By Traci Haynes MSN, RN, BA, CEN
Reducing hospital readmissions has been a focus of the healthcare environment for many years. Steven Jencks MD, dubbed by many as the father of readmission research, along with Mark Williams MD and Eric Coleman MD, analyzed medical claims data from 2003-2004 to describe the patterns of rehospitalization and its relationship to demographic characteristics of hospitals.
They learned that almost one-fifth (19.6 percent) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within thirty days. They also found that 34.0 percent were rehospitalized within ninety days; and that 67.1 percent of patients who had been discharged with medical conditions and 51.5 percent of those discharged after a surgical procedure were rehospitalized or died within the first year after discharge.
Furthermore, of the 50.2 percent of patients rehospitalized within thirty days post medical discharge to the community, there was no bill for a visit to a physician’s office between the time of discharge and rehospitalization. Additionally the average length of stay (LOS) of rehospitalized patients was 0.6 days longer than that of patients in the same DRG (diagnosis-related group) whose most recent hospitalization had been at least six months prior. The cost to Medicare for rehospitalizations in 2004 was $17.4 billion (Jencks, S.F., Williams, M.V. & Coleman, E.A., 2011).
In 2007, the Medicare Payment Advisory Commission (MedPAC) reported to congress that 13 percent of patients rehospitalized within thirty days of discharge in 2005 were for reasons potentially preventable. These readmissions accounted for $12 billion in Medicare spending.
As a result, the Patient Protection and Affordable Care Act (PPACA) of 2010 mandated that the Centers for Medicare and Medicaid Services (CMS) implement a program in which hospitals with higher-than-expected readmission rates for certain designated conditions experience reductions (penalties) in their Medicare payments. Beginning in October, 2012, the hospital readmission reduction program (HRRP) began adjusting hospital payments based on excess readmissions within thirty days of Medicare patients following myocardial infarction (MI), heart failure (HF), and pneumonia hospitalizations.
The maximum penalty at that time was 1 percent of a hospital’s base Medicare reimbursement rate per discharged patient. Beginning October, 2013 the penalty increased to 2 percent and then to 3 percent the following year (2014). The first year more than 2,200 hospitals were penalized for failing to meet standards, with 8 percent incurring the maximum penalty. In addition to the MI, HF, and pneumonia penalties, readmission penalties now include elective knee and hip replacements and chronic obstructive pulmonary disease (COPD).
The healthcare reform mandate required addressing a long-time quality issue. According to Bisognano and Boutwell, the primary reasons for readmission were no physician follow-up visit, medication discrepancies, and communication failure during transitions of care (Bisognano, M. & Boutwell, A., 2009). Eric Coleman MD and others identified poor information transfer, poor patient and caregiver preparation, and limited empowerment to assert preferences as the primary reasons for readmission. Contributing factors include nurses not having time to thoroughly address the needs of both the patients and caregivers upon discharge, the hospital setting not being conducive to education that will drive behavior change before discharge, and the care continuum breakdown between hospital discharge and the hand-off to primary care (Coleman, E.A., Parry, C., Chalmers, S., & Sung-joon, M., 2006).
The uneven impact of the penalties has been a significant concern for hospitals that care for a larger number of low-income patients. They claim it is more difficult for their patients to adhere to post-hospital instructions including payment for medications, dietary modifications, and transportation to follow-up appointments.
To address these challenges some hospitals have implemented measures including discharging patients with medications, home-visits, and follow-up calls. Other interventions include hiring specialty care coordinators and transition coaches to provide follow-up care for patients with multiple comorbidities, providing patients with extensive teach-back for multiple days prior to discharge so they’ll better know what to do once they are discharged. In addition, many include comprehensive medication reviews with a clinical pharmacist.
The contact center can be an integral team player in reducing avoidable readmissions by enhancing the quality of care in the hospital-to-home transition through the combined capabilities of technology and human interaction. While discharge planning should begin upon admission to the hospital and include arranging for durable medical equipment (DME), transfer to step-down as appropriate, home health care, transportation needs, communications with primary care providers (PCPs), and discussions with caregivers, the extended care team which includes the PCP, caregivers, pharmacist, and other members of the interdisciplinary team can be greatly improved by the services of the contact center in helping to comprehensively coordinate the patient’s care.
The patient and their caregivers will also benefit from the reinforcement of information provided, teach-back, appointment reminders, and coordination of services including transportation, as well as medication reconciliation and symptom assessment resulting in earlier interventions and improved outcomes. Extending the contacts beyond the thirty-day penalty period will bring even greater benefits to patients and caregivers that may prolong readmissions indefinitely.
What readmission reduction activities are occurring within your organization? What is your contact center’s role in reducing readmissions? What level of service do you or can you offer?
Some contact centers make one post-discharge call to review the patient’s diagnosis, instructions, medications, education materials, and ensure the patient has scheduled their follow-up appointment with positive results. Others make several outbound calls to the discharged patient including a call within the first twenty-four to forty-eight hours post-discharge.
In addition the call center staff or care coordinator may reach out to the patient again after their first appointment, which ideally occurs within seven days post-discharge. This call typically is used to review the follow-up appointment instructions, any changes in medications, assist in referrals and scheduling with additional providers or resources, and communicate to the interdisciplinary team as appropriate. During this contact, biometric monitoring may also be tracked through technology or as self-reported by patients or caregivers.
Whatever level of service provided, it’s a win-win for the patients, their caregivers, and the organization. Utilizing the contact center to identify and implement communication strategies that effectively engage the patient and their caregivers adds value to the organization and the opportunity of better outcomes for their patients.
Traci Haynes, MSN, RN, BA, CEN is director, clinical services at LVM Systems, Inc.
- Bisognano, M., Boutwell, A. (2009). Improving transitions to reduce readmissions. Frontiers of Health Services Management 25(3), 3-10.
- Coleman, E.A., Parry, C., Chalmers, S., & Sung-joon, M. (2006). Care transitions intervention. Arch Intern Medicine 166(17) 1822-1828. Retrieved from com/journals/jamainternalmedicine/fullarticle/410933
- Jencks, S.F., Williams, M.V., & Coleman, E.A. (2011). Rehospitalization among patients in the Medicare fee-for-service program. New England Journal of Medicine 364:1582. Retrieved from nejm.org/doi/full/10.1056/NEJMx110014