Hospitals are desperate for your help. Next October, Medicare will begin to penalize hospitals that do not bring their patient readmission rates under control. Fines will start at 1% of a hospital’s annual Medicare payments and rise every year until readmissions decline. Hence, hospital administrators will be open to any and all suggestions. Home health care providers are in a key position to help.
This was the message delivered to a standing-room-only audience during the annual Southwest Regional home health care conference, “Catching the Dream of Home Care,” held last week in Albuquerque. The presenter, Scott Flowers, is a project director for EQ Health Solutions, the Medicare QIO for Louisiana. His topic, “Care Transitions Community Collaborative: Working Together Across Care Settings,” described how 3-year pilot projects in 14 states have already begun to have a dramatic effect on rehospitalization rates. (see sidebar)
The cost to Medicare of hospital readmissions within 30 days of discharge is staggering, Flowers said. Nationally, 17.6% of Medicare beneficiaries are re-hospitalized with 30 days. The Medicare Payment Advisory Commission (MedPAC) believes that up to 76% of those readmissions may be preventable, representing a potential annual savings to Medicare of over $12 billion.
Home care’s message to hospitals should be to point out that, of Medicare beneficiaries who are readmitted with 30 days, nearly two-thirds, 64%, receive no post-acute care between discharge and readmission. For those who do receive some form of post-acute care, Flowers reported, readmission rates have been seen to drop as low as 5.3%.
Editor’s note: It is important to point out that the well-publicized 29% national average acute care hospitalization (ACH) rate for home care, which ranges from lows in the teens in some states to highs of nearly 40% in other states, cannot be compared to the 17.6% rate that Mr. Flowers uses. There are two reasons. One, home care’s rate is based on PPS payment episodes and considers, therefore, returns that occur during a full 60 days instead of 30. Second, it measures all hospital admissions, not merely re-hospitalizations that follow a recent discharge.
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SIDEBAR: Three Models for Reducing Readmissions These three models use evidence-based practices to reduce hospital readmissions. Some hospitals and healthcare groups have incorporated elements of all three; some use different models for different risk groups of patients. Costs vary but researchers say all have proven more cost-effective and resulted in higher patient satisfaction than rehospitalization. • Transitional Care Model, developed by Mary Naylor, RN, PhD, and colleagues at the University of Pennsylvania: The Transitional Care Model uses transitional care nurses — advance practice nurses who follow patients identified as being high risk for readmission, from the time they enter the hospital until they are completely transitioned into community care, which usually spans two months. The nurses use their time in the hospital to work with all providers caring for the patient, including attending rounds, talking to the patient and family members, and working with discharge planners. The nurses make follow-up appointments with specialists and primary care providers, visit the patient within 24 hours of returning home to assess conditions there, reconcile medications, make regular home visits and phone calls, and accompany the patient to medical appointments to assure a proper handoff. • Care Transitions Intervention Model developed by Eric Coleman, MD, MPH, and colleagues at the University of Colorado Health Sciences Center: This model focuses on teaching patients and families how to continue care once the patient leaves the hospital. For four weeks, a trained transition coach works with patients, visiting them at least once in the hospital and once at home, and making at least three follow-up phone calls. The transition coach helps manage and reconcile medications, schedules appointments with specialists and primary care providers, helps create and maintain a personal health record the patient can share with providers, and teaches the patient and family members how to identify serious and lesser symptoms of his or her condition, and how to respond to each type. A study by the Centers for Medicare and Medicaid Services showed this model cut 60-day readmissions in half. • Project RED Model developed by Brian Jack, MD and colleagues at Boston Medical Center: Project Re-Engineered Discharge uses an 11-point checklist for hospital staff to follow during discharge, and is coordinated by a nurse trained as a discharge advocate and a pharmacist, both employed by the hospital. The list includes educating patients about their diagnoses, confirming medications, creating a personal health record, making follow-up appointments with primary care providers and giving patients a written discharge plan. A recent randomized study showed a 30% decrease in readmission when all steps were followed. |
Understanding the cause
Flowers holds both MHA and MBA degrees and is a “Lean Six Sigma Black Belt.” He approaches the project strategically, starting with an analysis of rehospitalization’s drivers:
- Data fragmentation
- Inappropriate end-of-life care
- Medication issues
- At-risk patients not properly identified at discharge
- Lack of post-discharge follow-up
- Lack of disease-specific protocols
- Lack of patient self-management
- Lack of community awareness
Multiple re-admissions have been found to be a smaller but nevertheless costly problem, Flowers reported in Albuquerque. Of those re-admitted within 30 days, 20% return more than once. 15% have two re-admissions; 3% return three times and 2% are re-admitted four or more times.
