Hospital Perspectives on Reducing and Preventing Readmissions [Healthcare Financial Management]

It violates the first law of the Hippocratic Oath: First, do no harm. However, the unfortunate fact is that, each year, hospital environments create more than 1.7 million infections - from ventilator-associated pneumonia to Clostridium difficile ana urinary tract infections - that contribute to 99,000 deaths.1 These nosocomial infections are particularly challenging because transmission may occur in different ways, including airborne and direct and indirect contact, and many patient populations are particularly vulnerable due to low levels of immunity and resistance.

Not surprisingly, hospital-acquired infections (HAIs) are drawing intense scrutiny from regulators and payers alike, who recognize that they not only are a primary result of unacceptable lapses in the quality of care, but also contribute to substandard patient outcomes that may result in hospital readmissions. These readmissions drive up healthcare costs by as much as $4.5 billion to $11 billion.2 Starting in October 2012, hospitals with high readmission rates for certain patient diseases and conditions will face reductions in Medicare payment. New healthcare reform legislation also will expand Medicare's ability to deny payments to a hospital for the extra care required to treat designated preventable infections. What's more, the hospital's performance record in these areas will be published for public and payer review.

Although hospitals continue to aggressively embrace a wide range of infection-prevention measures, such as disinfection of surfaces and equipment, frequent hand-washing/gloving, and patient isolation, perhaps the most powerful strategies for preventing HAIs and avoiding subsequent patient readmissions involve careful case management. Such strategies include discharge planning, transition plans for home care and tertiary care, and coordination with a patient's primary care providers, tertiary care facilities, and home health plans.

Unfortunately, the processes that will largely support the necessary collaboration among these care providers in various settings - data sharing, housing health information in central repositories, and properly aligning incentives - also tend to be where hospital competencies are most in need. Even though most hospital executives report feeling "prepared" or "very prepared" to manage readmissions and HAIs, many still struggle with the operational challenges associated with developing systems that support cross-continuum collaboration, according to a 2011 HFMA survey sponsored by McKesson. Of the 84 healthcare executives surveyed by HFMA, only 18 percent feel "very able" to consolidate and provide access to complete data across the continuum, and only 9 percent express similar confidence in integrating patient and population health data in one resource.

Anecdotal evidence supports these findings, with many hospital leaders describing internal success with managing HAIs and readmissions but expressing a desire to further strengthen relationships and data sharing with physician practices, payers, and even recently discharged patients and their families.

Successes Taking Place Inside the Hospital's Walls

HAIs are an important indicator of a hospital's quality of care, making it essential to track and report these incidents carefully. Clinicians need continual updates to best manage the hospital's prevention and improvement efforts.

Participants in a recent HFMA roundtable generally feel comfortable with the level of HAI data tracking and sharing taking place within their organizations.3 "Our clinical department leaders are getting that information and filtering it down to our clinical staff so that they can identify trends and make interventions necessary to improve our results," notes Terry Brennan, FHFMA, controller at Arizona'sYavapai Regional Medical Center.

Having such information is key to motivating change, he says, citing as an example an intervention taken by the medical center when they implemented a program to successfully address C. difficile within the facility. Experts in infection prevention monitored hand-washing techniques, shared the data with clinicians, and devised policies to improve practices, such as placing posters on transmission prevention in strategic areas. Staff were kept apprised of the occurrence of C. difficile infections in their areas, so they would see the success of their efforts. The program was credited with decreasing infection occurrences from six to one per month.

Data use also can be an important tool in managing readmissions. At Florida Hospital, a health system that includes eight hospitals throughout the Orlando area, an approach called "LACE" is helping address the likelihood of readmissions by flagging instances with high length of stay, acuity, comorbidities, and emergency department visits. Points are assigned for each of these four metrics. When the score exceeds a threshold, the patient is deemed highly likely to be readmitted, warranting further preventive/interventional measures.

"We're looking at creative ways to apply the data," says James English, the system's administrative director of revenue management. "The first pass of our data showed some good reliability, so we're looking to use this - even while the patients are still in-house - as a 'living score.' When a patient is 10 tol5 percent above the LACE benchmark, then we intervene in the discharge-planning process and take additional steps to help ensure that the patient doesn't need to return." The organization has scored every patient for about 12 months - more than 1,000 patients - and is getting excellent accuracy. "It's a lot more informative and useful than the traditional practice of looking retrospectively at why a patient is back in the hospital," he says.

