How to chip away at preventable readmissions

Key takeaways:

• Hospitals are identifying patients at high readmission risk and targeting them for interventions.
• Facilities are setting up post-discharge calls and virtual visits to double-check patients’ medications and make sure they have the refills they need.
• Hospitalists are paying more attention to advanced care planning discussions to head off readmissions.
• Health systems are giving primary care doctors incentives to fit in post-discharge visits sooner.

SINCE THE CMS began its readmission-penalty program more than 10 years ago, hospitalists have been under the gun to reduce preventable readmissions. According to Kevin Sowti, MD, MBA, hospitalist group medical director at Penn Medicine Chester County Hospital in West Chester, Pa., that pressure has only grown since the pandemic.

“I would say it’s the perfect storm,” says Dr. Sowti, who’s also his hospital’s chief quality and safety officer.

He ticks off the reasons why he believes “perfect storm” applies: Reimbursements to hospitals from both government and private payers continue to decline, and health systems have taken on more risk. In addition, many seasoned clinicians retired during the pandemic, leaving some hospitals still short-staffed. And more patients now are on government-funded plans—Medicare and Medicaid—that pay less than private payers.

“For hospitalists,” Dr. Sowti says, “that all gets translated to, ‘We need you to reduce length of stay, and we don’t want preventable readmissions.’ While we all agree that reducing waste in readmissions is good for everyone, hospitals now are under a significant financial burden to survive.”

“A lot of our readmissions tend to be toward the end of life.”

Catherine Raver, MD
Baylor University Medical Center

So what are hospitals and health systems doing to try to prevent readmissions? A key study that appeared in the June 2018 Annals of Internal Medicine looked at the preventability of early vs. late hospital readmissions. “Early” was defined as within seven days of discharge, while “late” were readmissions occurring between eight and 30 days after discharge.

The authors’ conclusion: “Early readmissions were more likely to be preventable and amenable to hospital-based interventions.” (In fact, researchers estimated that as many as 36% of early readmissions could be prevented.) To stave off late preventable readmissions, on the other hand, the research found that more targeted outpatient and/or home-based interventions were needed.

But given that facilities are on the hook for the full 30 days post-discharge, here’s a look at what hospitals and health systems are doing to chip away at the number of all patients who bounce back.

Making readmissions a quality incentive

In Dallas, Catherine Raver, MD, chief of hospital medicine at Baylor University Medical Center in Dallas, part of Baylor Scott & White Health, says that she and her colleagues have very much taken to heart that 36% figure of readmissions within seven days that may be preventable.

In fact, Dr. Raver heads a committee that reviews every bounceback to her hospital within seven days. That committee, which has been sitting for more than two years, has looked at nearly 400 readmissions.

“We do an analysis of demographic factors and to see if our group—or a consultant—had an opportunity to do something different,” Dr. Raver says.

To help keep hospitalists’ focus on preventing early readmissions, the hospital factors readmissions into hospitalists’ quality incentives.

“My heart sinks every time I hear a consultant say, ‘Our office will call the patient to schedule follow-up.’ No, I want it scheduled now, and I want that appointment on the discharge paperwork.”

Jeremy Jaskunas, MD
UnityPoint Health-Meriter Hospital

On the hospitalist group’s Epic dashboard, Dr. Raver explains, hospitalists can drill down and see their rate of seven- and 30-day readmissions, as well as the group’s collective seven- and 30-day readmission rates. Part of their quality incentive is pegged to the group’s—not the individual’s—seven-day readmissions.

“We want to target those things that hospitalists actually have some control over,” says Dr. Raver, “and providers in my practice really have no control over patients’ access to primary care physicians in Dallas-Fort Worth.” They do, however, “have control over asking patients before discharge if they need refills. We can control if the med rec is done correctly and if patients would benefit from having a virtual transition appointment after discharge.”

A key role for pharmacists

At UnityPoint Health-Meriter Hospital, a community teaching hospital in Madison, Wis., hospitalist Jeremy Jaskunas, MD, points out that many of the interventions his hospital has implemented over the years to head off preventable readmissions are now “woven into the background” of hospital care.

Social workers and nurse case managers “see virtually every patient and troubleshoot those issues that feed into readmissions,” Dr. Jaskunas says. At the top of that list are socioeconomic factors that drive readmissions, such as not having transportation to follow-up appointments.

Four nurses who work within the hospital medicine department now devote themselves to transitions of care. They follow up after discharge on patients who don’t have a primary physician or whose care plan is complicated.