During the 3-year, federally funded pilot, grantees in the fourteen states (see list at right) will focus on patients with three diagnoses: heart attack survivors (AMI), Congestive Heart Failure (CHF) and pneumonia. Flowers found that Louisiana’s recidivism rate for all three conditions is 19.05%, with CHF patients having the highest average, 27.79% and pneumonia the lowest at 18.92%. AMI is in the middle at 23.74%.
Using a combination of techniques, including coordinating with post-acute care services and training nurses as health coaches, EQ Health Solutions is targeting five Baton Rouge area hospitals. Though it is too early to report meaningful results, Flowers said he and his colleagues expect to show significant progress at the project’s two evaluation points, at 18 and 24 months, approximately September, 2010 and March, 2012.
Preliminary results, which Flowers emphasized do not yet lend themselves to extrapolation, show that EQ has accepted about one-fourth of referred patients into their program, 188 of 714. They do not accept patients from managed care plans, who live outside the study area or who are discharged to nursing homes. Within that group, 30-day re-admissions are at 5.3% after nine months, which brings the region’s overall rate down from 18.68% to 17.51%
EQ’s detailed approach
To further reduce re-admissions for the three selected diagnoses, — plus COPD, which was added to the CMS list at EQ’s discretion — in the project’s five targeted hospitals, Flowers explained, the Louisiana QIO has selected tools matching the above-listed re-admission drivers:
- Medication management
- Plan of Care
- Post-discharge follow-up
- Bridging nurse support with “Transition Coaching”
- Clinical protocols
- Information transfer
- Community engagement and education
- Early identification of high-risk patients
“Transition Coaching” is the lynchpin
According to Flowers’ definition, Transition Coaching is carried out by nurses but does not involve care, nor does it interfere with any care services the patient might have following discharge. Using a model developed by Dr. Eric Coleman, of the University of Colorado Health Sciences Center, Transition Coaching focuses on “empowering the patient with the tools they need to navigate the healthcare system after discharge.”
Patient-centered tools include medication reconciliation, discharge plan of care, making follow-up appointments and recognizing red flags. Flowers emphasized that the nurse-coach never makes the follow-up appointment — and, in fact, does not do anything the patient can be taught to do for him/herself — but talks the patient through the process, encouraging them to take reminder notes along the way. “Transition Coaching reinforces the discharge plan of care established by the treatment team,” he elaborated. “It does not do for the patient.”
“The coach visits the patient in the hospital and completes a first coaching session at the time of discharge,” Flowers continued. “Subsequent telephone contacts occur on post-discharge days 2, 7, 14, 21, 30 and 45. Each session focuses on the post discharge plan of care, medications, post discharge follow-up and red flags.”
Bringing home care on board
Asked whether home health care providers might have a place in EQ’s program, Flowers stated that many home care agency personnel have already attended Transition Coaching training. Several of these have added coaching as a complementary service to standard skilled nursing. Agencies are using EQ-provided tools such as medication reconciliation forms, a handout explaining red flags for re-hospitalization and a patient personal health record. “Coaching services are not billable,” Flowers clarified. “Agencies cover them within their PPS reimbursement.”
He made sure to point out, however, that there is a financial benefit to deploying health coaches, not only to the hospital but potentially to the home care agency as well. The first way to analyze a less obvious benefit such as this is to consider patient census.
Currently, 25% of hospital patients are discharged to home care and 1% to hospice but fully 44% go home with no follow-up care services. One question Flowers hopes his company’s demonstration project will answer is whether increasing the percent of discharges to home health and hospice will reduce a hospital’s re-admission rate.
“Reducing acute care hospitalization rates does not cost, it pays,” he believes, supporting his assertion with Lousiana figures. “At an average RN hourly wage of $30.32, and an estimated three hours spent managing transfer and resumption of care (ROC) reporting, hospital re-admissions cost Lousiana home care providers $2,735,803 every year. Perhaps not all of this amount is avoidable but, according to findings revealed in a recent, 35-state ACH record review, only 56% are appropriate. 44% of all acute care hospitalizations were judged to be avoidable. Eliminate inappropriate hospitalizations and Louisiana home care agencies save $1,203,765.”
Scott Flowers concluded his presentation with the suggestion that home care agencies use his formula to calculate their own potential savings. “Do not forget to add to that total whatever additional revenue you can forecast after you convince hospital discharge planners to further reduce their re-admission rates by increasing the percentage of patients they discharge to home health care.”