Cross-Continuum Collaborations

Of course, hospitals should not be alone in their efforts to reduce readmissions. The coordination of discharge processes and communication of after-care protocols is best supported by providers across the care continuum, such as patients' primary care physicians, tertiary care staff, and home healthcare providers.

According to Florida Hospital's English, it's essential to make everyone aware of the implications of various choices and decisions regarding the patient's care plan. "There is no substitute for awareness," he says. "Yes, it's a challenge, but we strive to let our partners in the community, such as those working at nursing homes and clinics, know what's transpiring with readmissions. Such communication helps us achieve a better level of cooperation."

The hospital's data typically drive these discussions. Says English: "We're basically taking a list and saying, 'OK, here are the five patients readmitted last month. What has happened with our processes that we can improve?' Just this simple act of reviewing together means that we can perhaps forestall the instinct of our partner to say, 'OK, let's just check the patient back into the hospital.' If we can avoid that revolving-door situation even a little bit, it has a meaningful impact. I think it's the No. 1 thing we can do."

Many hospitals appear to be recognizing the power of such conversations, with 79 percent of participants in the 2011 McKesson-sponsored HFMA survey ranking consolidation and provision of access to complete patient data across the care continuum as "important" or "very important" to ways their organization is addressing health system change.

Payer Efforts

At present, payers often are a primary keeper of crosscontinuum patient data. As such, many readmissionreduction initiatives are occurring between hospitals and health plans.

"Our payers are helping us significantly in this area," notes Bradley Olson, director of payer relations and contracting at Centura Health, a Colorado not-forprofit system that includes 13 hospitals, seven senior communities, home care, and hospice care. "We have one payer that is providing us with quarterly data that essentially says, 'Here are the readmissions that you're getting from this skilled nursing facility or these providers. Here are the physicians that are having a harder time with readmissions. Here are the diagnoses your facility is struggling with.' We're passing this information on to our nursing leadership, who then work with case managers and address potential issues or opportunities for improvement with the units or external care givers together."

Some efforts with payers are even going to the next level, where such information sharing and the efforts that result are being reflected in how the hospital is being paid.

As an example of such partnerships, Daniel Rinaldi, FACHE, FHFMA, vice president of financial services at three-hospital system Ellis Medicine, based in Schenectady, N.Y., describes a program taking place with his organization: "One of our major payers has entered into an arrangement where we're paid for the readmissions we avoid. Let's say that we have a 20 percent benchmark for cardiac surgery readmissions. If we get that down to 10 percent, then they would pay us for half of those 'missed' readmissions, which we're excited about. That is a winning strategy for everyone."

Although other roundtable participants report similar interest or participation in pay-for-performance arrangements, applying this incentive structure across the care continuum presents its share of challenges. Many organizations still have a long way to go before they develop the sophisticated understanding and modeling of costs and risk across care settings that will best support adoption of a physician-hospital bundled payment structure. Although 38 percent of those responding to the HFMA survey report they feel ready for value-based payment, only a small percentage say they are "prepared" (12 percent) or "very prepared" (1 percent) for bundled payment.

Patient Compliance with Care Protocols

The other primary player in reducing readmissions is, of course, the patient. Some healthcare executives suggest a key aspect to reducing readmissions is providing patients with better motivation to follow after-care instructions.

Says Bonnie Bowls, senior vice president of revenue cycle, Florida Hospital: "Somewhere along the line, we need to address patient responsibility for complying with care instructions after discharge, because many individuals simply refuse to stick with the appropriate regimens their doctors have prescribed - and then they end up back in the hospital within 30 days."

As Rinaldi notes, a hospital has limited ability to control what takes place after the patient is initially discharged. "Once the patient is out in the community, somebody needs to track that patient," he says. "How can we intervene? We have no means to track whether the discharge instructions have been followed. For example, is the patient taking the right antibiotics and finishing them completely to fight that HAl? How we can best manage the patient while out in the community needs to be a focus."

