Published in the January 2012 issue of Today’s Hospitalist
TRANSITIONAL CARE often performs well in randomized trials, but can it prevent readmissions and save money in the real world? Two recent studies provide mixed answers to those questions, but with results that investigators view as largely positive.
One study, which was conducted in six Rhode Island hospitals, enrolled patients at high risk for readmission in an intervention to help them manage their illnesses. A coach (a nurse or social worker) conducted a hospital visit, a home visit and two follow-up telephone calls. Coached patients had lower 30-day readmission rates (12.8%) than individuals who were offered but did not receive coaching (18.6%). That difference that persisted even after adjusting for demographic differences between the two groups.
In the second study, advanced practice nurses from the 263-bed Baylor Medical Center in Garland, Texas, provided even more extensive follow-up for patients with congestive heart failure. During the three months following discharge, nurses logged at least eight home visits per patient and were available by phone seven days a week. Thirty-day readmission rates for those patients dropped 48%.
Each program, however, revealed challenges that were not readily apparent in the scientific bubble of the controlled trials. The studies, which both appeared in the July 25, 2011, Archives of Internal Medicine, found that one of the biggest obstacles hospitals face with transitional care initiatives is that patients have a hard time understanding them. And while researchers learned that initiatives reduce readmissions, those programs certainly aren’t cheap.
Both programs had problems getting patients to participate, for instance, and the Baylor program, which examined costs, was a money loser. After admission and intervention costs (which weren’t reimbursed by insurers), each patient in the intervention program cost the hospital $751.
The cost equation shouldn’t be blamed on the program but on the payment structure, contends Brett D. Stauffer, MD, MHS, lead author of the Baylor study and clinical scholar with Baylor’s Institute for Health Care Research and Improvement in Dallas. As long as hospitals are paid for readmissions “which may affect nearly one in five Medicare admissions “and not for transitional care, such initiatives will cost hospitals money.
For now, Baylor is banking on its new system of transitional care, even if it is a bit ahead of the curve. “We think it’s the right thing to do,” Dr. Stauffer says. “And we think we are eventually going to get paid for transitional work.”
But his study “like the investigation in Rhode Island “underscores the costs and hurdles that hospitals need to clear to make transitional care more effective.
The results of the two studies are particularly relevant given that patients can now check individual hospitals’ 30-day readmission rates for heart attack, heart failure and pneumonia patients on the HHS’ Hospital Compare Web site. As patients become more aware of their risk of readmission, they may start putting more pressure on hospitals to help them manage their conditions.
Then there are looming financial penalties. As part of health care reform, Medicare will begin to cut reimbursement for readmissions for heart attack, heart failure and pneumonia by 1% starting in fiscal year 2013. That jumps to 2% in 2014, then 3% in 2015 and subsequent years.
Ultimately, docking hospital pay for readmissions will make an excellent business case for improved transitional care. However, Dr. Stauffer argues that hospitals need time to get ready to respond. In Baylor’s case, it took a year to rev up the program and iron out details such as who would oversee the nurse providing the transitional care, where the program notes would be stored, who would take what calls when and how much patient education was needed.
Another financial game-changer is bundled payments. Hospitals can now sign up for Medicare’s bundled payment initiative, which links payments for various services that patients receive across an entire care episode. Some iterations of that payment method make effective transitional care a must.
“Most big systems would rather get all the dollars up front and be responsible for everything, including a certain time afterwards for follow-up,” Dr. Stauffer says.
The obvious downside is that hospitals are left holding the bag when it comes to patients who are readmitted. “At some point, you have to give hospitals money at the front end and say, ‘Now you’re responsible for transitional care as well, so if you have a readmission you have to eat that whole cost,’ ” he says.
Problems and challenges
The studies raised an even bigger question about transitional care initiatives: Will patients buy in?
Researchers in the Rhode Island study, for example, wanted to simulate some of the challenges that hospitals will face in getting patients to participate in managing their own care. So they approached as many patients as possible, instead of conducting a randomized controlled trial.
