Home Cover Story Preventing readmissions

Preventing readmissions

Any more juice to squeeze?

October 2017

The latest round of hospital readmission penalties, which take effect Oct. 1, will reach $564 million for fiscal year 2018, an amount that’s $27 million more than this year’s. While only about 100 hospitals will be assessed the full 3% maximum, three-fourths of eligible hospitals will be hit with some level of penalty.

Before you read the article, check out what our readers knew about preventing readmissions.

Complaints about the penalty program have long piled up. One beef is the fact that the Centers for Medicare and Medicaid Services (CMS) doesn’t adjust readmission rates for socioeconomic factors, which unfairly dings safety-net hospitals. (That adjustment should begin in 2019.) Critics also complain that the program punishes hospitals for a host of other factors beyond their control, like patient compliance.

And when this year’s penalties were announced, commentators noted that the pace of readmission reduction has really slowed, with some reports claiming that average rates fell only 0.1% between 2013 and mid-2016. Haven’t all the preventable readmissions already been accounted for, experts asked, and isn’t it time to retire the penalty program?

“The focus on readmissions is going to ramp up and be unrelenting.”

Greeno~ Ronald Greeno, MD TeamHealth

“There’s only so much juice in the orange, and we’ve squeezed out a lot,” says Daniel Brotman, MD, director of the hospitalist program at Baltimore’s Johns Hopkins Hospital. Dr. Brotman was the lead author of a study published in the September 2016 issue of the Journal of Hospital Medicine that pushed back against the notion that readmissions can be a proxy for hospital quality. According to that research, facilities with the highest hospital-wide readmission rates were more likely to have the lowest mortality rates for three common conditions.

But while many hospitalists admit they’re weary of the pressure to reduce readmissions, groups are still identifying new opportunities to drive all those rates down. And even if hospitalists believe they’ve tapped every readmission-prevention source, those who think the focus on readmissions may go away are fooling themselves.

“I have no idea if the CMS will get rid of the penalty program,” says Ronald Greeno, MD, senior advisor for medical affairs at TeamHealth, as well as this year’s Society of Hospital Medicine (SHM) president and long-time chair of SHM’s public policy committee. But given the ongoing push from the CMS and private insurers to aggressively move to value-based purchasing, “the focus on readmissions is going to ramp up and be unrelenting.”

A burden for safety-net hospitals
Because his hospital is in Maryland, Dr. Brotman points out, it’s exempt from federal readmission penalties. Maryland runs its own readmission program for hospitals in the state, and Johns Hopkins this coming year will receive a bonus.

But “if we were eligible for the CMS program,” Dr. Brotman says, “we would be in the readmission penalty zone. That underscores how sensitive these metrics are to certain, somewhat arbitrary factors, such as disease-based exclusions, and which types of patients are included, such as Medicare patients only or all-payer patients, as in Maryland.”

Given Johns Hopkins’ tremendous reach and resources, the powerhouse system has implemented a long list of readmission-prevention initiatives. While Dr. Brotman agrees that socioeconomic issues should be factored into readmission rates, he doesn’t believe federal penalties should be entirely retired.

“Readmissions are just one more health care add-on that we’re trying to control among competing priorities.”

vashist~ Amit Vashist, MD, MBA
Mountain States Health Alliance

“I think it’s healthy to have hospitals focused on readmissions and to have some incentives to do so,” he says. “And I certainly like practicing in the current Hopkins care model much more than in the old one, where patients left the hospital and I had no further tools to help take care of them.”

But Amit Vashist, MD, MBA, system chair
of hospital medicine for Mountain States Health Alliance, a 13-hospital health care system in Virginia and Tennessee, isn’t so sanguine.

“Quite a few of our hospitals have been dinged with penalties, some to the full 3%,” says Dr. Vashist. And given the socioeconomic realities in Appalachia where his hospitalists serve, “we will always see more than our fair share of readmissions as the safety-net hospitals.” Readmissions are something the hospitalists “follow and try to get better at. But we don’t have as much enthusiasm for these initiatives as perhaps we do for ones that improve clinical documentation, embrace high-value care and reduce unwarranted clinical variation.”

What’s worked
That hasn’t stopped Dr. Vashist’s system from putting innovations in place to reduce readmissions. Clinicians rearranged staffing at a postop clinic that serves joint replacement patients, for instance, to make more hours available at the beginning of the week. That’s helped patients who have concerns over the weekend.

“That led to a dramatic reduction in those readmission rates,” he points out. It also helped to clearly define comanagement responsibilities for joint-replacement patients with medical comorbidities, with “better definition of who’s responsible for pain control, DVT prophylaxis and discharge.”

In larger markets, the system has appointed RN coordinators for heart failure, COPD and pneumonia to follow patients after discharge. Outpatient heart failure clinics staffed by advanced practice providers have opened, while one facility launched a transitional care clinic last year staffed by two NPs/PAs who work with the hospitalist team.