At present, many hospitals are simply doing the best they can with limited abilities for follow up. For example, Florida Hospital has taken some added steps to support better community management through post-discharge follow-up practices. "We schedule an appointment with the patient within three to five days after discharge," says Bowls. "We call the patients at home to make sure there is means to make it to the appointment and will arrange transportation, if necessary. We also go over any medications prescribed at discharge and confirm instructions for proper use. In addition, we encourage patients to write down any questions about after-care that they may need to discuss with their physician. This approach really seems to work. We've seen a significant reduction in the acute MI [myocardial infarction, or "heart attack"] readmission rates, and the same is true for CHF [congestive heart failure] management."

Catholic Health Partners also is focusing on patient outreach after discharge, notes Teresa Donley, corporate director of ancillary contracting for the healthcare system, which has 24 hospitals, more than 800 employed physicians, and more than 100 healthcare facilities in Ohio and Kentucky. "Through our Care Coordination Collaborative, our hospitals are working to put in place a process where we schedule the follow-up visit with the physician for the patient upon discharge. Follow-up phone calls are placed to patients within 48 hours of discharge to make sure they understand discharge instructions and are taking medications as ordered. We also have a pilot program in some hospitals where care transition nurses visit patients in their homes following discharge and interview the patient and care givers within 24 hours. We're striving to make the discharge instructions simpler for patients to follow, and our hospitals also are working to make sure the discharge summaries reach the primary care physician within 24 hours of discharge," she says.

Of course, these efforts take resources. "There's a significant cost to support case management across the continuum of care outside the hospital, but there's no revenue attached to it," says Bowls.

Several hospital executives express frustration at bearing this cost with little to no support. "It's a no-man's land," says Rinaldi. "We have a large Visiting Nurses Association presence, and we go out into the community and try to manage the patient - but Medicare and other payers aren't yet willing to pay for these preventive measures. Industry incentives are simply off-track."

Some even suggest payers should be held financially responsible for readmissions to a degree. "Does the denial of home care by the payer factor into readmission rates?" Olson asks. "Who owns this part of the puzzle? This needs to be shared and managed appropriately."

Going Forward

Most roundtable participants predict that incentive structures will need to shift as the industry decides the best ways to reduce readmissions. This push for payment reform might explain why "readmissions and HAIs" and "value-based purchasing" rank highest in importance among those surveyed by HFMA, even coming before strategies to address newly insured patient populations and payment bundling.

"It's the right thing to do, but there's a cost," Rinaldi says. "And if we're going to emphasize community care to reduce readmissions and lower costs, we need to figure out some viable options and systemic methods to pay hospitals for their work in caring for patients out in the community."

Bowls echoes this sentiment. "At some point, when hospitals are held financially accountable for such readmissions, we need measures to support patient compliance with after-care protocols and a stronger voice in making sure the appropriate follow-up is taking place in other care settings."

ROUNDTABLE PARTICIPANTS

Bonnie Bowk is senior vice president, Florida Hospital, Orlando, Fla.

Terry Brennen is controller, Yavapai Community Hospital Association, Prescott, Ariz.

Teresa Ooniej is corporate director, ancillary contracting, Catholic Health Partners, Cincinnati.

Jarass English is administrative director, revenue management, Florida Hospital, Orlando, Fla.

Bradley Olson is director, payer relations and contracting, Centura Health, Englewood, Colo.

Daniel J. Rinaldi, FACHE, FHFMA, is vice president of financial services, Ellis Medicine, Schenectady, N.Y.

McKesson Corporation, currently ranked 15th on the FORTUNE 500, isa healthcare services and information technology company dedicated to making the business of healthcare run better. We partner with payers, hospitals, physician offices, pharmacies, pharmaceutical companies and others across the spectrum of care to build healthier organizations that deliver better care to patients in every setting. McKesson helps its customers improve their financial, operational, and clinical performance with solutions that include pharmaceutical and medicalsurgical supply management, healthcare information technology, and business and clinical services. For more information, visit www.mckesson.com.

Endnotes

1 "Rising Threat of Infections Unfazed by Antibiotics," The New York Times, Feb. 27, 2010.

2 http://wn.com/hospital_infections_in_us_continue_to_ rise?orderby=relevance&upload_time=today

3 HFMA Executive Roundtable, sponsored by McKesson, Orlando, Fla., June 27, 2011.