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Preventing hospital readmissions


As payment models shift toward value, physicians will increasingly be measured on their ability to keep patients out of the hospital. Here’s how to get ahead of the curve.

Traditionally, physicians have had a professional desire to keep their patients out of the hospital, but “no economic skin in the game,” says Lance Lang, MD, medical director of the California Quality Collaborative, a healthcare improvement organization. The growing number of accountable care organizations (ACOs) and other bundled reimbursement models is changing that equation, he says.

“It’s only now that there is an actual schedule under which CMS is moving away from fee-for-service, and it’s becoming believable that there’s really going to be a change, that the business case is growing to work on this,” Lang says.

The question still being hashed out in studies and by those on the front lines of care is two-pronged. First, what specific interventions work best to keep patients from bouncing back? Meanwhile, how can doctors-particularly those in smaller practices-afford to provide that additional discharge support in a world that remains largely fee-for-service?

Lang argues that size matters, and to be successful primary care doctors will need to join forces into larger collaborative networks, at a minimum. Other doctors maintain that smaller practices can redesign their discharge approach, taking advantage of relatively new revenue streams, such as the Transitional Care Management (TCM) billing codes that are designed to reimburse for the additional time required for post-discharge care coordination.

Still, even a small shop can step up efforts to maximize the time and skills of each person on staff, says Carol Henwood, DO, a family medicine physician in Royersford, Pennsylvania.

Related:Thousands of hospitals penalized for high readmission rates

With only a physician assistant and nurse practitioner, Henwood’s practice still can tap into the resources of the larger physician network that she’s part of through Philadelphia’s Main Line Health, with roughly two dozen practices totaling more than 80 physicians. Together, the practices share the discharge backup services of five nurse care managers.

Henwood relies on a nurse care manager to call patients within 48 hours of discharge and to gauge, with her guidance, how quickly each one should be brought in for an office appointment. The first visit occurs within five to 14 days depending upon the patient’s post-discharge vulnerability, Henwood says. “Say they have chronic obstructive pulmonary disease and they were in [the hospital] with pneumonia,” she says. “Well that patient is going to be seen quickly because they could get worse.”

A small practice could revamp its own processes to provide similar support, such as by requiring the office’s licensed vocational nurse to call any newly-discharged patients each morning. “Then for the first half hour, that’s her job,” Henwood says. “It might be one patient a day-it might be five a day. Handle that very first thing, do the [medication] reconciliation and then see when they need to be seen, and see what else they need.”


NEXT: Bridging discharge


Bridging discharge

For their part, hospitals already have increasing incentives to forge closer relations with their local doctors. Last year, officials at the Centers for Medicare & Medicaid Services levied readmission penalties against a record 2,610 hospitals, three-fourths of those eligible, according to a Kaiser Health News analysis.

Moreover, numerous studies reveal significant room for improvement-for both doctors and hospitals. Consider that one out of every three patients discharged don’t see a doctor within 30 days, according to a 2011 study conducted by the Center for Studying Health System Change.

A 2007 review article in the Journal of the American Medical Association highlights other communication gaps: among them, a median of only 53% of discharge letters and 14.5% of discharge summaries reach the primary care doctor within the first week following a patient’s discharge.

Researchers and doctors are still sorting out the best strategies to prevent turnstile readmissions. A review article published in 2011 in the Annals of Internal Medicine found a dozen potential interventions that have been studied, including medication reconciliation and home visits. But the researchers couldn’t isolate any one, or specific bundle of steps, that has consistently reduced readmissions, in part because of limitations in the quality of the studies.

One common measure, implemented in studies and quality improvement efforts, has been to add a post-discharge care coordinator. In one initiative involving Oregon Health & Science University (OHSU) a care manager was added in each of four primary care clinics. The manager was a registered nurse able to triage medical issues, says Brett White, MD, the study’s lead author. The nurse was able to address gaps in care, starting with ensuring that the hospital discharge paperwork reached the clinic, White says.

Related:Remote patient monitoring: How mobile devices will curb chronic conditions

Previously, the hospital physician typically would fax that paperwork to the primary care physician, he says. “With really no way of knowing whether that ever arrived, whether it was attended to, whether that primary care physician then followed up on it, reviewed it, or any of that,” says White, who previously practiced at OHSU and now is health plan medical director at ZoomCare in Portland.

