Medicare may penalize hospitals that readmit too many patientsPublished 3 weeks ago

It’s
a return trip nobody wants to take: You are discharged from the
hospital, only to find yourself readmitted  a few days later. 

More and more people are finding themselves in this revolving door — at a cost to both hospitals and patients. A 2009 study in the New England Journal of Medicine showed
that one in five Medicare patients discharged from the hospital had to
be readmitted within 30 days; 34 percent were back within 90 days. Those
return trips cost the health-care system more than $17 billion over one
year.

Readmission rates have increasingly become a measure of a
hospital’s quality of care. As part of the Affordable Care Act, Medicare
is planning to tie payment to readmission statistics, even penalizing
hospitals for readmissions deemed avoidable.

With that punishment
looming, hospitals and health policy experts are trying to figure out
why so many patients are making round trips.

Are patients simply
being let go too soon? While some patients may be let go before they are
“completely and totally recovered,” says Carolyn Clancy, director of
the Agency for Healthcare Research and Quality (AHRQ), the issue is far
more complex than that. Sometimes, infections develop. In other cases,
there is unexplained bleeding. Medication errors are a big factor, too.
Often a patient isn’t able to get an appointment with a primary-care
doctor or the patient simply feels that something isn’t right and
doesn’t know where else to turn.

Researchers looking at this trend are discovering that breakdowns
occur on multiple levels. The most critical failure seems to be in the
discharge process, when the hospital should be preparing a patient for
release. Instead, says Brian Jack, a family physician at Boston
University Medical Center, the process is often a “perfect storm” of
errors that begin even before a departing patient has reached the
parking lot.

Many patients leave the hospital without
understanding much about their diagnosis or how to handle their
condition at home, including what medications to take, says Clancy.

Poor
coordination of care and poor transitions in a fragmented system is how
Jesse Pines, director of the Center for Health Care Quality at the
George Washington University School of Public Health and Health Services
describes it.

Proper post-hospital care involves many
complicated steps. There are medication routines,  follow-up sessions
with doctors or physical therapists, adjustments to diet and lifestyle,
even knowing what number to call if there’s a problem or a question. It
can be very difficult to manage all this, especially if a patient has no
caregiver at home or is in a weakened state upon release.

Many
hospitals put instructions in writing, handing departing patients a
“discharge summary” of steps they need to follow at home. But that
summary can be difficult to read or understand; often it is handwritten
and filled with jargon. And putting a discharge summary together is not
always a doctor’s highest priority. The task often falls to others —
nurses or medical residents — who rarely have the time to make sure the
patients understand the plan for follow-up care.

Jack and his
colleagues designed an approach that aims to streamline the process. It
relies on checklists for the staff to make sure that nothing is missed,
and it assigns a staff person called a discharge advocate to coordinate
post-hospital care and follow up with patients after discharge.

Of course, this process can be quite time-consuming. This is why
Jack and his colleague Timothy Bickmore of Northeastern University have
enlisted “Louise,” an avatar, or virtual discharge advocate. She appears
on a computer-like screen that is rolled up to patients’ hospital beds
to walk them through the discharge process.

Louise can spend 40
minutes or more with every departing patient. She is never distracted
and can create well-targeted discharge summaries using information about
each patient. Louise can communicate using synthetic speech and through
a touch-screen display. And patients actually like her, says Clancy,
“some . . . better than real, live nurses.”

Louise is part of a program called Project RED, for “Re-Engineered Discharge,” which has shown a 30 percent reduction in readmission rates in clinical trials, according to Jack. Similar initiatives are being tested in hospitals around the country.

There is some urgency for hospitals to start to take matters into their
hands, says Pines, because Medicare penalties are set to kick in soon,
and avoiding readmissions “will become a real economic incentive.”
Initially, performance evaluation will be focused on readmissions
related to three major conditions: heart failure, heart attack and
pneumonia.

Hospitals cannot reduce readmission rates on their own. Success
will depend on a coordinated approach involving primary-care doctors,
pharmacists, an improved system of electronic health records and,
perhaps most important, patients themselves. There are several simple
but vital steps that patients should follow before and after leaving the hospital:

 

●Make sure you understand your diagnosis, and what was done to you.

●Know whom to follow up with (physical therapist, your regular doctor,

a nurse, etc.).

●Schedule a follow-up appointment with your regular doctor before leaving the

hospital; make sure to see him or her soon after discharge.

●Ask your hospital doctor to communicate with your regular doctor.

●Go over every medication on your discharge list
with your doctor or nurse. Compare those drugs with medications you
were taking before you entered the hospital to ensure there are no
duplications or dangerous interactions. 

●Get contact information for any questions or problems you might have after discharge.

●Ask about what to expect during your recovery and what symptoms to look for should something go wrong.

●If some test results are pending, make sure you know how to obtain the results.

●Before you sign your discharge summary, make sure you understand everything. Ask someone — a nurse, a doctor, a social worker — to explain it to you.

●Bring a copy of your discharge summary to your follow-up appointment.

 

All
of this increases the odds that, when you leave the hospital after
surgery or illness, you won’t be coming back again soon. The health-care
system will save money, and you’ll be able to undertake your recovery,
in your own bed, at home. And who wouldn’t prefer that?

Mishori is a family physician and faculty member in the
Department of Family Medicine at Georgetown University School of
Medicine.