Automated Post-Discharge Care: An Essential Tool to Reduce Readmissions


Published on

Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.

  • Be the first to comment

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Automated Post-Discharge Care: An Essential Tool to Reduce Readmissions

  1. 1. phytel | whitepaperReadmissionAutomated Post-Discharge Care:An Essential Tool to Reduce Readmissions
  2. 2. ContentsThe ChallengeEliminating Systematic Failures That Begin in the Hospitaland Continue in Fragmented Healthcare SettingsImmediate CausesNew Government IncentivesNew RegulationsAffordable Care ActNew InitiativesShared Savings ProgramGaps In Care TransitionsInadaquate PreparationPoor Educational TechniquesPoor HandoversBest PracticesIHI’s Patient Centered ApproachKey ChangesColeman Care Transitions InterventionNaylor Transitional ModelAutomationPatient Education and EngagementConnecting Providers With Each OtherConclusion
  3. 3. The Challenge: Eliminating Systematic Failures That Begin in theHospital and Continue in Fragmented Healthcare Settings.Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are dischargedfrom the hospital returns there within 30 days,1 and between 50 percent and 75 percent of those readmissionsare considered preventable.2 Medicare pays about $17 billion annually for 2.5 million rehospitalizations of itsbeneficiaries, and other payers spend roughly the same amount every year for all readmissions of non-Medicarepatients.3Immediate CausesThe immediate cause of a readmission is usually a rapid deterioration in the patient’s condition,related to the patient’s primary diagnosis and/or comorbidities. But in a broader sense, it can beattributed to systemic failures that begin in the hospital and continue in the fragmented health caresettings that patients move through after discharge.In a typical scenario, patients receive inadequate preparation for discharge; the handover from thehospital to their outpatient providers is poorly handled; and patients and their family caregivers areleft to cope on their own with medical issues that they don’t understand.4 In fact, only about halfof discharged patients follow up with their primary-care physicians after they leave the hospital,and those who don’t are much more likely to be readmitted than those who do see a doctor.5New Government IncentivesUntil recently, some hospitals took the attitude that their responsibility for care ended when thepatient walked (or was wheeled) out the door. Other facilities have used a variety of techniques toreduce readmissions, with mixed results. But new government incentives, plus a rising awarenessof the need to improve patient safety, are forcing hospitals to place an increased emphasis ondischarge planning and post-acute care.1. Stephen F. Jencks, Mark V. Williams, and Eric A. Coleman, “Rehospitalizations Among Patients in the Medicare Fee-for-service Program,” N Engl J Med 2009; 360:1418-1428.2. Mark Taylor, “The Billion-Dollar U-Turn,” Hospitals & Health Networks, May 2008.3. Jencks, “Rehospitalization: The Challenge and The Opportunity,” presentation, Integrated Healthcare Association conference, Oct. 2009.4. Suni Kripalani, Amy T. Jackson, Jeffrey L. Schnipper, and Eric A. Coleman, “Promoting Effective Transitions of Care at Hospital Discharge,” Journal of Hospital Medicine 2007;2:314–323.5. Jencks, Williams, and Coleman, “Rehospitalizations Among Patients,” op. cit.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 3
  4. 4. New Regulations and their community partners decrease Shared Savings Program readmissions over a five-year period endingFront and center are Centers for Medicare Finally, in 2012, CMS will launch its shared- in 2016. Through the government-sponsoredand Medicaid’s (CMS’) new regulations savings program for accountable care Partnership for Patients, CMS will payon preventable readmissions. Starting organizations (ACOs), which are groups of these “community-based organizations”Oct.1, 2012, hospitals with “excessive“ hospitals and doctors that are committed to a set amount per discharge for managingreadmissions-rehospitalizations that are raising the quality and lowering the cost of Medicare beneficiaries at high risk forsignificantly higher than expected will lose a care. To receive financial rewards from CMS, readmission.7percentage of their Medicare reimbursement these organizations will have to save money,across the board. In FY 2013, the decrease which will give them a strong incentive to cut New Initiativescan be up to one percent of reimbursement, readmissions.9rising to two percent in 2014 and three Two other CMS initiatives authorized Nevertheless, it will be difficult for healthpercent in 2015.6 by the health reform law are worth care organizations to decrease readmissions considering: payment bundling andIn the first year of this program, CMS will significantly in a fragmented, uncoordinated accountable care organizations. Under CMS’examine 30-day readmission rates for system. While most of the levers of recently announced plan for its bundlingpatients with heart failure, acute myocardial improvement are known, reengineering demonstration, providers may chooseinfarction, and pneumonia—three of the inpatient processes and engaging patients among four different options. One optionleading conditions for which patients are and outpatient providers remains challenging. includes all care provided from admission toreadmitted. Beginning in FY 2015, CMS may Fortunately, new applications of health the hospital to 30 or 90 days after