In this two-part blog, Director Wanda Pell of Novia Strategies shares six strategies to reduce readmissions. Her first blog introduces the burning need to reduce readmissions.
The need to manage readmissions continues to feature highly on C-Suite priorities. CFO’s are concerned with the loss of income, CEO’s with the public disclosure, and CNO’s with the implication on quality of care. With Medicare Spending Per Beneficiary (MSPB) extending the readmission period to as long as 90 days post-discharge, hospitals need to consider more comprehensive strategies to reduce readmissions. This long timeframe is particularly difficult for hospitals to manage. Studies show that at this time, hospitals are only able to effect the first 7 days after discharge. Expanding to 90 days out requires very significant changes in our approaches to patients.
Here, we discuss six trends we’re seeing our clients adopt in their efforts to manage particular patient populations and reduce the number of readmissions.
1. Engage early
Prior to CJR, (Comprehensive Care for Joint Replacement), many hospitals had programs often known as Joint Camp. Patients who were enrolled in Joint Camps came to the hospital prior to admission for a program that lasted from 2-4 hours. All patients were scheduled to undergo either a Total Knee or Total Hip Replacement. In addition to pre-operative testing, patients were provided detailed information about their surgery, anesthesia, the inpatient experience and their post-operative care. They had the opportunity to select their post-acute care providers. They often watched videos that explained in detail what was going to happen every step of the way. Today, some surgeons provide daily newsletters postoperatively that outlines the day ahead and expectations. Often these patients attend rehabilitation therapy together and serve as a support group. While this concept has taken off for joint patients, there is reason to believe that the same will happen with patients having a CABG (Coronary Artery Bypass Graft).
One trend is the use of transition coaches or patient navigators. This person is a higher-level clinician available to the patient and family with the knowledge and skills to manage the patient’s care throughout the episode. This navigator takes care management outside the hospital, coordinating the patient’s care prior to admission, within the acute care setting, and post-discharge for 30 to 90 days. This approach ensures patients are ready for surgery, transition appropriately from one level of care to the next in a timely manner, receive appropriate discharge planning to the least restrictive environment, and are followed after discharge to minimize readmission.
Another concept that is experiencing growth is that of Prehab. Prehab is the process of getting a patient in the optimal physical condition pre-operatively so that the chances of post-operative complications are minimized. It may include physical therapy and exercises, or nutrition therapy to lose weight, or maintaining a healthy life style to reduce medications for chronic diseases. The concept is to mitigate any complicating conditions and put the patient in the best physical shape possible prior to surgery. This concept along with the camp programs will reduce the chances of readmission.
2. Focus proactively on patients and caregivers
Nurses, care managers and others involved in caring for patients have taken the adage “discharge planning starts at admission” to heart. We have seen staff work to streamline the discharge instruction process and simplify documentation so that directions are in layman terms and in a font that is legible. Patient education occurs throughout the stay rather than the last day. Discharge instructions may be recorded so that they can replayed at home and heard by all caregivers. Teaching materials and instructions have been translated into multiple languages to meet the needs of the patient and family.
The focus of all of these activities is patient-centric. By keeping the patient front and center in all education the caregivers can provide instruction and have the patient and caregivers demonstrate their understanding of the instructions. This serves to ensure that they understand post-acute care processes and related expectations. For example, CABG patients often have anxiety, don’t know what to expect during their recovery, and often return to their physician or the hospital with symptoms that are just normal healing. Addressing this during the discharge process can reassure CABG patients and minimize trips to the Emergency Department and potentially readmissions
The trend for early discharge is no longer the focus that it once was. Physicians and the care team are often looking at an additional day stay that in the long run may prevent a readmission, or allow the patient to return home rather than admission to a post-acute facility. We are particularly seeing this thought process with the advent of the bundled care programs and the focus on Medicare Spending Per Beneficiary (MSPB).
3. Identify patients at risk for readmission
A variety of tools have been developed to identify patients who are at risk for readmission and many hospitals use them. While some are simple point systems, others are complex and may include predictive analytics. There are similarities in outcomes from these tools. Studies have shown that patients who live alone are more likely to be readmitted, as are those with cancer, mental illnesses and polypharmacy. Multiple ED visits or hospital admissions are often a trigger as well. These tools give the hospital a chance to provide the extra attention required with these patients and caregivers to try and anticipate potential issues and find remedies proactively.
During a recent conversation with an Internal Medicine physician, he indicated that he could often pick patients who would be readmitted within 7-10 days. His premise was that first time Skilled Nursing Facility (SNF) patients are at risk. The nursing home staff members don’t know the patient, or their family. As a result, if something appears to be “not right” they are quicker to send that patient to the ED than a patient with a history in the facility. This brings us to our next point.