Under the new approach, the nurse care manager also would call the patient shortly after discharge, reaching roughly 90% compared with fewer than 10% previously, according to White’s recollection. That early call was particularly key to catching medication problems, from potential interactions to difficulties in obtaining or affording prescriptions, he says.

White recalls a patient of his who had been hospitalized for an exacerbation of his chronic obstructive pulmonary disease.

Follow up after discharge determined that the patient wasn’t faring well. “It was in large part because of the inhalers that he was prescribed upon discharge-he couldn’t afford them,” White says. “And so he just didn’t pick them up. So he was using his albuterol inhaler over and over and over to no avail.”

The patient was brought in for an office appointment and switched to a more affordable inhaler, says White, who believes that a readmission was thus prevented.

During the 12-month period studied, readmission rates at those four OHSU primary care clinics declined from 27% to 7.1%, according to findings from 685 post-discharge patients published in February 2014 in The Journal of Family Practice. (The intervention group also incorporated eight of the dozen potential interventions described in the Annals study.) In the usual care group of 276 patients, the readmission rates were variable with no discernible pattern.


NEXT: Practice changes


Practice changes

White notes that the four primary care clinics did benefit from additional funding enabling them to add the nurse care managers. Oregon is one of seven states or regions selected to participate in the Comprehensive Primary Care initiative, a CMS program, which provides participants a monthly non-visit case management fee for fee-for-service Medicare patients.

Even without a similar funding stream, White says, a smaller practice can alter its process to better help patients after discharge. One crucial step is setting up a mechanism with hospitals so the practice is routinely notified of any discharged patients, ideally electronically and not via fax, he says. “Things can get lost. It’s not incorporated into the records. Someone then has to abstract that paperwork into the chart.”

Electronic notification allows Henwood to check from her computer on a weekend to see which patients have been discharged. “I might even call them on a Saturday and say, ‘are you OK?’”

Related:Seven steps for managing transitions of care

Primary care doctors also need to be prepared on their end, building some wiggle room in their schedule for that recently discharged and struggling patient, Henwood says. She keeps at least one transition of care slot open daily, one that she can typically fill with a back pain or sore throat patient if it’s not needed. If the requirements are met, the Transitional Care Management (TCM) billing codes-CPT codes 99495 and 99496-can help cover time devoted to patient care for the remainder of that first month, including phone calls, even if they don’t return to the office, she says. (More details at:

But billing services under the TCM codes is easier described than accomplished, says Bruce Williams, DO, part of a two-doctor practice in Blue Springs, Missouri. A visit that’s booked as hospital follow-up can quickly morph into other medical issues, such as when a patient hospitalized for heart failure develops diabetic complications that need to be addressed.

Williams strives to get a patient in within two weeks after discharge. For elderly patients with complex medical issues, that appointment can stretch as long as 45 minutes, he says. To assist with reconciliation, patients are encouraged to bring their medications to their appointment.

“It is challenging for smaller practices, particularly if they have an elderly population,” White says. “I am a family physician, but most days I feel like I’m a geriatric internist. There are days where I don’t see anybody under the age of 50.”


NEXT: Is bigger better?


Is bigger better?

Despite a doctor’s best efforts, a patient may show up with no records, requiring a further sorting out of the diagnosis and the care plan, before even getting to how the patient is feeling and whether they’ve had any medication issues, says Lang, with the California Quality Collaborative. “Can you imagine doing that in 15 minutes by yourself with a medical assistant? So it simply doesn’t usually work.”

The collaborative serves as a partner for an ongoing initiative-Avoid Readmissions through Collaboration (ARC)-that has significantly reduced readmissions since it began collecting data in January, 2010. By October of 2014 the roughly two dozen participating California hospitals reported a 30-day readmission rate of 10.8% compared with 12.5% at the start.

The Cynosure Health project encourages hospitals to work more closely with outpatient doctors and other entities such as skilled nursing facilities to tackle readmissions. While the participating hospitals have been educated about various prevention strategies, they’re encouraged to tailor their approach based on their own facility’s readmission patterns and challenges, says Pat Teske, RN, implementation officer for Cynosure Health.

