Health Law Forces
Changes to Reduce Hospital Readmissions of Medicare Patients
Experts say
problems might have been avoided with better handoff from hospital to
people responsible for next phase of patient's recovery
By Michelle
Andrews, Kaiser News Network
Feb. 23, 2011 -
"Welcome back" are two words you'd really rather not hear at a hospital,
especially if you've just been discharged. Yet, one in five Medicare
patients primarily senior citizens - found themselves back in the
hospital within 30 days of leaving it in 2003 and 2004, according to a
recent
study in the New England Journal of Medicine. Even more troubling is
the possibility that three-quarters of those readmissions might have
been
prevented, as estimated in a 2007 report by the Medicare Payment
Advisory Commission (MedPAC), an independent agency that advises
Congress.
What gives? All
too often, experts, say, the problems that send patients back to the
hospital might have been avoided if there had been a better handoff from
the hospital to the people responsible for the next phase in a patient's
recovery, whether it's the patient himself and his family, a home health
agency, a nursing home or a hospice.
"We don't do a
good job of coordinating care," says Patricia Rutherford, vice president
at the Institute for Healthcare Improvement, which is directing a
multi-state
initiative to reduce rehospitalizations.
Discharged
patients may be confused about their new medication regimen, for
example, or they may not understand diet restrictions. Maybe they don't
have transportation to a follow-up appointment; worse, they may not have
an appointment scheduled at all. In fact, the New England Journal of
Medicine study found that half of patients who were readmitted within 30
days hadn't visited a doctor since their discharge.
"For very sick
patients being discharged by hospitals, we think that's way too late,"
says Rutherford.
Hospital
readmissions aren't only bad for patients' health, they're expensive.
MedPAC estimated that in 2005 readmissions cost the Medicare program $15
billion, $12 billion of which could have been avoided.
The health-care
overhaul takes aim at the problem by penalizing hospitals with
higher-than-expected readmission rates for Medicare patients who had
been treated for heart failure, heart attack or pneumonia. Those
hospitals could see their Medicare payments reduced by up to 1 percent
beginning in October 2012, 2 percent the following year and 3 percent
the next. The law expands in later years the list of conditions that can
result in penalties.
The Department
of Health and Human Services allows consumers to make side-by-side
comparisons of hospitals readmission rates for heart failure, heart
attack and pneumonia at
hospitalcompare.hhs.gov.
"There's a very
strong case to be made that if you want to change something as important
as readmission, you've got to look at every lever you've got," says
Stephen Jencks, a physician and lead author of the NEJM study. "Payment
is a very important one, but by no means the only one."
A growing number
of hospitals and health systems are already working on the readmissions
problem with support from nonprofit groups and foundations.
Piedmont
Hospital in Atlanta is one. A few years ago, it began participating in
Project Boost, a discharge-transition program developed by the
Society of Hospital Medicine.
Through Boost,
Piedmont proactively targets patients who are at high-risk of
readmission. Staff members use a checklist to ensure that potential
logistical and psychosocial problems are addressed before the patient
leaves the hospital. Another priority: scheduling patients before
discharge for their first follow-up visit to the doctor.
Patients also
receive a form to take home that explains in simple terms why they were
in the hospital; what they need to do to continue their recovery,
including medications, diet restrictions and warning signs of trouble;
and whom to call if they experience problems. Within three days of
discharge, a nurse calls to check on them.
"It's more work,
it takes more time and there's more confusion" until the new processes
are in place, says Matthew Schreiber, chief medical officer for the
480-bed hospital. But the effort has paid off. Thirty-day readmission
rates for patients under age 70 have declined from 13 percent to just
under 4 percent since the program began; rates for those 70 and older
have dropped from 16 percent to 11 percent.
A Project Boost
phone call may have helped Bill Cox avoid a hospital readmission. Among
many medical problems, the 58-year-old recently had femoral bypass
surgery at Piedmont to reroute blood from the large artery in his leg to
avoid a blockage there. After Cox returned home, a nurse practitioner
from the hospital called to check on how he was doing. One of the
questions she asked his wife, Rhonda, was whether he had had a blood
test to see if his dose of Coumadin, a blood thinner, was the correct
one. Coumadin can cause fatal bleeding, and patients who are on it must
have their blood tested regularly. He hadn't done so, so the nurse
practitioner asked the local home health agency helping the couple to
arrange for the test.
As it turned
out, the dose needed adjustment. "His blood was too thin," says Rhonda
Cox. "It was just like water."