discharge.also scrutinize chronic obstructive pulmonary information technology now offer inexpensive Another would cover only post-acute care fordisorder and several cardiac and vascular ways to automate post-acute-care up to 30 days.8surgical procedures. processes. These solutions, which are In both scenarios, providers would be discussed later in this paper, can raise theAffordable Care Act paid on a fee-for-service basis, adjusted effectiveness of care managers, improve retrospectively for variance from a budgetedCMS has also launched other programs the communications between inpatient and amount. While neither option penalizesthat might contribute to lower readmission outpatient providers, and make it easier for providers for readmissions, both encouragerates. To begin with, the agency plans to patients and caregivers to absorb and apply improvements in the quality of post-acutespend $500 million—or half of the $1 billion the knowledge required for self-management care, which should reduce the number ofearmarked in the Affordable Care Act for of complex conditions. rehospitalizations.improving patient safety—to help hospitals6. Neil Gold, “3 Readmissions to Reduce Now,” HealthLeaders Media, March 15, 2011, accessed at Ken Terry, “Patient Safety Front and Center,” Hospitals & Health Networks, July 2011.8. Department of Health and Human Services, “Improving Care Coordination and Lowering Costs by Bundling Payments,” fact sheet, Sept. 21, 2011, accessed at Rich Daly and Jessica Zigmond, “CMS Issues Proposed ACO Regulation,” Modern Healthcare, March 31, 2011.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 4
  5. 5. Gaps In Care Transitions: The Five Main ContributorsThe literature on transition problems shows there are five main areas that contribute topreventable readmissions:•  Poor preparation for discharge•  Patients’ low health literacy and comprehension•  Failure or inability of patients to see physicians for follow-up after discharge•  Lack of hospital follow-up•  Lack of communication between inpatient and outpatient providersInadequate PreparationReadmissions occur, by definition, after a patient has left the hospital. Yet the foundation for post-acute careis laid during the hospital stay—and that preparation is often inadequate. “The hospital discharge process ischaracterized by fragmented, nonstandardized, and haphazard care,” note Brian Jack, an expert on hospitalreengineering, and his colleagues.10Nurses and first-year residents are often placed in charge of discharges. These staffers have many other dutiesand may relegate discharges to a lower priority. Making matters worse, there are no clear lines of authority. As aresult, the system sets these individuals up to fail and creates a dangerous situation for patients.10. Kripalani, et al., “Promoting Effective Transitions of Care.”PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 5
  6. 6. A prime safety issue cited by many experts hospital.13 communications to ensure that they areis missing or inadequate medication Providers are partly responsible for this lack adhering to their medication regimens,reconciliation at the time of discharge. The of comprehension. Physicians or nurses following up with their outpatient physicians,medications that patients received in the may rush through their instructions and and looking for danger signs in their ownhospital are often discontinued at discharge, not encourage patients to ask questions. conditions.while the drugs they were taking before they They may not use the proven “teach-back”were admitted may or may not be resumed. method of having patients restate theDosages may also change.11 instructions in their own words. And theyThe Joint Commission has identified may not realize that because of a patient’smedication reconciliation as a key cognitive issues, his or her family caregiverrequirement for ensuring patient safety. 12 is the one who needs to receive theThe Institute for Healthcare Improvement instructions.14also cites medication reconciliation as an Another big—and underappreciated—opportunity to reduce readmissions. So problem is the low health literacy of the U.S.this is clearly an area where hospitals could population. Roughly 90 million Americans—contribute to lower rehospitalization rates. nearly half of the adult population--have lowRoughly 90 million Americans—nearly half of the adult population--havelow functional literacy. “Such patients typically have difficulty reading andunderstanding medical instructions, medication labels, and appointment slips.” functional literacy.15 “Such patients typicallyPoor Educational Techniques have difficulty reading and understandingAnother challenge is getting patients to medical instructions, medication labels, andunderstand what will be required of them appointment slips,” according to one study.16after discharge. In one study, for example, What this means is that only oral but also78 percent of patients discharged from written instructions must be couched inthe ER did not understand their diagnosis, terms that somebody with fairly little formaltheir ER treatment, home care instructions, education can understand. It also meansor warnings signs of when to return to the that many patients require post-discharge11. Ibid.12. Susan Baird Kanaan, “Homeward Bound: Nine Patient-Center Programs Cut Readmissions,” California Healthcare Foundation report, September 2009.13. Edwin D. Boudreaux, Sunday Clark, and Carlos A. Camargo, “Telephone follow-up after the emergency department visit: experience with acute asthma.” Ann Emerg Med. June2000;35:555-563.14. Gail Neilsen and Peg Bradke, presentation at Institute for Healthcare Improvement conference, July 13, 2011.15. Kripalani, Jackson, op. cit.16. Ibid.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 6
