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Dome - Admit no defeat

December 2011

Admit no defeat

Date: December 16, 2011

Readmissions task force persists in the face of complex drivers.

Marie Zeiler
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In one successful pilot project to reduce hospital readmissions, Marie Zeiler and other nurses serve as transition guides to make sure patients like Hazel Hendrick follow their discharge treatment plan.

On a recent visit to Halsted 6, Amy Deutschendorf whisked out her smart phone/recording device and played reporter. “What do you think of multidisciplinary rounds?” she asked several clinicians. “I can’t live without it,” one nurse replied. “It’s the bomb!” a resident exclaimed. “There’s more communication between doctors and nurses,” affirmed another nurse.

For Deutschendorf, leader of an ambitious, system-wide initiative to reduce preventable readmissions across the Johns Hopkins Health System, such responses from the hospitalist unit attest to the advantages of care coordination, one of the initiative’s core strategies.

So do the numbers. In the six months that Halsted 6 providers have met daily to plan each patient’s care, the readmission rate has dropped by 5.6 percent. That’s because, “Everybody is on the same page and nobody is chasing the care plan,” says Deutschendorf, the health system’s senior director of utilization and clinical resource management.

With preliminary results trickling in from pilot units at The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Howard County General Hospital and Suburban Hospital, it is too early to declare an evidence-based victory in the campaign against preventable readmissions. Still, as Deutschendorf and her clinician colleagues on the preventable readmissions task force work to comply with the incentive-based goals set by the Maryland Health Services Cost Review Commission (HSCRC), they see a patient-centered silver lining in their difficult assignment. “If the mandate to reduce readmissions is where we started looking at this, it will lead us to better care coordination, to meet all of our financial goals and to do the right thing for patients,” Deutschendorf says.

Defining the target 

 Every day, though, a new readmissions report reminds Deutschendorf of the formidable challenges confronted by the taskforce. For one, she and her team have found it extremely difficult to identify what constitutes a “preventable” readmission in a multilevel health system that serves a large underinsured or uninsured acute-care population. “We’re finding things that illuminate the complexity of these problems, far beyond anything we’ve ever dreamed of,” Deutschendorf says.

For example, the daily readmissions report, culled from all pilot projects, is filled with patient stories that don’t fit neatly into a formula for prevention. Deutschendorf cites a patient with advanced lung cancer who was discharged pending a PET scan. Because he was uninsured, the patient’s PET scan was delayed for a week. When he was seen in an oncology clinic six days later, the patient had post-obstructive pneumonia and had to be readmitted.

“If he had been definitively treated two weeks before with radiation, could that have prevented pneumonia?” Deutschendorf says. “The bottom line is there was a big delay which shows that we don’t have a seamless process for getting the patient in, getting financial clearance, and doing the PET scan. We’re a behemoth of an organization with a lot going on.”    

Readmissions through a wide-angle lens

The unwieldy size of the Hopkins Health System, as well as its patient demographics, presents daunting hurdles to meeting HSCRC goals. Also challenging the readmission task force are new measurements from the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF) that equate all readmissions with poor patient care.

The daily readmission report, plus a growing body of research, tells a different story. Readmission, in and of itself, is not necessarily evidence of low-quality care or patient harm, Deutschendorf asserts. It’s also important to look at readmissions as a “big utilization indicator” for very sick patients who have no option but to return to the hospital, she adds,  referring to a letter published in the July 15, 2010, issue of the New England Journal of Medicine that cited evidence of an inverse relationship between 30-day mortality rates and hospital readmissions.

Another crucial indicator missing in CMS and NQF readmission measures is the impact that socioeconomic status has on patient rebound trends. Low-income patients face many barriers to complying with the discharge instructions intended to prevent return trips to the hospital, she says. “We might set the patient up with an appointment with a cardiologist at Greenspring, but he can’t afford the $40 cab to get there, and nobody asked him that question,” Deutschendorf says. “Or a patient may split medications in half to save money. Many, many factors go into explaining why patients return to the hospital besides just access to care.”

 In an array of other ways, noncompliance frequently arises as an obstacle to reducing avoidable readmissions. Post-acute patients often opt for home care rather than going to a rehabilitation center. “If we believe that a patient needs 24 hour assistance to get back up on their feet, and they refuse that and don’t have the appropriate support at home, that raises the likelihood of a return hospital visit,” Deutschendorf says.