“Give ED doctors some skin in the game.”

Nicole Jones~ Nicole Jones, DO
John Muir Health

In the future, says Dr. Vashist, primary care physicians will be able to refer patients to that clinic, allowing providers to aggressively intervene—with IV diuresis, for example—and head off a possible readmission. Also being planned: additional heart failure clinics, and a palliative care service in the system’s level I trauma center.

In addition, Dr. Vashist says, hospitalists in the past year have received intensive training “to increase their comfort level with end-of-life conversations, especially in patients with frequent readmissions who are nearing end of life.”

And in all markets, “I’ve started both informal and formal forums among ED doctors, hospitalists, outpatient physicians, post-acute care and consultants, who meet quarterly,” he says. “A large part of that conversation is driven by readmissions.” Dr. Vashist also plans to move at least one hospitalist team into a post-acute facility “to optimize care transitions.”

No “knockout punch”
One intervention that hasn’t worked, says Dr. Vashist, is incentivizing hospitalists through performance bonuses to reduce their group readmission rates. “We discontinued that last year,” he says. “There was no way to make that attribution fair. It’s unfair to pinpoint who’s to be dinged for having caused readmissions: the hospitalists, case managers, ED physicians, primary care docs or the patients themselves.”

Another frustration: having to pursue what he calls “a whack-a-mole kind of strategy. We found that when we started reducing heart failure readmissions, we’d see a spike in COPD and pneumonia readmissions.”

And after five years, “a huge subset” of his hospitalists “feels that readmissions are just one more health care add-on that we’re trying to control among competing priorities,” Dr. Vashist says. “Some months it’s readmissions, while others it’s length of stay, documentation improvement, high-value care or patient experience.” When it comes to designing initiatives to prevent readmissions, he explains, “I see myself as a pugilist, a jabber, and so far, I have not found my knockout punch.”

Mismatched incentives
One big challenge in getting hospitals to pursue new ways to prevent readmissions, says TeamHealth’s Dr. Greeno, is that most health care systems are still operating under fee-for-service medicine.

“We’re particularly targeting readmissions due to lack of social support.”

aboutalib~ Angela Aboutalib, MD
US Acute Care Solutions

“Hospitals get penalized,” he explains, “but they also make money on that readmission. You can’t provide any kind of service at scale that can tackle readmissions unless you can make a business case to get reimbursed for it.”

But that’s changing, Dr. Greeno notes, as the CMS develops more advanced bundled payment and ACO models, which should deliver more resources to help tamp readmissions down. The focus on readmissions, he adds, “will continue but for a different reason: not because of penalties, but because health care organizations will be taking risk.”

A good example can be found in John Muir Health, an integrated delivery system in San Francisco’s East Bay that has long had innovations in place to rein in all readmissions. The system has, for example, transitional coaches who target frail and elderly patients or those struggling with clinical, function or compliance problems.

But John Muir is now taking partial or full risk for some patients, explains Nicole Jones, DO, associate medical director for the John Muir Medical Group’s hospitalists, who cover three hospitals. Risk-based patients include those in the CMS’ comprehensive care for joint replacement (CJR) program, as well as patients in John Muir’s own Medicare Advantage plan.

To prevent joint-replacement readmissions, the preop clinic director has worked with both the ED physicians and the hospitalists to let them know “what a fresh postop knee looks like, so patients aren’t readmitted who don’t actually have cellulitis,” says Dr. Jones. New order sets and clinician education also target common postop complications—constipation, UTIs—to keep patients from returning to the ED in the first place.

And Dr. Jones, who’s also a physician advisor for case management, meets every Friday with both inpatient and outpatient multidisciplinary care teams to review every Medicare Advantage readmission.

“We pull information not only from the EMR, but from a variety of sources to figure out what happened,” she says. “Was it a compliance problem where patients wouldn’t accept home health, a problem with discharge instructions or a system problem?” Some readmission cases are referred to peer review, while Dr. Jones reaches out to the discharging physician in others.

One big theme that crops up in those sessions: ED doctors aren’t incentivized to prevent readmissions or avoid unnecessary ad-missions. While that’s no fault of the ED, says Dr. Jones, it is a huge opportunity.

“ED turnaround time is such a high-pressure metric that it’s easier to readmit or admit patients than spend more time with them, treating them with the goal of sending them home,” she says, pointing to publicly-reported ED performance measures. She’s been criticized, for instance, for keeping a patient in the ED for another four hours with IV fluids and orthostatics, instead of admitting them.

“My response was, ‘Isn’t that better than inappropriately readmitting them?’ ” To prevent further readmissions, she adds, senior administration needs to “give ED doctors some skin in the game,” instead of maintaining “separate groups with separate metrics.”

