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How to reduce readmissions


Improving collaboration between physicians and hospitals.

Reducing the rate of  unplanned hospital readmissions has always been important, but it has become even more critical under the Affordable Care Act (ACA) because they are a major driver of healthcare costs and patient harm. Primary care physicians are emerging as a secret weapon in this process.

Hospitalizations represent almost a third of the $3 trillion that the United States spends on healthcare annually. A significant portion of these hospitalizations involve patients returning soon after they are discharged, according to the Institute for Healthcare Improvement, a Cambridge, Massachusetts-based non-profit.

The organization promotes some measures that can reduce the rate of preventable re-hospitalizations: better core discharge planning and transition processes; coordination at the interfaces between care settings; and coaching, education and support for patient self-management.

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After a patient is discharged, the primary care physician has the challenge of finding out what transpired in the hospital-a feat difficult to accomplish in a 15- or 20-minute office visit, especially without a universal electronic health record, says Danielle Snyderman, MD, who practices family medicine, geriatrics, and primary care and is a professor at Thomas Jefferson University Hospitals in Philadelphia, Pennsylvania.  

“Many of us are not the clinicians taking care of patients through the hospital stay,” she says. “Anytime there is a handoff to another provider, it adds to the complexity and is a potential area where errors can occur.” 

The ACA levies financial penalties on hospitals for avoidable readmissions of Medicare patients within 30 days of their first discharge. Since the Centers for Medicare & Medicaid Services (CMS) began penalizing hospitals in October 2012, readmission rates have been declining. 

Next: Fines and barriers


The level of fines is tied to the degree of excess readmissions, so those with higher rates than the national average receive lower Medicare payments. Hospitals lose as much as 3% of their total Medicare reimbursement for high rates of patients readmitted within 30 days of discharge. 

CMS set the post-discharge time frame at 30 days because readmissions over longer periods could be related to factors beyond hospitals’ control-for example, complicating illnesses, patient behavior or post-discharge care. 

Specific medical conditions for which hospitals incur readmission penalties are chronic obstructive pulmonary disease (COPD), heart attack (acute myocardial infarction), congestive heart failure (CHF), and pneumonia. Unplanned readmissions for surgical procedures include hip or knee replacements. 

Of the 3,464 facilities included in the CMS Hospital Readmissions Reduction Program, 2,665 of them had excess readmissions on at least one of these measures and are subject to a payment cut for fiscal year 2016-an estimated total of $420 million.

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Barriers exist that make it difficult for primary care physicians to help manage the handoff from the inpatient to outpatient setting, acknowledges John Meigs, Jr., MD, a family physician in Centreville, Alabama and president-elect of the American Academy of Family Physicians.  

The reasons vary: Sometimes the patient doesn’t identify a primary care provider upon arrival at the emergency department or the hospital fails to give timely discharge information to that physician. In other cases, Meigs adds, the patient hasn’t established a rapport with a primary care physician.

Next: Make the care connect


Also, many primary care physicians no longer follow their patients in the hospital, where hospitalists and specialists now oversee much of the care being delivered.

Examining the resurgence of primary care

“In many situations, they have very little influence, interaction, or engagement with the inpatient team taking care of that patient. Lack of sharing of information is one of the challenges that needs to be overcome to reduce avoidable readmissions,” says Ana McKee, MD, chief medical officer and executive vice president at The Joint Commission, which accredits healthcare organizations. 

“We view an avoidable readmission as a failed discharge,” she adds. “Once organizations adopt this perspective, they can begin to analyze and understand the causes that lead to readmissions and prevent future recurrences.”


Make the care connect

Under traditional payment models, primary care teams typically struggled without any additional reimbursement for post-hospital discharge coaching to help patients cope  in the face of complex chronic and life-threatening illnesses, says David C. Judge, MD, an internist and chief medical officer at Iora Health in Boston, Massachusetts, and a member of the Medical Economics editorial advisory board. Iora provides primary care services to  more than 30,000 patients nationally with physicians in capitated and risk-based contracts.

Increasingly, however, payment modalities are emerging  as a result of financial support and interventions under the ACA.  “Savings for these types of interventions can be used to invest further in primary care,” Judge says. “We will see more innovation and progress on this front.  It will largely be driven by primary care.” 

Next: Rewards for reducing readmissions


Primary care physicians can help facilitate the exchange of information between hospitals and their practices in several ways. First, they can educate patients about the importance of telling the hospital who their primary care physician is-ideally, at the time of admission. Physicians should also establish good communication with local hospitals, especially discharge planners, so that the hospitals can implement policies and procedures to notify physicians of their patients’ discharges, says Meigs.

“Hospitals can advise patients to contact their primary care physician, but without timely discharge information from the hospital, the physician cannot be proactive in initiating follow-up visits, medication reconciliation, lab work, and referrals,” he says.

Primary care physicians can bill for these functions under transitional care management CPT codes 99495 and 99496. Transitional care management benefits patients, physicians and hospitals, Meigs says, and  will gain traction as the healthcare system gravitates even more toward value-based reimbursement.

Payers will evaluate physicians to a greater extent based on hospitalizations, readmissions and emergency department visits, attributing unnecessary or avoidable uses of resources to the provider who is primarily responsible for a patient’s care. Most often, that’s the patient’s primary care physician. 


Rewards for reducing readmissions

Primary care physicians who have entered into financial risk-sharing agreements with hospital systems may reap rewards for preventing readmissions. In an accountable care organization (ACO), a physician’s compensation depends in part on the overall cost of care for a defined patient population. “That would definitely put pressure on primary care providers to keep people out of the hospital to begin with and then to keep them from coming back,” says Katherine Hempstead, PhD, director of health insurance coverage initiatives at the nonprofit Robert Wood Johnson Foundation.