Another factor standing in the way of lower readmission rates is an insufficient ambulatory infrastructure,  Deutschendorf says. For example, “There aren’t enough ambulatory psychiatric clinics out there to accommodate a large population with substance abuse and mental health problems.” The resulting default solution becomes a round-trip back to the hospital.

Most challenging for the readmissions task force are the “frequent utilizers” who return to the hospital five times a year. Although this group comprises 1.5 percent of all readmitted patients, it accounts for 16 percent of all readmissions. The taskforce’s bundle of strategies addresses the remaining patients who only return once a year, Deutschendorf says. “We’ve got this hard-core group that is going to take something way beyond the bundle.”

No silver bullets

Deutschendorf returns to the modest, but encouraging wins the task force has claimed in spite of its daunting task. “Making multidisciplinary rounds happen on Halsted 6 and Weinberg 4D is a huge feat,” she says. “To have everyone in the room—social work, pharmacy, home care, all specialists—is extremely important.”

Another new care model designed to decrease medication-related readmissions already has proved beneficial as well. Before they’re discharged, at-risk patients in pilot units now receive their prescriptions at bedside, through a program developed by Home Care’s outpatient pharmacy group and the inpatient Department of Pharmacy. By making sure that patients receive the correct medications and have the correct insurance or means to pay for them, “We are really streamlining the process,” says Meghan Davlin, division director of ambulatory and care transitions for the Department of Pharmacy.

As a stopgap measure, Johns Hopkins Home Care Group developed a pilot that brings nurses trained as transition guides into patients’ homes to assist with medication instructions and check for hindrances to recovery, such as inaccessible bathrooms or a shortage of food. That strategy has faced resistance as well, says Mary Myers, vice president of Home Care. “A lot of people welcomed phone calls from transition guides, but they were reluctant to allow them inside their homes,” Myers says. “In the beginning, we didn’t push the point. Now, we’re trying to be a little bit more assertive and say, ‘Your doctor wants this for you.’ It’s been amazing how we’ve been able to turn it around.”

Such success stories sustain Deutschendorf, who maintains her faith in the spate of strategies she and the task force have developed and continue to fine tune in the readmissions reduction effort.

“We are trying to develop processes that create seamless continuity of care from inpatient to outpatient, from out into the community to the primary care providers, and from the providers back to the hospital,” she says. It’s a monumental endeavor, Deutschendorf says. “I can’t say we’re going to move mountains yet.”

—Stephanie Shapiro

Since going live in April, several of the preventable readmission task force’s pilot projects have produced promising results, although all data are preliminary:

• After the introduction of interdisciplinary rounds on Halsted 6, the unit has seen a 5.6 reduction in readmissions and a 130 hour total reduction in length of stay.

• An improved medication management program including pre-discharge education by a pharmacist with a focus on new and “high-risk” medications, and a post-discharge phone call for high-risk patients.

• Patient and staff satisfaction scores are improving on pilot units that introduced efforts to coordinate care and provide medical instructions at the bedside.


What’s at stake

For health care experts who want to reduce escalating Medicare costs, the high rate of preventable readmissions is an obvious target.  Roughly one of every five elderly patients returns to the hospital within a month of discharge. These early readmissions—many of them preventable—cost the Medicare program $15 billion a year.

For health care experts who want to improve patient care nationwide, the rehospitalization rate is also indicative of insufficient care coordination, patient education and post-discharge support.

By making readmissions reduction a cornerstone of national health reform, policy makers hope to lower costs and to raise the quality of patient care. Recognizing that the two goals go hand in hand, the federal Patient Protection and Affordable Care Act will soon begin to penalize hospitals that fail to meet measures for preventable readmissions.

In Maryland, hospitals may sign up for a voluntary program to reduce readmissions that is administered by the state’s Health Services Cost Review Commission (HSCRC). The agency has capped readmissions for the Hopkins health system at 10,000 a year. If the health system can push the readmissions rate to 10 percent below that cap, it may keep the money it saves. But the health system must cover the costs incurred by readmissions exceeding the annual cap.