By Traci Haynes
Reducing hospital readmissions has been a focus of the healthcare environment for many years. Steven Jencks, MD, dubbed by many as the father of readmission research, along with Mark Williams, MD, and Eric Coleman, MD, analyzed medical claims data from 2003–2004 to describe the patterns of rehospitalization.
Readmissions Rates
Almost one-fifth (19.6 percent) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within thirty days. In 2007 the Medicare Payment Advisory Commission (MedPAC) reported to Congress that 13 percent of patients rehospitalized within thirty days of discharge in 2005 were for preventable reasons. These readmissions accounted for $12 billion in Medicare spending.
As a result, the Patient Protection and Affordable Care Act (PPACA) of 2010 mandated that the Centers for Medicare and Medicaid Services (CMS) implement a program in which hospitals with higher-than-expected readmission rates for certain designated conditions experience reductions (that is, penalties) in their Medicare payments.
Beginning in October 2012, the hospital readmission reduction program (HRRP) began adjusting hospital payments based on excess readmissions within thirty days of Medicare patients following myocardial infarction (MI), heart failure (HF), and pneumonia hospitalizations. The maximum penalty at that time was 1 percent of a hospital’s base Medicare reimbursement rate per discharged patient.
A year later the penalty increased to 2 percent and then to 3 percent in 2014. The first year more than 2,200 hospitals received penalties for failing to meet standards, with 8 percent incurring the maximum penalty. In addition readmission penalties now include elective knee and hip replacements and chronic obstructive pulmonary disease (COPD).
Reasons for Readmission
According to Bisognano and Boutwell, the primary reasons for readmission were no physician follow-up visit, medication discrepancies, and communication failure during transitions of care.
Coleman and others identified poor information transfer, poor patient and caregiver preparation, and limited empowerment to assert preferences as the primary reasons for readmission. Contributing factors include nurses not having time to thoroughly address the needs of both the patients and caregivers upon discharge, the hospital setting not being conducive to education to drive behavior change before discharge, and the care continuum breakdown between hospital discharge and the handoff to primary care.
The impact of the penalties has been a significant concern for hospitals that care for a larger number of low-income patients. They claim it is more difficult for their patients to adhere to post-hospital instructions, including payment for medications, dietary modifications, and transportation to follow-up appointments.
To address these challenges, some hospitals have implemented measures including discharging patients with medications, home visits, and follow-up calls. Other interventions include hiring specialty care coordinators and transition coaches to offer follow-up care for patients with multiple comorbidities, providing patients with extensive teach-back for multiple days prior to discharge so they’ll better know what to do after discharge. In addition many include comprehensive medication reviews with a clinical pharmacist.
Call Centers Help Reduce Readmissions
The healthcare call center can help reduce avoidable readmissions by enhancing the quality of care in the hospital-to-home transition through the combined capabilities of technology and human interaction. Discharge planning should begin upon admission to the hospital. This includes arranging for durable medical equipment (DME), transfer to step-down as appropriate, home healthcare, transportation needs, and communication with primary care providers (PCPs). Discussions with caregivers, the extended care team (which includes the PCP, caregivers, and pharmacist), and other members of the interdisciplinary team can be greatly improved by the services of the call center in helping to comprehensively coordinate the patient’s care.
The patient and their caregivers will also benefit from the reinforcement of information provided, teach-back, appointment reminders, and coordination of services including transportation, as well as medication reconciliation and symptom assessment resulting in earlier interventions and improved outcomes. Extending contact beyond the thirty-day penalty period will bring even greater benefits to patients and their caregivers, which may prolong readmissions indefinitely.
Some healthcare call centers make one post-discharge call to review the patient’s diagnosis, instructions, medications, and education materials. They also ensure that the patient has scheduled their follow-up appointment. Others make several outbound calls to the discharged patient including a call within the first twenty-four to forty-eight hours.
In addition, the call center staff or care coordinator may reach out to the patient again after their first appointment. Ideally this should occur within seven days post-discharge. This call typically reviews follow-up appointment instructions or changes in medications, assists in referrals and scheduling with additional providers or resources, and communicates to the interdisciplinary team as appropriate. During this contact, biometric monitoring may also be tracked through technology or as self-reported by patients or their caregivers.
Whatever level of service provided, it’s a win for the patients, their caregivers, and the healthcare organization. Utilizing the call center to identify and implement communication strategies that effectively engage the patient and their caregivers adds value to the organization and the opportunity of better outcomes for their patients.
Traci Haynes, MSN, RN, BA, CEN, is the director of clinical services at LVM Systems, Inc.
References:
- Bisognano, M., Boutwell, A. (2009). Improving Transition to Reduce Readmissions. Frontiers of Health Services Management 25(3), 3-10.
- Coleman, E.A., Parry, C., Chalmers, S., & Sung-joon, M. (2006). Care Transitions Intervention. Arch Intern Medicine 166(17) 1822-1828.
Jencks, S.F., Williams, M.V., & Coleman, E.A. (2011). “Rehospitalization Among Patients in the Medicare Fee-For-Service Program,” New England Journal of Medicine 364:1582.