must have the necessary information and communication capabilities at all times. Keeping patients, relatives, and care givers informed, educated, confident and comfortable with post discharge expectations, medications, therapies and treatments increases their compliance of the care plan, decreases urgent visits and reduces readmissions. This list also includes managing their chronic and complicating conditions, as well as, their immediate post discharge needs.

As you can see, there is no silver bullet to readmission reductions.  It takes the medical team, lead by the hospital; the patient and their support system; and technology to change outcomes and begin the road to accountable care across the continuum.

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