Hospital readmission prevention programs, such as the one my Accountable Care Organization (ACO) conducts, try to make sure the patient coming home from the hospital fully understands their discharge instructions and removes any roadblocks that would prevent the patient from following those instructions.

With our program one of our nurse Care Coordinators contacts the patient within two days of discharge from the hospital.  They make sure the patient sets up an appointment to see their physician within 1-2 weeks and, most importantly, review the Discharge Instructions the patient was given upon discharge from the hospital.  Basically, there are 4 areas that are covered:

• New Or Worsening Symptoms (NOWS) – The Care Coordinator  asks the patient how they are doing to determine whether they may be feeling worse than when they were in the hospital, either due to worsening of known symptoms or the development of new ones.  In my experience, it never ceases to amaze me how often patients minimize such worsening in their condition and delay contacting their physician.  Directly asking about NOWS helps identify their occurrence and teaches the patient their importance and the need to inform their doctor immediately when they are present.
• Medication Reconciliation – Have there been changes made to the medications the patient was taking before entering the hospital?  The Discharge Instructions that the patient was given before discharge include a list of the medications they should take, but often questions arise once the patient is home.  The Care Coordinator   goes over the discharge medicines with the patient and compares those to the ones the patient was taking before.
• Appointment Adherence – Has the patient made follow-up appointments that have been recommended so they continue to recover?  These could be with specialists seen in the hospital as well as the primary care physician.  In addition, certain testing may have been recommended as well.  These are usually specified in the Discharge Instructions, too.
• Self-Management – Are there things the patient was instructed to do to help their recovery?  If they had surgery, how do they manage the dressings of the surgical site?  If they are a diabetic, do they need to check their blood sugars more frequently than before the hospitalization?  What about their activity level and diet?

In each of these areas, the Care Coordinator makes sure that the patient knows what to do and has no obstacles to carrying out their discharge instructions.  Each day our 22 Care Coordinators reach out to dozens of Medicare beneficiaries who have been discharged from the hospital and, thanks to their efforts, miscommunications are corrected and problems solved on a daily basis to help these patients complete their recuperation at home.

For Your Health – Dr. Bob

So how can a hospital readmission prevention program actually work?  Over the next few posts I’ll look at each of the three components.  In this one I’ll cover Patient Identification & Prioritization.

It’s important to identify patients as close to the time of their discharge from the hospital as possible.  When a physician cares for his patients in the hospital, he clearly knows the discharge date so he can communicate it to the Readmission Prevention Program.  But it has become more and more common that the primary care physician does not see his patient in the hospital when they have been admitted.  In his place, a hospitalist does the inpatient management.  In this situation, how do the physician and Readmission Prevention Program learn about the patient’s hospitalization and discharge?

• The hospitalist could call or e-mail them, but that’s not very efficient.
• Sometimes health insurance companies have Readmission Prevention programs for non-Medicare patients.  They may have a staff person at the leading hospitals to identify patients that are being discharged.
• Alternatively, the health plan may call discharge planners at the hospitals to learn about their health plan members who have been discharged.
• In more and more locations, Health Information Networks (HIN) are being set up to enable one health care provider to share information with another. The patient needs to authorize the HIN to share their information with the health care providers that care for the patient.   But once that’s done, the hospital’s information can be passed to the PCP’s office and the Readmission Prevention Program.
• In our ACO, one of our hospitalists has developed a hand held application that automatically sends e-mails to the PCP and the Care Coordinator with the Readmission Prevention Program when the hospitalist sends a patient home.

As far as Patient Prioritization or Stratification, some of these Readmission Prevention Programs use clinical criteria, such as the reasons for the hospitalization to determine which patients should be contacted after hospital discharge.  Sometimes a scoring system is used, but that depends on someone at the hospital scoring the patient and that score getting transmitted to the Readmission Prevention Program.  A very popular readmission risk scoring tool is the LACE Tool which calculates a score based upon,

• Length of stay – how long the patient was in the hospital.
• Acuity – whether the patient was a hospital inpatient or not.
• Co-morbidities – how many other diseases the patient has.
• Emergency room visits – the number of these visits in the past 6 months.

A score over 10 indicates that the patient has a high likelihood of readmission and should be contacted promptly after he is sent home.

In the next post I’ll talk about what is covered in the Outreach component of these Readmission Prevention Programs.

For Your Health – Dr. Bob

So picking up from my last post, it seems like decreasing hospital readmissions is an opportunity perfect for the ACO.  Quality can be improved and unnecessary costs lowered.  Everyone would benefit.  You might think that the only possible exception would be the hospitals since decreasing readmissions would decrease their revenue.  Until recently that was the case.  But one of the provisions of the Accountable Care Act has established a financial penalty for hospitals whose readmission rates for Medicare patients with heart failure, heart attack or pneumonia exceeded the national average in the past.  The penalties began in October of 2012 and can decrease a hospital’s reimbursement from Medicare by up to 1% of its charges during 2013.  It is estimated that the penalties will amount to $250 million dollars in 2013.  The maximum percentage penalty will increase to 2% and then 3% in the next two years for hospitals that don’t lower their rate.  So hospitals now also have a strong reason to support programs designed to prevent readmissions.

 Preventing Readmissions

No matter who manages it, a program to prevent readmissions must have some basic components:

• Patient identification – It is critical that the team responsible for the program gets notification of the patient’s discharge as promptly as possible.
• Patient prioritization (if possible) – This can help the team focus on the patients more likely to be readmitted.
• Patient outreach to
  • Schedule an office visit with the patient’s physician to check on their progress.  The patient is also told what symptoms should cause them to contact the physician immediately and not wait until the scheduled appointment since deterioration can sometimes occur very rapidly.
  • Assess needs and make sure components of the discharge plan are being implemented as intended.
  • Medication reconciliation to make sure the patient is taking the right medications.  This includes addressing any problems the patient may have in obtaining the medications.

