Hospitals Look to Post-Discharge Clinics to Help Hold Down Readmissions
Medicare may penalize hospitals with higher than expected 30-day readmission rates for pneumonia, heart failure, heart
attack - see video
By Michelle Andrews, Insuring Your Health
See video below on the Revolving Door of Readmissions
Dec. 20, 2011 - For patients, the transition from hospital to home is a critical time. Discharged with follow-up
instructions and often a fistful of medications, many need medical guidance. But too often a smooth handoff to a primary-care physician
doesn't happen, and small recovery glitches become larger ones. The result: In short order the patient is often back in the hospital.
According to a
study released this month by the Center for Studying Health System Change, a
Washington-based research group, a third of adult patients discharged from a hospital don't see a physician within 30 days -- and experts say
this is a key reason so many of them are readmitted.
Some hospitals are trying a new strategy to interrupt this predictable and pricey pattern: post-discharge clinics. These
hospitals are identifying patients who are more likely to have trouble after discharge, either because of their medical conditions or because
they lack health insurance or a primary-care provider, and funneling them to the clinic where they receive one-on-one
assistance.
The Revolving Door Of Readmissions
Ralph Rust's decade-long struggle to stay out of
the hospital involves some of the factors that cause patients to be readmitted frequently -- poor diet, poor literacy and inability to
pay for medications. Rust, a Southeast Washington man who is covered by Medicaid, said that for years he was hospitalized as often as
three times a month at Howard University Hospital. When Rust was transferred to Washington Hospital Center in 2008 to get his
pacemaker replaced with a defibrillator, however, he had a change of heart about changing his habits to stay out of the hospital.
Deloris Eason, 64, was discharged from Boston's
Beth Israel Deaconess Medical Center earlier in December, after having been
treated for severe stomach cramps, diarrhea and vomiting. Clinicians weren't sure whether she had had a bad case of food poisoning or
colitis, an inflammation of the colon. Because her primary-care physician
couldn't see her until mid-January, hospital staff referred her to the post-discharge clinic.
By the time she came in four days after leaving the hospital, Eason was feeling better but was concerned because she
hadn't had a bowel movement since returning home. The practitioner at the clinic told her to give it another day and then take a laxative. If
that didn't work, she was instructed to come back.
"I had a chance to ask questions I didn't get to ask at the hospital," Eason says, "key questions that came up after I
got home."
The doctor also checked that she was following the diet she had been given and was taking her antibiotics, and made
follow-up appointments for her with a gastroenterologist and her primary-care provider.
The
clinic helps streamline the process of getting patients in to see their
primary-care physicians, says its medical director,
Lauren Doctoroff.
A typical patient visits Beth Israel's post-discharge clinic, located near the hospital, just once or twice. But
treatment may last longer at post-discharge clinics affiliated with safety-net hospitals that serve large numbers of low-income, uninsured and
other vulnerable patients.
"We're a bridge until we are guaranteed they are in . . . primary care," says Dean Watson, Tallahassee Memorial's chief
medical officer.
The center targets patients at high risk for readmission, including the uninsured, those who don't have a primary-care
physician or who can't get an appointment with their doctor within a week of discharge, and patients who have been admitted at least three
times in the past year.
Patients who are referred to the center work with clinicians to develop a plan for their ongoing care and receive
referrals to rehab or other medical services. The center's staff finds a primary-care provider for them if they need one and connect them with
social services for such needs as transportation, food and home care.
Since the center opened in February, more than 600 patients have visited it, says Watson, and emergency room visits and
hospital readmissions have decreased by 61 percent for these high-risk patients.
Hospital officials and policy experts agree that the impetus for the post-discharge clinics comes in part from new
penalties for certain hospital readmissions that will take effect starting in 2012. Under the 2010 federal health-care overhaul, hospitals
that have
higher than expected 30-day readmission rates for three conditions - pneumonia,
heart failure and heart attack -- may face Medicare payment penalties.
But some analysts question whether the clinics are an efficient solution.
"Creating a whole separate post-discharge follow-up clinic when you've got an outpatient network in existence could be
duplicative," says
Ann O'Malley, a senior researcher at the Center for Studying Health System
Change, the Washington-based research group that did the study that was released this month. "What we need is better support of the
primary-care infrastructure in the community."
Even with that, some patients are likely to fall through the cracks.
Barnes-Jewish Hospital, a safety-net hospital in St. Louis, opened a
post-discharge clinic about three months ago. Medicare-eligible patients with chronic obstructive pulmonary disease, pneumonia, heart attack
and heart failure are referred to the Stay Healthy Clinic for follow-up care.
But there's a hitch. Even though the hospital schedules the initial post-discharge appointments and offers to arrange a
ride for patients to the clinic, about half of them don't show up.
"We're trying to understand it," says
John Lynch, the hospital's chief medical officer. It's unclear, he says, whether
patients don't understand the importance of the appointments, for example, or feel better and don't think they need to come in. With roughly a
third of high-risk Medicare patients being readmitted within a week of discharge, it is critical to look for answers. "We'll continue to try
to tweak it," he says.
Some hospitals are trying a new strategy to interrupt this predictable and pricey pattern: post-discharge clinics. These
hospitals are identifying patients who are more likely to have trouble after discharge, either because of their medical conditions or because
they lack health insurance or a primary-care provider, and funneling them to the clinic where they receive one-on-one
Almost 7% of acute-care hospitals had higher-than-expected readmissions rates for heart failure, heart attack or
pneumonia