Related:What's the verdict: A case of changing medical records

Doctors who are not part of a large system can build their own discharge support network, Lang says. For example, four to eight doctors could team up to hire a clinician to visit patients in their homes and contract with a pharmacist to assist with medication reconciliation, among other investments, he says.

Lang points to a recent such effort, albeit on a much larger scale, in California’s Riverside County, where doctors created an accountable care organization (ACO). The ACO, formed by the Inland Empire Foundation for Medical Care and Accountable Care Associates, includes about 350 doctors, according to Dolores Green, executive director of the Riverside County Medical Association.

The participants range from a large multi-specialty practice to very small primary care offices, Green says. As part of the ACO, the practices can access the help of a care coordination team, which includes a medical assistant backed up by a registered nurse and a part-time medical director. That team, working with the doctor’s office, strives to call patients within 48 hours of discharge to schedule a follow up appointment, answer medication questions or even arrange for the pharmacy to deliver the prescriptions if the patient can’t get there, Green says.

“By grouping together these doctors, using the care coordination of the ACO,” she says, “we can help them provide those services when they couldn’t afford to have that staff person just in their office.”

Small practices, though, might possess undersold strengths, according to an analysis of preventable admission rates published 2014 in the journal Health Affairs. The analysis found that practices with one or two doctors had 33% fewer such avoidable hospital admissions and practices of three to nine doctors had 27% fewer compared with their larger practice counterparts (10-19 physicians).

While the study focused on preventable hospital admissions, not readmissions, both scenarios require similar care management approaches, says Lawrence Casalino, MD, PhD, a study author and chief of the division of health policy and economics at the Weill Cornell Medical College in New York City. In that regard, larger practices have a clear leg up, because they can afford to hire additional staff, he says.

“What our article raises is the question of whether there is something that goes on in small practices that doesn’t depend upon being big, and that in fact being big might make worse,” Casalino says.

One possibility is that doctors in smaller practices might know patients better, and have forged closer staff bonds through years of working together, says Casalino, reflecting on his own experience in a family practice.

“It would happen frequently that I’d be running between exam rooms, and my medical assistant would stop me and say, ‘Larry, Mrs. Smith just called.’ And I might roll my eyes. And she’d stop me and say, `I know she calls almost every day. But today I think there’s really something wrong with her. I just don’t like the way she sounds. I think we ought to get her right into the office.’ ”




Requirements for billing Transitional Care Management services

CPT code 99495

  • Face-to-face visit within 14 days of discharge from inpatient setting

  • Medical decision-making of at least moderate complexity

  • Communication (defined as phone call, e-mail exchange, or face-to-face) with patient or caregiver within two business days of discharge

CPT code 99496

  • Face-to-face visit within 7 days of discharge from inpatient setting

  • Medical decision-making of high complexity

  • Communication with patient or caregiver within two business days of discharge

The 30-day TCM period begins on the date the beneficiary is discharged from the inpatient setting and continues for the next 29 days. The reported date of service should be on the 30th day.

Source: Centers for Medicare and Medicaid Services, Medicare Learning Network


Managing transitions of care: Seven key interventions

After evaluating transition of care models for years across different populations, from rural to big cities, the National Transition of Care Coalition has identified seven key interventions that all models have in common:

  • Medications management: Ensuring the safe use of medications by patients and their families and based on patients’ plans of care.

  • Transition planning: A formal process that facilitates the safe transition of patients from one level of care to another including home or from one practitioner to another.

  • Patient and family engagement/education: Education and counseling of patients and families to enhance their active participation in their own care including informed decision making.

  • Information transfer: Sharing of important care information among patient, family, caregiver and healthcare providers in a timely and effective manner.

  • Follow-up care: Facilitating the safe transition of patients from one level of care or provider to another through effective follow-up care activities.

  • Healthcare provider engagement: Demonstrating ownership, responsibility and accountability for the care of the patient and family/caregiver at all times.

  • Shared accountability across providers and organizations: Enhancing the transition of care process through accountability for care of the patient by both the healthcare provider (or organization) transitioning and the one receiving the patient.


Source: National Transition of Care Coalition

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