  7. 7. Poor Handovers patients.19Another glaring deficiency in post-acute While ambulatory-care physicians maytransitions of care is the inadequate be shooting in the dark when they see acommunications between inpatient and recently discharged patient, at least they mayoutpatient providers. Here are a few statistics know something about the patient’s history,that underline the chaotic state of these and they can find out what medicationscommunications: they’re on. All of that works to the patient’s advantage. But many discharged patients•  Direct communication between hospital don’t or can’t make an appointment to see physicians and primary care physicians a doctor within a week of discharge. If the occurs in only three to 20 percent of cases patient is at high risk of complications and deterioration, they should be seen within 24•  Only 12-34 percent of doctors have hours, but often this doesn’t happen. received hospital discharge summaries by the time patients make their first post- discharge visits. The range rises to only 51-77 percent after four weeks, affecting the quality of care in about a quarter of the follow-up visits. 17 Studies have found that•  Approximately 40 percent of patients discharge summaries have pending test results at the time of discharge, and 10 percent of those require often fail to provide basic some action; yet, in the majority of cases, information about hospital outpatient physicians are unaware of these visits. Some summaries results. 18 never even reach theOther studies have found that dischargesummaries often fail to provide basic primary care doctors whoinformation about hospital visits. Some are caring for dischargedsummaries never even reach the primarycare doctors who are caring for discharged patients.17. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety andcontinuity of care. JAMA 2007;297(8):831-841.18. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005;143(2):121-128.19. Kripalani, Jackson, op. cit.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 7
  8. 8. Best Practices: Best Methods for Reducing ReadmissionsA great deal of research has been done on the best methods for reducing readmissions. In this section, wewill focus on the Institute for Healthcare Improvement’s (IHI’s) recommendations; the Coleman Care TransitionsIntervention; and the Naylor Transitional Care Model. Other resources for healthcare organizations include theBOOST program of the Society of Hospital Medicine;20 the Care Transitions Performance Measurement Set of thePhysician Consortium for Performance Improvement;21 and the Transitions of Care Consensus Policy Statementof the American College of Physicians and five other specialty societies.22IHI’s Patient - Centered ApproachIHI, a Boston-based nonprofit organization that is leading two transitions-of-care initiatives,recommends that healthcare organizations create “cross-continuum” teams that involve allcommunity stakeholders. It advises institutions to use a patient-centered approach that looks atpost-discharge care through a patient’s eyes. By doing “deep dives” into several patient histories,IHI says, and finding out why the patients were readmitted, it’s possible to understand where theentire process falls short and begin to fix it.23Specifically, IHI recommends:•  Focusing on the patient’s journey over time across care settings•  Making discharge preparations early•  Redesigning health education materials using health literacy principles•  Providing intensive care management services for high-risk patients•  Making sure that patients have follow-up appointments with physicians•  Improving communications between inpatient and outpatient providersBy doing “deep dives” into several patient histories, IHI says, and finding outwhy the patients were readmitted, it’s possible to understand where the entireprocess falls short and begin to fix it.20. Society of Hospital Medicine website, Project BOOST, accessed at Physician Consortium for Performance Improvement, “Care Transitions Performance Measurement Set,” June 2009.22. Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. J Gen Intern Med. 2009 Aug;24(8):971-6.23. Phytel presentation, “IHI and PCMH Perspectives.”PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 8
  9. 9. Recognizing that patients and their caregivers are key parts of the post-discharge care team, the transition coach visits the patient in the hospital andagain at home and makes three follow-up phone calls.The key changes that hospitals need Overall, the CTI supports patients in during the first month; telephones the patientto make, says IHI, are: four areas: weekly; implements a care plan that is•  Enhanced assessment of post-discharge continually reassessed in consultation with •  Making sure patients and/or caregivers needs the patient, the caregiver, and the patient’s can manage their medication primary care physician; and continues calling•  Effective teaching and learning by patients •  Giving patients personal health records to the patient monthly after the initial two-month and or caregivers facilitate communications with providers period.