Readmissions = Penalties
Has your hospital ever had a percentage of its Medicare payments withheld because of poor readmission rates? If so, you are not alone.
In 2014, the Centers for Medicare and Medicaid (CMS) determined the total cost of all readmissions exceeded $26 Billion. Seventeen Billion dollars, or 65% of this came from preventable readmissions. The Center for Healthcare Quality and Payment Reform states preventable readmissions are:
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Complications or infections arising directly from the initial hospital stay;
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Poorly managed transitions during discharge
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Recurrence of a chronic condition that led to the initial hospitalization
In 2015, CMS penalized a record 2,610 hospitals for readmission rate violations as defined by the Affordable Care Act. In Fiscal Year 2018, there were 2,573 hospitals penalized for $564M. Here is an interactive map made by advisory.com that shows how hospitals across the nation faired in regards to penalties levied in 2018. As you see, it is a very busy map.
The penalties come as reduced payments made to inpatient prospective payment system (IPPS) if there were an excessive amount of readmissions. The penalty is up to 3% of a hospital’s annual Medicare reimbursements. It may come as a surprise, but Kaiser Health News looked at CMS data and identified 1,621 hospitals being penalized 5 years in a row! The problem of readmissions needs a different approach since whatever hospitals are doing now is not working.
So, what’s a hospital to do?
“Reducing readmissions requires careful planning and communication among each of a patient’s providers and caregivers, as well as with community and social services and patients themselves.”
The Center for Health Information and Analysis (CHIA)
January 2015 report
No hospital likes readmissions, but they will never be eliminated completely — at least not with our current understanding of medicine and the technology available. However, there are some proven steps a hospital can use to identify, reduce and lower their readmission rates. Here are the four key elements to focus on.
IDENTIFY WHY PATIENTS ARE BEING READMITTED
Understanding why patients return to the hospital after being discharged is the first step in preventing future readmissions and improving the challenges of follow-up care.
Conditions Contributing To The Majority Readmission
According to The Healthcare Cost and Utilization Project the top ten causes for readmission to hospitals are:
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Congestive Heart Failure
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Schizophrenia/psychotic disorders
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Respiratory failure
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Alcohol-related disorders
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Deficiencies or other anemias
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Hypertension
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Diabetes
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Acute renal failure
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COPD
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Complication of device, graft or implant
Other Items To Address
Other important information to gather is a baseline of the current readmission rate by condition. Next, create SMART goals. Finally, confirm the patient’s social/support system prior to intake, or prior to discharge at . Being able to connect patients to support (in-house or community-based) is an important step to reducing readmissions.
“Are they really there for the hip fall? Are they are really there because they did fall and broke their hip or shoulder, or what’s really driving it? Is it anxiety, dementia, or depression?”
Bryan Cote
Managing Director at Berkeley Research Group.
Deloitte reported in 2017 that 88% of hospitals screen patients for these needs, but only 62% screen “systemically or consistently”.
How Telemedicine Fits In
Telemedicine will assist with this initial screening process by permitting staff to perform and complete required checks and ask patients and their caregivers specific questions before they make their way to the hospital.
OPTIMIZE THE TRANSITION OF CARE
Health Affairs estimated in 2011 that poor coordination of care, which includes sub-optimal care transition management, incurred $25B to $45B in unnecessary spending.
Transitioning Patients Must Improve
According to the June 2012 report, Transitions of Care: The need for a more effective approach to continuing patient care published by The Joint Commission, “problematic transitions occur from and to virtually every type of health care setting, but especially when patients leave the hospital to receive care in another setting or at home... hospitals must improve the effectiveness of transitions of care in which they play a role.”
Create A Transition Program Or Use A Current One
The Care Transitions Program, developed by Eric Coleman, MD, MPH, uses a nurse or nurse practitioner as a “transition coach”. This coach manages a patient’s post-discharge care and is usually the single point of care for patients. Telemedicine is the perfect platform to facilitate such a program. The protocol flow is:
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Transition coaches perform home visits within 72 hours of a patient’s discharge;
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Follow up via phone (a perfect fit for telemedicine) or home visits over the next four weeks;
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Help patients manage their medications;
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Schedule follow-up care;
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Recognize and respond to signs/symptoms of a worsening condition;
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Complete a personal health record.
The Pittsburgh Regional Health Initiative Readmission Reduction Guide: A Manual for Preventing Hospitalizations published in January 201, confirmed this. It states that phone calls (telemedicine fits here) are more effective after an initial home visit by a nurse care manager (or transition coach). This also gives the nurse care manager/transition coach the opportunity to show the patient how to start a telehealth visit and gives them an opportunity to evaluate the home environment.
How Telemedicine Improves Patient Transitioning
In the past, barriers like technology have prevented providers from sharing patient information among themselves and caregivers. Telemedicine can overcome many of these barriers and provide a healthcare delivery system that not only benefits the patient but also the discharging hospital.
The American Hospital Association released the report, Why Telehealth Is Critical to Health Care Transformation, and in it they identify three ways to optimize a hospital’s telemedicine platform. One of these ways is using the platform to organize care across multiple settings and specialties to track the health status of patients after discharge. Telemedicine also allows the team to remotely monitor their patient’s health at home. This creates better outcomes and lowers overall healthcare costs.
By using telemedicine as the main form of contact and examination, the coaches will manage their time more effectively between patients, and the physicians involved will be able to consult and see the patient if needed.
IMPROVE PATIENT ENGAGEMENT AND EDUCATION
In Volume 4, Issue 2 of the 2017 the Patient Experience Journal, reported that patients not involved in their own care during their discharge process were “34 percent more likely to experience a readmission”. It also reported that when patients stated they did not receive written instructions for care once discharged, they were 24% more at risk for readmission.
How Telemedicine Can Complement and Improve the Discharge Process
If you have ever been involved in a discharge from a hospital, you probably remember the anxiety you initially felt, and the anticipation and eagerness to leave the hospital and go home. It is easy for a person to forget what someone told them, or to lose paperwork, or come up with questions they could have asked prior to being discharged. Telemedicine allows a provider or coach to address effectively all these things.
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Cover the discharge instruction again;
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Send secure email instructions to those who say they did not receive written instructions;
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Verbally reiterate post-discharge instructions;
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Answer the inevitable questions that patients think of once they return home.
FOLLOW-UPS AND MONITORING
Telemedicine provides the means for follow-up appointments where the patient is most comfortable: their home. They will not have to travel back to the hospital or to the physician’s office where they are more likely to become a no-show, another contributing factor to increased readmission rates.
The platform also provides a way to address a patient’s concerns if they feel something is amiss. The provider can examine and reassure the patient and determine if they should go to the ER or schedule an immediate appointment.
Obviously, every situation is different, but by implementing the four proactive steps listed above and using telemedicine with them, readmission rates and healthcare costs will drop, outcomes and patient satisfaction will improve, and your bottom line will be healthier. If you already have a telemedicine platform integrated into your system and you are not utilizing it for discharge and post-surgical protocols, do yourself a favor and look into it. If you are considering a telemedicine platform for your hospital or healthcare system, 
paper for more information.