4. Partner with post-acute providers
Partnerships with post-acute providers have taken on a variety of areas of focus. Hospitals have provided education to SNF staff on care for particular patient populations in order to make the staff more comfortable with their clinical skills in accepting and caring for these patients. Examples include patients who are discharged with everything from Wound Vac Machines to Ventricular Assist Devices (VADs), which are often very hard to place in a post-acute environment. In addition, they have worked together to create care plans that transcend the continuum into the SNF stay, giving care teams a better idea of what to expect in providing care and appropriate outcomes. These care plans outline in detail what should happen each day the patient spends in the SNF and outlines milestones for discharge. In addition, hospital staff may make themselves available to answer questions from the SNF team. This type of relationship has proliferated with the implementation of the Comprehensive Care for Joint Replacement (CJR) model (a.k.a. Bundled Payment System). With these models, there is a set reimbursement for the entire patient episode of care (acute and sub-acute) regardless of environment. Therefore, it makes sense for the hospital to work with the SNF to have a smooth hand-off and require the minimal amount of time before movement to the next level (home, or home with home health).
As you might expect, hospitals cannot have this type of intense relationship with every SNF or post-acute provider in their area. The next challenge is informing patients about these preferred provider networks while maintaining patient choice. Many Care Management departments believe that they cannot present anything more than a list of local providers for patient choice. Medicare patient choice, a Condition of Participation requirement, prevents hospitals from making choices on behalf of the patient. That doesn’t mean that Care Managers cannot inform patients about the clinical quality of their post-acute options. In fact, the CJR final rule specifically notes that although hospitals cannot restrict patient choice, they can make recommendations. This allows patients and families to understand the continuity of care available and may help relieve some of the anxiety surrounding hospital discharge.
5. Track patients post transition
Healthcare literature is filled with different approaches to follow patients after they leave the hospital. Studies show that patients experience better results with follow-up in the first 48 hours. Statistics show that the average time to get a PCP (Primary Care Provider) appointment is 19 days. This leaves a gap to be filled by other clinicians and approaches. Strategies include phone calls, house calls, and home visits. Hospitals may utilize RNs, Pharmacists, Social Workers, Clinical Nurse Specialists or Nurse Practitioners for these services. A few hospitals have recognized that medication administration (medications, dosage and frequency) can be one of the largest issues encountered by the patient population. As a result, pharmacists make the initial post-acute call and transfer over to a nurse if other questions arise. There are outsource firms who will track patients using a call center staffed with RNs. Typically, these services are targeted only at those patient populations at risk for readmission penalties and may follow the patient for up to 30 days.
Other transitional care practices utilize physician extenders or physicians to provide bridge services to the patient. With the advent of care coordination Evaluation & Management (E&M) CPT codes, and resulting Medicare reimbursement, many businesses have been established to focus on the transition of the patient from the hospital to the Primary Care Physician. These businesses partner with primary care physicians and have a similar goal as hospitals to prevent readmissions and provide transitional care.
All of these approaches focus on ensuring that patients have made, and keep, their physician appointments, follow their new medication regime and understand discharge instructions. One of the values of home visits is an opportunity to see the living environment and understand any restrictions that may be present (e.g., no refrigerator for insulin, no bathroom scales for daily weights, multiple steps for getting in and out of their home). These professionals are then able to help problem solve and arrange for the needed resources. Some patients are reluctant to have strangers in their homes and will refuse these services, making phone calls an alternative. Some communities throughout the country have partnered with city or county First Responders to check on patients at regular intervals. The result is that we must look outside the walls of the hospital to identify community partners that will assist in helping the patient to maintain their health.
6. Manage ED patients aggressively
Over the years many hospitals have embraced the trend to place care managers in their EDs to ensure that patients are admitted in the correct status (i.e., inpatient, observation). Social Workers may also work in the ED to assist patients and families through traumatic circumstances and may be more warranted to add to staffing in lower socioeconomic areas.
The newer trend is placement of care managers and social workers in the ED to help defer admissions and readmissions. A secondary goal may be to reduce recidivism in the ED. These staff members work with patients to identify community services, home health agencies and other providers that are available to provide needed services (e.g., food, medications, shelter). They work with patients and families with a recent hospital admission, within 30 days and covering a 3-night stay, for direct SNF placement bypassing the hospital. They may also work directly with SNFs when they send patients to the ED to return them with follow-up instructions and directions for care, preventing a hospital admission. Finally, some hospitals are exploring the role of an SNFist, a hospitalist or advanced practice provider specializing in skilled nursing, to follow up with these patients after discharge, or an ED visit.
Hospitals must look at their patient populations to determine which of these steps will work best for them. No single approach will solve the readmission dilemma. Helping patients to understand their disease process and how to manage for maximal benefit will go a long way. In the end, true communication and solid hand-offs are key.
By Wanda Pell, Director, Novia Strategies