•  Real-time handover communications and promote continuity of care Randomized controlled trials have shown •  Scheduling, preparing for, and completing that the Naylor model reduces all-cause•  Assurance of post-hospital follow-up. 24 follow-up visits with physicians readmission rates, increases patient •  Understanding danger signs for their satisfaction, function and quality of life; andColeman Care Transitions conditions and knowing how to respond decreases overall healthcare costs. In oneIntervention to them study, the model reduced the number ofEric Coleman, MD, a geriatrician at the readmissions at six months by 36 percent, Studies have shown that the CTI approachUniversity of Colorado Health Sciences and costs by 39 percent.31 reduces the chances of rehospitalizationCenter, and his colleagues have created a by 40 to 50 percent.27-28 According to a The literature on the efficacy of post-Care Transitions Intervention (CTI) model that California Healthcare Foundation report, discharge phone calls has shown mixedemphasizes the use of a transition coach.25 more than 130 hospitals across the U.S. results. But in one study, 19 percent ofRecognizing that patients and their caregivers have adopted the CTI model. 29 patients experienced medication-relatedare key parts of the post-discharge care team, issues that were resolved with post-the transition coach visits the patient in the Naylor Transitional Care Model discharge calls.32 In another study, 35hospital and again at home and makes three percent of patients who received callsfollow-up phone calls. The coach teaches Mary Naylor, Ph.D., RN, and her colleagues needed significant referral and aftercarethe patients/caregivers, helps them develop at the University of Pennsylvania have instructions.33 This evidence points to theself-management skills, and assesses their developed another approach for decreasing need to reach out to the whole populationlearning. While some coaches are nurses, readmissions. Their model involves care of discharged patients, while stratifyingstudies have shown that people with a wide coordination by a transitional care nurse patients in order to increase the efficacy ofvariety of backgrounds can perform this who generally has advanced practice these phone calls and of care managementfunction. training.30Following evidence-based in general. protocols, the nurse care manager visits the patient daily during his or her hospital stay; visits the patient at home during the first 24 hours after discharge and then weekly24. Nielsen and Bradke presentation, op. cit.25. Kanaan, “Homeward Bound,” op. cit.26. Coleman Eric A; Parry Carla; Chalmers Sandra; Min Sung-Joon. The care transitions intervention: results of a randomized controlled trial. Archives of internal medicine2006;166(17):1822-8.27. Ibid.28. Eric A. Coleman, Jodi D. Smith, Janet C. Frank, DrPH, Sung-Joon Min, Carla Parry, and Andrew M. Kramer, “Preparing Patients and Caregivers to Participate in Care Delivered AcrossSettings: The Care Transitions Intervention.” J Am Geriatr Soc 52:1817–1825, 2004.29. Kanaan, “Homeward Bound.”30. Ibid.31. Naylor, M.D. et al. 2004. J Am Geriatr Soc 52:675–84.32. Vicky Dudas, Thomas Bookwalter, Kathleen M. Keer, Stephen Z. Pantilat, “The impact of follow-up telephone calls to patients after hospitalization.” American Journal of Medicine, TheVol. 111, Issue 9, Supplement 2, Pages 26-30.33. The Journal of Emergency Medicine, Volume 6 (1988).PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 9
  10. 10. New automation tools can greatly facilitate the range ofbest practices designed to improve post-discharge careand reduce readmissions.Automation Assessing Patient RiskThe approaches outlined above have been Some patients who are at high risk forshown to work with certain kinds of patients, readmission can be identified in the hospital.and they can also be cost-effective with Certain conditions, such as congestive heartparticular subpopulations. But, without the failure, make readmission likely; but, in manyaid of automation, they cannot reach all cases, comorbidities are responsible forpatients who have been discharged from rehospitalization.34 So some patients who arethe hospital. Moreover, their approach to not obvious candidates for readmission maypatient education is not as cost-effective slip through the cracks. Other factors, suchas it could be, because it relies on one-to- as adverse drug events because of poor orone communications between patients or no medication reconciliation, can also lead tocaregivers and coaches or nurses. unexpected ER visits or readmissions.35The existing models are also labor-intensive Ideally, hospitals should use predictivein other respects. The coaches and nurse modeling to identify high-risk patients whocase managers in the Coleman and Naylor are likely to be readmitted if they don’tmodels can handle only a limited number receive appropriate care after discharge.of patients. And, while human contact is Utilized widely by managed care plans,essential in high-risk cases, automated predictive modeling software analyzesapproaches can perform many of the basic hospital data, claims data on utilization andtasks required to support patients during the comorbidities, and patient surveys to stratifypost-discharge transition. patients by risk level.New automation tools can greatly facilitatethe range of best practices designed toimprove post-discharge care and reducereadmissions. Among the areas whereautomation can pay off in higher quality andlower costs are:•  Risk stratification of patients•  Post-discharge communications with patients•  Patient education and engagement 19% of patients experienced medication•  Closing provider communication loops related issues were resolved with post-discharge calls34. Nielsen and Bradke presentation, op. cit.35. Kripalani and Jackson, op. cit.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 10