A new flagging system
Preventing readmissions from the ED is getting a major push at two hospitals—Somerset Hospital and Indiana Regional Medical Center, both in western Pennsylvania—where US Acute Care Solutions, a national physician-owned company based in Canton, Ohio, staffs both the ED and the the hospitalist programs through its integrated acute care division.

“All patients who present to the ED are asked if they’ve been hospitalized within the past 30 days,” says Angela Aboutalib, MD, the company’s medical director of clinical operations. Patients who answer “yes” are automatically considered high risk and flagged within the EHR.

That flag may trigger an immediate phone
call to the hospitalist to work with the ED to prevent a readmission. “Or a social worker becomes involved, instead of letting the ED
go through an entire workup,” Dr. Aboutalib
 says. An integrated acute care nurse also 
calls patients’ primary care physician or specialists to “come up with a disposition and a
plan before the patient is discharged from the ED.”

For patients who are readmitted, a high-risk clinical team—case managers, social workers, physical therapists, dieticians, palliative care and pharmacists—screens them in the hospital to help prevent them from bouncing back again, she points out.

“We also have 72-hour follow-up phone calls with a patient care liaison,” Dr. Aboutalib says, “to make sure high-risk patients get proper follow-up post-discharge.” In one of the two hospitals, she adds, the high-risk screening program still uses the LACE score to assess patients’ readmission risk. However, the high-risk team in the other hospital has started using the BOOST scoring tool, which assesses eight variables, not four as with LACE.

“The LACE score doesn’t give you the psychological perspective,” she notes. Because the ED-flagging system and BOOST scoring system have been up and running only several months, the company doesn’t yet know the effect on readmission rates. But they hope to see an impact after six months, she says. “We’re particularly targeting readmissions due to lack of social support.”

Readmissions from SNFs
US Acute Care Solutions also staffs several SNFs. In those facilities, a SNFist provides care with an advanced practice provider (APP), who divides his time between the SNF and the hospital. “When our SNF staff doc or APP sends the patient to the ED,” says George Mitri, MD, chief medical officer of the company’s integrated acute care division, “they’re also calling the ED with a clear ask.”

That points to another major avenue of potentially preventable readmissions: post-acute care settings like SNFs. “In many parts of the country,” says TeamHealth’s Dr. Greeno, “that care is massively over-utilized and poorly managed. The most gains in the entire health care system are to be made in the post-acute space.”

Hospitalist Bennett Clark, MD, led a study published in the August 2017 issue of the Journal of Hospital Medicine. In that research, Dr. Clark—who at the time practiced at Yale-New Haven Hospital in New Haven, Conn., but now works at the University of Minnesota Medical Center in Minneapolis—interviewed more than two dozen clinicians from 15 skilled nursing facilities about why they believe patients bounce back to hospitals from SNFs within 30 days.

As for hospitalist-level interventions that SNF clinicians felt could affect readmissions, one big factor was goal-setting and goals-of-care interventions. One problem, for instance, was hospitals sending patients with end-stage disease to a SNF instead of to palliative care.

“The SNF clinicians have to then have that goal-of-care discussion,” says Dr. Clark, “but they have less credibility with family and patients than hospital clinicians.”

An even bigger perceived problem fueling SNF readmissions was systems issues with referrals and care coordination and how hospitals decide which SNFs to refer patients to. According to SNF clinicians, that referral process leads to “a mismatch in patient needs,” with care coordinators in hospitals not ensuring that patients are transferred to SNFs with the clinical capabilities they need. Some SNFs, for instance, don’t have wound vacs or the ability to provide PRN IV furosemide.

“That’s a hospital management issue, not a clinician issue,” Dr. Clark points out. While he finds that case managers are generally “pretty savvy” about SNF capabilities, “they are under pressure to discharge, so it becomes a length of stay concern. Do you keep a patient in the hospital until a bed opens up in an ideal SNF? Or do you take your third choice and discharge the patient?”

The good news, he adds, is that the CMS plans to start assessing readmission penalties on SNFs starting Oct. 1, 2018. That means that “SNFs will be incentivized to figure this out.” In preparation, SNFs are now “expanding their clinical capabilities to handle more acute admissions without referrals back to the ED.”

Moreover, says Dr. Clark, if EDs develop a better sense of how much effort SNFs are putting into developing those expanded capabilities, “they might be more comfortable sending patients back to the SNFs, not readmitting them.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Final frontier: patient engagement
WHEN IT COMES to finding new ways to reduce readmissions, Daniel Brotman, MD, director of the hospitalist program at Baltimore’s Johns Hopkins Hospital, makes this observation: “What is most interesting in our internal data is how big a discrepancy there is between readmission rates for patients who engage vs. those who do not.” Patients who, for instance, do not receive transitional interventions or patient-access phone calls “get readmitted far more frequently than those who get those interventions.”

