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

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

It’s been months since my last post.  I apologize for the delay, but I’ve been busy working as the Medical Director for an Accountable Care Organization (ACO) since August and think some of my experiences can offer some insights about new developments in our health care system –  insights that everyone can use.  In this post, I’ll give you a brief overview of Accountable Care Organizations.

CMS through regulations found in the Patient Protection and Accountable Care Act is encouraging the formation of ACOs to address some of the problems in our health care delivery system through innovation that moves us from a fee for service to fee for value.  Here’s the definition from the Centers for Medicare & Medicaid Services (CMS):

“ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.”

They are focused on achieving the Three-Part Aim of:

• Improving the experience of care
• Improving the health of populations
• Reducing per capita costs of healthcare

To make sure that quality is enhanced, ACOs must report 33 quality measures within the following 4 areas:

• Care coordination & patient safety
• Preventive health services
• Care for at-risk populations
• Patient & caregiver experience of care

In my next post I’ll talk about some of the opportunities for ACOs to improve how care is delivered for Medicare patients, many of which are applicable to the entire U.S. population.

For Your Health – Dr. Bob