  11. 11. During the critical 24 to 72 hours after histories from integrated primary caredischarge, an automated phone survey systems.can be used to measure the satisfaction ofdischarged patients with their care while Patient education andgathering data on their risk factors. This engagementinformation allows a computer program to Automation can also provide better, morecalculate a risk score. Based on that and consistent patient education that overcomeson answers to condition-specific questions, health literacy problems and ensures thatalerts about high-risk patients can be patients understand the information they’retransmitted to hospital care managers or receiving. This is an enormous opportunitytriage nurses. to help patients increase their confidenceIn addition, if patients don’t understand and their ability to do self-managementdischarge instructions or would like to be while reducing the amount of time and laborcontacted by the hospital for additional required to boost patients to that level.follow-up, they can be transferred Web-based, audiovisual educationalautomatically to a hospital nurse help line or materials are available, and some of thema call center. even provide links back to providers so thatIf a patient has been identified in the hospital they can see whether patients have viewedas high-risk, a nurse or transition coach the materials.36 But these programs lack theshould follow up with that patient at home or ability to test the patients on what they’vein the next care setting. learned and make sure they’re applyingHome telemonitoring may also be indicated, that knowledge to their own care. Digitalparticularly for patients with heart failure. coaching tools can fill this gap and helpSignals from monitoring equipment alert patients manage their conditions as much ascare managers when the patient’s condition they can on their own. 37deteriorates.But for low- or medium-risk patients,the automated survey approach canestablish whether the patient needs further During the critical 24 to 72 hours afterprofessional assistance. discharge, an automated phone surveyMoreover, the system can tell the hospitalstaff whether or not the patient has a follow- can be used to measure the satisfactionup appointment with a physician. And if itis connected with an outpatient registry, it of discharged patients with their carecan supplement hospital data with medical while gathering data on their risk factors36. Emmi website, Mari Edlin, “Digital health coaching brings care management to everyday life,” Managed Healthcare Executive, Jan 1, 2011.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 11
  12. 12. Connecting providers to each The use of EHRs could speed the deliveryother of these summaries; but, as one observer notes, hospitals and ambulatory-careAs the statistics cited earlier show, the practices frequently use different systemscommunication between hospital physicians that are incompatible.41 In the future,and ambulatory-care doctors is generally health information exchanges will probablysubpar. There a number of reasons for this, overcome this barrier. Meanwhile, healthcareincluding a shortage of time, the difficulty systems could investigate the use of theof reaching outpatient providers, and Direct Project protocol to “push” informationthe inherent problems of phone and fax from one EHR to another. 42communications.The patient outreach system described Conclusionearlier can help close the communicationloop in one significant respect: If ambulatory By preventing readmissions, healthcarecare providers are using the same system to organizations could improve patientcontact patients with preventive and chronic health and safety while responding to newcare needs, that service can also be used to government incentives and penalties. Anotify primary care physicians and outpatient patient-centered, automated approach iscare managers when patients in their panels the most efficient and cost-effective wayare admitted to the hospital and after they to make sure that all patients who haveare discharged. This alone would fill a been discharged are properly taken caresignificant communication void. of. But such a model must be judiciously combined with high-touch care managementThe Physician Consortium for Performance to address the needs of high-risk patientsImprovement and an article in the Journal appropriately.of Hospital Medicine38-39 both recommendproviding a transition summary to primarycare doctors within 24 hours, rather thanwaiting for discharge summaries to beprepared and transmitted. Such a summary,which could be communicated by phone, fax A patient-centered, automated approach isor e-mail, would include discharge diagnosis, the most efficient and cost-effective way tomedications, results of procedures, pendingtest results, follow-up arrangements, and make sure that all patients who have beensuggested next steps.40 discharged are properly taken care of.38. PCPI, “Care Transitions Performance Measurement Set.”39. Kripalani and Jackson, op. cit.40. PCPI, “Care Transitions Performance Measurement Set.”41. Kathleen Louden, “Creating a Better Discharge Summary: Is Standardization The Answer?” ACP Hospitalist, March 2009.42. Janice Simmons, “Direct Project Gets Widespread Industry Support,” Fierce EMR, March 24, 2011, accessed at | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 12