Disease-specific protocols for conditions associated with high rates of preventable readmissions such as heart failure and COPD are embedded in the hospital’s EHR. Part of the protocol for hospitalized COPD patients is to have respiratory therapists make sure patients know how to use their inhaler.

“Patients who don’t have a primary physician all get their transitions of care management visit via telehealth.”

Preetham Talari, MD, MBA
Ballad Health

And outpatient pharmacists—who staff a pharmacy onsite at the hospital—take the opportunity while patients are still hospitalized to educate them about their medications. Confusion over medications or patients not having the refills they need factor into a sizeable number of readmissions.

“Often, an outpatient pharmacist will come to a patient’s room on the day of discharge,” Dr. Jaskunas says. The pharmacists go over patients’ medication lists and make sure they understand their care plan and prescriptions.

Pharmacists also, he adds, troubleshoot insurance coverage. That’s one reason why he encourages all his patients at discharge to fill any new prescriptions they have at the outpatient pharmacy onsite.

“Then patients will have their meds in hand when they leave,” says Dr. Jaskunas, “and I know there won’t be surprise insurance issues like, ‘What you ordered isn’t covered.’ ”

Using hospitalization for education

In Dallas, Dr. Raver points out that her hospital, which has 900 beds, is part of the largest not-for-profit health system in Texas. The facility is also large enough that clinicians can staff transition clinics for diseases at high-readmission risk including COPD and heart failure. Still, her colleagues have learned to bring some interventions that traditionally occur post-discharge in outpatient clinics into the hospital before patients leave.

Patients who are post-stroke, for instance, are now given blood pressure cuffs while they’re still hospitalized—and taught before discharge how to use them. The facility is working to do the same with continuous glucose monitors and insulin pens (along with education on how to use them) for patients with diabetes before they leave.

“We have an outpatient endocrinology transition clinic,” Dr. Raver notes, “but many people with outpatient appointments don’t show up. Because we have a moment with people while they’re in the hospital, let’s take advantage of that and do what education we can there.”

Goals-of-care discussions for those with terminal illness are also increasingly a target for hospitalist intervention.

“Giving patients the right diuretic dose, such as twice their amount of home diuretics, as their first dose in the ED, then monitoring their response by volume or urine sodium, actually reduces preventable readmissions.”

Kevin Sowti, MD, MBA
Penn Medicine Chester County Hospital

 

“A lot of our readmissions tend to be toward the end of life,” Dr. Raver points out. “We focus on whether patients have had an advanced care planning conversation in the last six months.” If not, “we try to have those conversations with patients and families.”

That’s also a push for Dr. Sowti and his colleagues at Penn Medicine Chester County Hospital outside Philadelphia.

“A lot of oncology patients don’t want to be in the hospital because there are really no interventions we can do,” he says. “Having those conversations early and continuously and moving to hospice care sooner really makes an impact on preventable readmissions.” Moving goals-of-care discussions up earlier in a patient’s disease process, Dr. Sowti adds, “is probably the one place we need to continue to work on.”

After patients leave

According to Dr. Sowti, hospitalists actually have control over perhaps 10% to 20% of all 30-day readmissions.” As for the other 80%, he adds, that largely depends on outpatient resources.

“You must have the right setting where you can send the patient and the right structure to help the patient not come back to the hospital”—an often daunting prospect, particularly for patients who are underinsured.

“There is just no good place for them to go or have a warm handoff, or a specialist to be seen,” says Dr. Sowti. Even for insured patients, it has become “really tough to find an appointment anywhere in America these days with a urologist within two weeks of discharge, or a cardiologist or a GI doc.”

In Madison, Dr. Jaskunas says that his hospital has a good partnership with University of Wisconsin. But if a patient about to be discharged needs a specialist appointment, he worries that they won’t be seen as quickly as they need to be.

“My heart sinks every time I hear a consultant say, ‘Our office will call the patient to schedule follow-up.’ No, I want it scheduled now, and I want that appointment on the discharge paperwork. I want to make sure that this will happen because patients may or may not be scheduled in the timeframe I’ve requested.”

Within Penn Medicine, Dr. Sowti says the health system “leans very heavily on our primary care physicians.” It helps that primary care physicians throughout the health system are incentivized to make post-discharge appointments sooner.

“It’s part of PCPs’ quality measures,” he notes. “Having discharged patients see their primary physician is one big push we’re making.” Other top priorities: coming up with more population health strategies and adopting good predictive models to stratify high-risk patients for interventions.

