Managing readmissions is a key topic in healthcare reform. They are prevalent, expensive and often avoidable. Readmission rates of heart failure patients are among the highest. To counter rising readmissions, the Centers for Medicare and Medicaid Services (CMS) has enacted the Hospital Readmissions Reduction Program. The Program will reduce total Medicare payments to hospitals with excess readmissions, including those for heart failure, effective for discharges beginning on October 1, 2012 (Fiscal Year 2013). The schedule for payment reductions is a 1 percent maximum reduction in 2013, 2 percent in 2014 and 3 percent in 2015. So a hospital with an average annual Medicare payment of $100 million could lose up to $1 million in 2013, $2 million in 2014 and $3 million in 2015.
We spoke with David Bernard, MD, Senior Vice President and Chief Medical Officer of Beth Israel Medical Center and Continuum Health Partners in New York City, and Raj Lakhanpal, MD, Chief Executive Officer of SpectraMD about the reasons for preventable readmissions and how to reduce them.
What are the four key sites that need managing?
Dr. Bernard: The four key sites where patients with heart failure need to be managed well are the following:
In the hospital
In the patient’s home
At the office
In the Emergency Department
In the hospital, it is essential that patients are educated about the disease, the medicines they are taking, and how to monitor themselves at home. Beth Israel now has a full time transition coach who coordinates all activities for patients to avoid readmissions. Significant steps to prevent readmissions in the hospital include ensuring that patients have follow-up appointments with primary care physicians (PCPs) or cardiologists, and that medication reconciliation has been performed. Patients should clearly understand who to call for assistance in the case that symptoms reoccur. Caregivers should be involved wherever possible. It is the responsibility of the hospital’s care coordination team to ensure that these issues are addressed prior to discharge.
Different approaches adopted by Emergency Departments (EDs) to manage heart failure successfully include admission to a 23 hour observation unit, providing access to home care in the ED, and getting the cardiologist involved.
At home, patients are often unsupervised, and there is a substantial risk that they may not understand and follow discharge instructions. It is important to involve caregivers from the start. Patients should be monitored if necessary, either through a telephonic system or via telemonitoring. Pharmacists or nurses are also being deployed to do medication reconciliation. Physician home visits, RN/Nurse Practitioner home visits or visits to a “daily clinic” to ensure that appropriate treatment is being adhered should be considered as well. With heart failure in particular, the home health nurse needs to remain very alert for a potential exacerbation during treatment.
In an ambulatory care setting, it is essential that the patient’s PCP get a discharge summary from the hospital and connect with specialists as required. Thus appropriate medications, monitoring, strong care coordination and education are essential to managing heart failure patients. Inpatient and outpatient care must be coordinated.
What are some solutions for reducing Readmissions?
Dr. Bernard: Care coordination of course is the key to reducing preventable readmissions. Some specific examples of care coordination include conducting a “Readmission Prevention Checklist” before the patient leaves the hospital. Research presented at the American College of Cardiology’s (ACC) annual scientific session in March showed that using a 27-question checklist before discharge for Congestive Heart Failure reduced 30-day readmissions from 20 percent to 2 percent.
At Beth Israel, we are evaluating all of the approaches at all four sites listed to ensure that our patients receive the best possible care.
What is the value of an analytics technology solution to help predict a patient’s readmission risk and what would you consider essential components to such a technology?
Dr. Lakhanpal: As Dr. Bernard has mentioned, the diagnosis of heart failure in particular is a clinical one and is often difficult to make. Sometimes the diagnosis is only made after discharge, when the patient’s bill is coded. If these patients are not identified during their inpatient stay, the full range of approaches to reduce readmissions cannot be initiated. So prior to discharge it is important to identify patients who are potential heart failure patients as well as those at risk of readmission.
Along with clinical findings, certain tests can assist the clinicians in predicting heart failure. The LACE Index and the Simple Index, also called the Texas Model, are two peer reviewed studies widely accepted to predict the risk of 30-day readmissions for heart failure patients.
Thus analytics can be of significant value in identifying patients with heart failure.