Next: Implementing strategies


The majority of such contracts only specify “upside” terms, in which physicians earn bonuses for meeting performance measures, but don’t incur risks for falling short of expectations. Other contracts delineate both an upside and a downside, with the possibility of greater rewards but heftier losses if disease management goals aren’t met. While the majority of physicians aren’t yet in risk-bearing arrangements, readmissions guidelines spurred new values and norms around improved care coordination, with hospitals reaching out more to primary care providers and vice versa, Hempstead says.

Coastal Medical Inc., a Providence, Rhode Island-based primary care ACO, has implemented multiple strategies to reduce hospital readmissions. For example, it receives daily alerts about hospital admissions, discharges, emergency department visits, and transitions to intensive care units for its patients, says Al Kurose, MD, Coastal Medical’s chief executive officer. 

Many of the alerts come from two Providence-area hospital systems. Each system posts alerts via a secure “file transfer protocol,” akin to an electronic mailbox, early every morning. Other alerts to Coastal come from Currentcare, the state health information exchange, for patients who have enrolled in that database, which allows hospitals throughout Rhode Island to transmit updates to those patients’ primary care providers, Kurose says. 

Coastal Medical’s nurse care managers track hospital admissions and discharges and call patients to schedule follow-up office visits, inform them of needed tests, and coordinate potential medication changes. In 2015, Coastal implemented a centralized transitions of care team-consisting of a nurse care manager, nurses and medical assistants-who now monitor alerts as patients make transitions and contact them to ensure proper follow-up care. The team serves five offices, and Coastal plans to scale up this program in 2016 to encompass all of its locations.

Making a smooth transition


Because Coastal has multiple shared savings contracts based on total cost of care-and a portion of those dollars are reinvested into new programs as well as distributed within the company-Coastal physicians have incentives to reduce preventable readmissions as a way of lowering the overall cost of care. The result, Kurose says, is alignment of incentives between Coastal’s ACO payment models and hospitals’ best interests.

“We’ve had to react to what the hospitals are doing and to work collaboratively with them, but we are really driving the same agenda,” he says. “What you want to do is optimally manage that transition of care from the hospital back home or from the hospital to a skilled nursing facility. This improves the safety of care and experience of care for patients, while also reducing avoidable readmissions.”

Making a smooth transition

Unlike a patient’s primary care physician, other healthcare specialists may not be able to focus as much on other medical problems that can impact care, or the personal values that may influence decision-making, says Snyderman.

“When patients have several chronic and potentially life-limiting medical problems, understanding their personal values may impact choices regarding how aggressive they want their medical care to be,” she explains. “If patients understand that although medical interventions such as dialysis and artificial nutrition may prolong life in select circumstances, pursuing these interventions may not always afford the quality of life many of them seek.”  

Next: Looking to the future


The recommended length of time between a hospital discharge and the first post-discharge doctor’s appointment has shortened in recent years. It used to be two weeks, but experts now recognize the importance of having patients follow up with their physicians sooner, says Gail A. Nielsen, who trained at the Institute for Healthcare Improvement and works as a consultant in Des Moines, Iowa.

During the office visit, physicians can employ the “teach-back” technique to ascertain how well patients understood post-discharge instructions. Asking patients to repeat directions gives physicians a sense of how well patients will care for themselves outside the hospital, Nielsen says. 

CMS encourages primary care providers to collaborate with their state’s Quality Innovation Network and Quality Improvement Organizations, which recruit community stakeholders to form coalitions focused on improving care coordination for Medicare beneficiaries as they transition from one healthcare setting to another. 

Leveraging information technology is essential in reducing readmissions. “Access to timely information for all healthcare team members, whether acute or ambulatory, is critical,” according to a CMS official. 

By 2019, CMS’s goals are to lower hospital admissions by 20%, reduce readmissions by 20%, and increase community tenure (the number of nights that patients spend in their homes) by 10%. Ongoing follow-up care for high-risk patients is key.  

To assist further with transitions, Coastal Medical‘s two nurse care managers make daily hospital rounds and another nurse   performs these functions in nursing homes visits. These individuals have a lot of input in the discharge planning process and can help to assure safer care transitions, Kurose says.

Next: Exciting progress


On the hospital side, a communications program is operating in full force between emergency physicians at academic medical center hospitals and Coastal physicians. The program stipulates that an emergency department physician call a Coastal Medical patient’s primary care physician soon after the assessment and before any decision on disposition.

At Coastal Medical, the on-call physician reviews the patient’s electronic health record, provides information to the hospital-based team, and participates in a discussion about the plan of care. 

For Coastal patients in the Medicare Shared Savings Program, Kurose says, the number of hospital readmissions has decreased by 15% since 2011. Kurose also expects a favorable impact from the disease management programs Coastal is implementing for patients with congestive heart failure and COPD.  

One hospital where Coastal patients often receive care has started a joint replacement center. The center’s quality improvement processes and a focus on transitions of care have reduced the number of patients who require stays at skilled nursing facilities after joint replacements, Kurose says. Another hospital has collaborated with Coastal to implement a “warm handoff” from its pharmacists to Coastal’s clinical pharmacists for patients with diagnoses specified by CMS in the Hospital Readmissions Reduction Program.

Kurose views the new incentives in a positive light. “More effective management of transitions of care will almost certainly result in better care for patients, reductions in avoidable readmissions, and lower total cost of care,” he says. “These are outcomes that patients, primary care physicians, hospitals, and ACOs should be willing to work together to support.”

There is already a significant awareness nationally of the importance of primary care at moments of transition, and organizations are sharing best practices, internist Judge says. Patients and caregivers who have availed themselves of health coaching resources are experiencing the power of self-management. “This area in particular is an exciting frontier where an incredible amount of progress will be made in the years ahead.” 

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