This article appears in the November 2013 issue of HealthLeaders magazine.
By John Commins, for HealthLeaders Media, November 22, 2013
In our July Intelligence Report, healthcare leaders, by far, cited 30-day readmissions as the clinical quality metric that presents the greatest challenge.
What makes that such a tough challenge and how can leaders effectively meet that challenge?
Thomas A. Selden
Southwest General Health Center
Middleburg Heights, Ohio
On meeting the challenge:
I don't think it's our "greatest challenge." It is one we have been very successful in dealing with. We are a $300 million operation with $120 million of Medicare net revenue. Our readmission penalty in 2013 was $250,000. We have reduced that to $60,000 for 2014. Because they are grading on the curve, the winners and losers, you have to move with it or fall behind. If we had the same position on that bell curve measuring this year, it would have resulted in a penalty next year of $500,000.
On collaborative problem solving:
We take a multidisciplinary approach to solving problems. We identified components of the health system that impact readmissions and decided that we needed a seamless transition of care across the continuum. We have monthly meetings with the multidisciplinary team that reviews the strategies we have implemented and the metrics we have achieved. We implemented a care coordinator on each of the patient units who works with the doctors and nurses to ensure that the process is going smoothly and the patient is getting ready for discharge and knows what they need to know when they leave.
On collaborating with outside partners:
We serve an older population so we collaborate with area nursing homes with a monthly meeting sharing best practices, practice guidelines, and patient education information. We give them a report card on how they are doing in managing the patients pre- and postdischarge. We're trying to streamline patient information for the nursing homes so they know what is going on in the hospitals and they can pick up the chain from there.
Charles Derus, MD
Vice President of Medical Management
Advocate Good Samaritan Hospital
Downers Grove, Ill.
There is a lot we have done at our hospital to reduce readmissions rates. When we looked into it we found not surprisingly that somewhere in excess of 20% of patients discharged to a skilled nursing facility were being readmitted within 30 days. We worked with our local nursing homes, set up a skilled nursing facility council and started to share some information and best practices around reducing readmissions. We brought that rate down to 14% in a year and a half. It was just sharing information about why people were coming back.
One of my other roles at Advocate was in a multispecialty group practice. They had put together a robust ambulatory management program for people with diabetes that focused on ambulatory care and improving transition in handoffs really reduced the readmission rate in that population as well. We at the hospital are pioneering with outpatient care managers embedded in physicians' offices to try to better manage people with chronic diseases and improved transitions. We have seen some early reduction is readmissions from improving both transitions and ambulatory care.
There is also a very clear connection between complications in the hospital for surgical patients and subsequent readmissions. Although some readmissions cannot be prevented there is a sizeable number that can be prevented and we just have to do things differently.
President and CEO
Fairfield Medical Center
The toughest challenge is that the penalty goes to the hospital provider but the control over what happens to the patient is dispersed among a number of places.
We have been working closely with our local healthcare network, which includes skilled nursing facilities, home care agencies, or long-term acute care facilities, and our community health center. Some of the challenge is getting the patient seen for follow-up with a primary care physician. We have two primary care residency clinics that we make available for that patient who either does not have a primary care physician or who can't be seen in a timely manner to try to alleviate that part of the problem.
We have worked with our nursing homes, with some of the specific diagnoses that this covers but more generally to make sure that their skills and talents are optimized in the care of specific patients. We work with our emergency room physicians. We work with our hospice agency collaboratively. I have heard ideas about collaborating with ambulance companies to do some quick triage as to whether the patient really needs to come to the hospital or if there are other stabilization opportunities that can be provided.
Bucktail Medical Center
It is a challenge primarily because we are a critical access hospital in a very rural part of the country. Those 30-day readmission rates are the element over which we have very little control. We are the only provider of healthcare services in a 25-mile radius. We aren't subject to a punitive action at this point. It is coming. It is going to be part of our quality metrics and that piece is going to be one of those things that we have to do a better job at managing the patient outside of the facility.
We can provide the community information. We can provide all of the resources. But at times you can lead a horse to water but you can't make it drink. With those preventive programs, it's definitely going to help us head off some of this, but not necessarily be one of those things that we are going to effectively manage.
One of the things we are preparing to do is to be able to build into our contractual allowances the idea that there are going to be cases where we are not going to get reimbursed. We project reserves for bad debt and for uncompensated care and it's going to be a part of that factor. It's unfortunate, but it's just one of the challenges we are faced with.