Virtual visits and telehealth

But Dr. Raver points out that in her area—Dallas-Fort Worth, which continues to grow—the primary care shortage is only getting worse.

She also notes that many early, preventable readmissions happen sooner than seven days. “If our only goal is to have a discharged patient seen by a primary care physician within a week,” she says, “then we’ve missed the boat.”

To help head off early readmissions, all Baylor Scott & White hospitals maintain discharge hospitality lounges.

The discharge nurses who staff that lounge at Baylor University Medical Center aim to call all patients discharged home by a hospitalist the next day to see how they’re doing and if they have questions about their care. Those nurses have a hospitalist and a care manager at their disposal to address any needed escalations.

“We’ve found that one big reason people readmit is that they don’t have a refill or the med rec had an error that’s causing confusion,” says Dr. Raver. Utilizing that resource has helped reduce readmissions—”and patient satisfaction scores in our hospital have also improved.”

In addition, the health system now offers virtual appointments within 48 hours for patients at high risk of being readmitted. “High risk,” Dr. Raver notes, is based on a risk assessment run in their EHR.

At Ballad Health, a health system with 20 hospitals serving 29 counties within four Appalachian states, Preetham Talari, MD, MBA, vice president, clinical transformation and outcomes optimization, says that his system likewise plans to utilize readmission tools embedded in Epic to identify patients at high readmission risk.

“We realized that the Epic readmission cognitive model is more specific and a better tool,” Dr. Talari says. That tool, with an algorithm that relies on several dozen factors, stratifies and color-codes patients (red, yellow, green) by readmission risk while they’re in the hospital.

“All our teams working on readmissions—case management, pharmacy, providers, primary care—focus on those particular patients to help them stay where they need to be post-discharge,” Dr. Talari explains.

He adds that Ballad Health maintains some transitions-of-care clinics and that some facilities are piloting how to standardize setting up post-hospital follow-up appointments. All too often, he notes, those appointments don’t have “good reliability.”

“Some patients get them and some don’t,” Dr. Talari says, “and some patients receive them but they weren’t asked what would be a good time and date, so they don’t show up.” Right now, he and his team recommend taking patient feedback into account around those appointments to devise a standard operating procedure for “who makes these appointments and how they make them.”

At the same time, Dr. Talari points out that Ballad Health has “a significant number of unattached patients”—those who don’t have a primary physician. “All of them, by default, get their transitions of care management visit via telehealth.” He notes that the health system, with its sizeable geographic footprint, is increasingly relying on “this big umbrella of digital medicine.”

One facility within Ballad Health is doing remote post-discharge patient monitoring, giving patients with either heart failure or COPD a wearable device. “Care coordinators keep an eye on the data being sent and they may make a recommendation: to increase a medication dose, have a follow-up appointment or tell a patient to go to the emergency department.”

Visiting-provider programs and ED innovations

Dr. Sowti notes that discharged patients in his health system, like in Dr. Raver’s, get a phone call within a day or two of discharge. The focus of that call is medications and making sure patients understand what they’re supposed to be taking.

He also points out that Penn Medicine keeps expanding its visiting nurse programs for patients post-discharge. Providers who visit patients at home have been particularly helpful for sepsis survivors and for those with heart failure. The visiting nurses also help educate patients and family members so they know who to call if patients get in trouble at home.

That helps keep discharged patients out of the hospital. “That’s a big win when the patient doesn’t hit the ED,” says Dr. Sowti. “One thing we’ve found is that we’ve lost the battle if a patient lands in the ED because there’s a high chance those patients will be readmitted.”

The hospitalists in his group have worked with ED staff on protocols for returning heart failure patients, most of whom end up in the ED because they need increased IV diuretics.

“We have learned—and this was a surprise to me—that giving patients the right diuretic dose, such as twice their amount of home diuretics, as their first dose in the ED, then monitoring their response by volume or urine sodium, actually reduces preventable readmissions,” he says. It also reduces length of stay if patients do get admitted.

For Dr. Raver in Dallas, a recent innovation in the ED has likewise reduced some readmissions.

“We’ve partnered with our emergency room to have what we call ‘social holds,’ ” Dr. Raver says. Those holds are patients who present back to the ED after discharge without any medical reason to be readmitted or placed in observation.

“It’s often people who we’ve encouraged to go to a SNF but they wanted to go home,” she says. “Or they were discharged home but realized they’re just not as strong yet as they need to be.”

Typically, Dr. Raver adds, “with aggressive care management, we’re able to get these patients placed in a post-acute facility very quickly. It avoids having to use an inpatient bed.”

Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.