Hospitalists will be very familiar with the factors—poverty, substance use and mental illness—that predict which patients won’t engage with available interventions, Dr. Brotman adds. Some health systems, including the University of Illinois Hospital in Chicago, have gone so far as to invest in permanent housing for their chronically homeless patients as a way to keep those patients from consistently returning to the hospital.

But moving forward, says Dr. Brotman, “I hope we as a society will decide that it is not sensible to assign hospitals that kind of responsibility.” Readmission penalties have helped hospitals recognize that the care they provide is just part of a long episode. And “we now have a much better safety net, but we are still not reaching some patients. We need to transition the ownership of some of these services to the community so they can be sustained long-term, not just for 30 days.”

A future for bundled payments?
THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) recently decided to shelve a mandatory bundled-payment program for cardiac care that would have applied in many metropolitan markets to MI, CABG and cardiac rehab patients. At the same time, the agency significantly pared back a mandatory joint-replacement payment bundle that’s been in effect since spring 2016.

Ron Greeno, MD, senior advisor for medical affairs at TeamHealth, has no problem with that change of plans. “The mandatory bundles didn’t even give physicians the option of taking risk, and we didn’t think that was fair,” he says. “As far as we were concerned, the way those mandatory bundles were set up was unfavorable to physician groups.”

As for voluntary bundled payments, on the other hand, “it’s full speed ahead,” Dr. Greeno notes. He says that this year’s political ferment over possibly repealing the Affordable Care Act has not dampened Medicare’s commitment to value-based purchasing and that the CMS continues to develop new (and voluntary) ACO and bundled payments for care improvement (BPCI) models. In both the existing and developing models, readmissions receive “a tremendous amount of focus.”

Then there’s the Medicare Access and CHIP Reauthorization Act (MACRA), which passed in 2015 and is slated to affect how doctors are paid beginning in 2019. Under the current rule, most physicians would be paid under MACRA’s merit-based incentive payment system (MIPS), with payment determined by physician performance in four areas. One of those areas is quality, which accounts for 60% of physicians’ composite MIPS score—and one factor in the MIPS quality measure is readmission rates, at least for doctors in groups of 16 or more.

The more attractive MACRA payment path, says Dr. Greeno, would be to be paid through an alternative payment model (APM) in which doctors (as well as hospitals) take some risk for patient outcomes. Unfortunately, most hospitalists right now don’t qualify to be paid via an APM.

But a new MACRA rule proposed this summer, which hadn’t been finalized yet at press time, would offer hospital-based physicians (including hospitalists and ED and critical care physicians) a facility-based option. Doctors would be able to choose to have their individual performance scores tied to their facility’s.

And under any model where doctors and hospitals take risk, readmissions and how to prevent them become key factors. While Dr. Greeno says he has no doubt the current readmission penalty program could be improved, “the overall focus of providers on readmissions is going to continue, just because of everything else that’s going on.”

Strategies to prevent readmissions
WHAT WORKS TO PREVENT readmissions? According to Daniel Brotman, MD, who directs the hospitalist program at Johns Hopkins Hospital in Baltimore, one consistent strategy for success is putting multiple strategies together. “One thing suggested in the literature that I agree with is that bundles of strategies work better than individual ones alone,” he says.

In developing interventions to reduce readmissions, Johns Hopkins has followed that rule. For patients post-discharge, for instance, a team of nurses makes structured phone calls, while transition guides and community social workers work with some higher-risk patients at home for 30 days after they leave the hospital, often free of charge. A pharmacy group delivers medications to patients before they leave the hospital and may continue to provide medications, again free of charge, for 30 days.

A post-discharge clinic—called the After Care Clinic—is available for patients who don’t have primary physicians or who can’t get to them soon enough after discharge. That clinic is staffed by physicians, nurses and social workers, and both the hospitalists and the ED doctors can refer patients there, allowing ED doctors to avoid admissions and readmissions. A heart failure bridge clinic can diurese patients, while an infusion clinic supplies IV fluids and blood products.

Plus, “we’re partnering with skilled nursing facilities,” says Dr. Brotman, “to make sure there are protocols in place so those facilities don’t reflexively send their patients back to us for minor post-discharge glitches.”

While patients are still in the hospital, a health study program “based on the premise that two sets of ears and eyes are better than one” has hospitalists encouraging patients to identify relatives or friends who can help in the weeks post-discharge and be present for the patient education during discharged. A behavioral health program in the hospital also screens patients for substance use issues and other concerns, while substance use programs can begin treatment.

And before they’re admitted, patients undergoing elective surgeries can access interactive videos and education modules. That makes sure, says Dr. Brotman, that “their questions are addressed when they’re not on painkillers.”

Published in the October 2017 issue of Today’s Hospitalist
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