Who Should Run A Readmission Avoidance Program?

While a hospital can run such a program, they will have to make sure they have adequate staff to manage the care coordination pieces.  Integration with the patient’s physician can also be a problem.  However, a common part of most ACOs is a team of clinical staff, usually nurses, who work with the patients’ physicians to coordinate their care.  This team is focused on the needs of the physicians’ patients so it is natural for them to play the role of reaching out to the discharged patient to assess and address their needs.  So, an ACO seems to have an advantage in conducting a readmission avoidance program.  Their only critical need is getting real-time notification of the patient’s discharge.  Thanks to the recent Medicare penalties for readmissions, hospitals have an incentive to get the ACO prompt discharge information so the ACO can reach out to the patient.

In the next post I’ll provide more details about how these program components can be put into operation in different communities.

For Your Health – Dr. Bob

After reading my last post on ACOs you may be wondering how an ACO consisting of primary care physicians can hope to save money on the costs of the Medicare patients attributed to them when so much of the care is beyond their control.  After all, the beneficiary can see any specialist they choose, and many hospitalizations can take place without the PCP’s knowledge.  That’s true, so there may always be components of a person’s care that cannot be well-coordinated, but there are still a lot of opportunities that an ACO can address if they are willing to invest in the system changes that are necessary.

I’d like to spend the rest of this post explaining why focusing on the transitions of care that a patient goes through is a prime target of most ACOs.  When I use the term “transition” it applies to any change of care setting for a patient.  It includes going from their home into a hospital, from a hospital to a rehabilitation hospital or from the hospital back to their home.  At each of these transitions there needs to be a communication of all elements of the care the patient has been receiving and what needs to continue or be changed going forward.  This is especially critical for a patient with multiple chronic medical problems such as high blood pressure or diabetes.  Probably the time when most miscommunications take place is when a patient is discharged from the hospital to their home.

Transitions of Care – Hospital Discharge

When a patient is discharged from an acute care hospital after being treated for something like severe pneumonia or a heart attack, someone from the clinical staff gives them a written copy of discharge instructions and discusses those instructions with them to make sure the patient understands them.  Unfortunately, what was often clear in the hospital isn’t so clear at home.  Lack of clarity around discharge instructions can lead to complications, reversal of the improvement that began in the hospital and hospital readmission.  There are studies that find that about 50% of these readmissions can be prevented.

Size of the Opportunity

Medicare estimates that 20% of patients discharged from a hospital are readmitted within 30 days.  One example of the financial consequences can be found in data for Knoxville, TN published by Qsource, a Quality Improvement Organization (QIO).  They found that in 2009 14% of the approximately 188,000 Medicare beneficiaries in Knoxville were hospitalized.  Consistent with Medicare’s national findings, 20% of those individuals had one or more readmission which cost $57 million and the 241 beneficiaries who had 4 or more readmissions had costs totaling $10 million.  Not every readmission is preventable, but when you look at the issues that lead to many of them, there are clear opportunities to improve the quality of care and prevent unnecessary and costly readmissions.  The challenge is to identify those whose readmission can be prevented and deliver the needed information and services to keep them healthy.

In the next post I’ll discuss some new regulations from Medicare that focus on the readmission issue and other strategies that can be used by ACOs.

For Your Health – Dr. Bob

In my last post I gave an overview of what Accountable Care Organizations (ACOs) are.  Before I start to explain the care coordination strategies they commonly use,  I’d like to go a little deeper into how an ACO has patients (Medicare beneficiaries) attributed to it and where savings can be found while maintaining quality.

Beneficiary Attribution

Let’s consider an ACO formed by a primary care medical group.  These physicians practice primary care and would include family practitioners, internists and, since the patients we’ll talk about are Medicare beneficiaries, geriatricians.  Medicare would look at all the claims for services of any patient the medical group took care of within the past several years (usually 3).  Medicare determines from which physician the patient got most of their primary care services & attributes that patient to that physician.  A key point to remember is that even though a Medicare beneficiary is attributed to a specific primary care physician, the patient can see any physician they want.  The patient is not a “member” of the ACO.  However, since that patient is attributed to the ACO, all their health care services become the responsibility of the ACO to coordinate.  The patient has all the freedom to go to any physician in the country who accepts Medicare for their health care needs.  They are still regarded as being in the traditional Medicare program.

Cost Benchmark

Once Medicare has attributed their patients to the ACO, it calculates a cost benchmark that will serve as the target for the ACO.  The benchmark is derived by a formula that looks at the previous three years of costs for the attributed beneficiaries and is adjusted for inflation.  If the ACO is able to provide quality care as measured by 33 quality measures and keep costs under the benchmark they will share in a portion of the savings with Medicare.  For most ACOs there is no penalty if costs are over the benchmark.  The ACO is not responsible for paying the care providers.  Medicare still does that.  Remember, the costs are all the costs (except Part D drug costs) for the attributed beneficiaries, including hospitalizations, tests, surgical procedures and physician charges.

Cost Reduction Opportunities

So where will the savings come from?  There are several main areas – areas that won’t compromise quality, but rather increase it.  Our system of health care delivery is hardly an efficient one.  Important clinical information is often not transmitted promptly to the next person involved in a person’s care.  Consequently, tests are often repeated unnecessarily.  More importantly misunderstandings and miscommunications can result in complications and poor clinical results that require more services which just add to the costs.

In my next post I’ll talk about the opportunity surrounding hospital discharges as an example of how care coordination can improve quality and lower costs.

For Your Health – Dr. Bob