Just more than half of the patients approached agreed to participate. Those most likely to say “no” were male, had longer hospital stays and had had more hospital admissions the previous year. (The authors adjusted for those characteristics in their analyses.) In the Baylor study, the participation rate was also lower than researchers had hoped for “only 40% of those eligible.
An unusual model
Getting patients to agree to participate was only the beginning of researchers’ troubles. In both studies, the number of participants continued to drop because patients just didn’t understand or want the intervention.
“It’s still difficult once you get people to say ‘yes,’ ” says Rachel Voss, MPH, lead author of the Rhode Island study and program coordinator for Healthcentric Advisors, Rhode Island’s Medicare quality improvement organization. Of those who initially agreed to take part, only 25% completed the home visit. That represented just 14% of all the patients who were approached.
Logistical problems included phone numbers that didn’t work, patients who changed their minds and said they didn’t want someone coming after all, or patients who cancelled because they had home health services and didn’t understand how coaching differed from the clinical care provided by home health. Others said they felt overwhelmed by having people in their homes so soon after a hospitalization.
That was also one of Dr. Stauffer’s findings. “They would say, ‘I don’t want you coming into my house,’ or ‘I know what I’m doing. I don’t really need this,’ ” he says. Even some patients who figured out what the transitional care program was all about were reluctant to let a stranger into their home.
In Rhode Island, Ms. Voss says her group tried to improve patient participation by attempting to reach patients at multiple phone numbers, calling several times, and speaking with caregivers when they were available. But when coaches arrived at a patient’s door and no one answered, they had to move on.
“This speaks to the whole idea of coaching,” Ms. Voss says. “It’s useful for some people, but we need to weave self-management into the normal care that patients receive so there’s ultimately less need for a coach.”
That means that hospitals should look for ways to more effectively incorporate education and coaching into their daily workflow. “It’s about interacting with patients in such a way that they want to be engaged in their care “and they expect to be held accountable,” says Ms. Voss. For example, nurses administering medications could show patients their pills at every medication pass. They should also ask patients to identify what each of those pills is for at least once during patients’ hospital stay.
Patients also need to know the symptoms that should prompt a phone call to a clinician or an urgent visit and the importance of scheduling primary care follow-up. And primary care physicians could help support post-discharge education by making prompt post-hospital appointments available. Such solutions would at least start helping patients better manage their own care “without that barrier of one more person trying to get into the home,” Ms. Voss says.
Refining the program
Dr. Stauffer hopes that as the Baylor program matures, it will achieve the kind of cachet now enjoyed by a transitional program the health care system created for diabetes outpatients. When that initiative was first launched a couple of years ago, many patients were resistant. Today, however, when patients with diabetes come to the hospital, they ask, “How do I get into the clinic?”
Baylor’s transitional care program for heart failure is already finding ways to do better. When the initiative started, nurses would see patients one time, then follow up the next week, then again two weeks later. Over time, the nurses have gotten much better at recognizing which patients need to be watched more closely.
Now, when they see that patients have good family support and can answer questions about their medications, the nurses leave a phone number and check back later. As a result, they can make fewer visits and see new patients instead. That helps bring down costs.
Despite the fact that the program is still losing money, it’s been expanded to another Baylor hospital. In addition, project leaders have earned a three-year grant (from Deerbrook Charitable Trust) to expand the program this March to patients with pneumonia and to even more hospitals in the Baylor system.
Baylor is also considering adding a call center where non-nurses would check on patients and ask, for example, if they’re taking their medications. Team nurses would then focus on patients who need more intervention. “The question is how we determine that,” Dr. Stauffer says.
While he acknowledges that a hospital with tighter margins might not be able to support a program until payment changes occur, Baylor can. And the hospital system is already seeing light at the end of the financial tunnel: It is now negotiating with Aetna and other third-party payers to offer the transitional care program to its members “and reimburse the hospital for its costs.
“If they don’t have to pay for another hospital admission, they’re happy,” Dr. Stauffer says. “And we’re happy if they cover the cost and we can fill an open bed with a surgery patient that makes us more money. That’s a different relationship than we’ve previously had with insurers or Medicare. It’s a win-win for everybody.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.