Halting the Revolving Hospital Door

For years, hospitals focused on getting patients home as quickly as possible—and applauded themselves for short length of stays. But five years ago, a landmark New England Journal of Medicine study showed that as many as one in five Medicare patients bounced back to the hospital within 30 days of discharge, revealing that a good number were leaving the hospital before they were ready.

“Readmissions have been occurring for many years, but we never really identified them as a quality issue until five years ago,” says Dr. Robert Keenan, chief quality officer for Allegheny General and West Penn Hospitals. “It was one of those ‘aha’ moments, and we recognized that a lot of readmissions are potentially preventable—up to 20 to 60 percent.”

Last October, Medicare implemented much-anticipated penalties for hospitals with 30-day readmission rates that were higher than expected for patients with heart attack, heart failure and pneumonia. The penalties can reach as high as 1 percent of a hospital’s regular Medicare payments. In October, the maximum penalty will jump to 2 percent and grow to 3 percent in 2014.

As part of the Affordable Care Act, the penalties are one way the federal government is rewarding quality—not just quantity—of care. It’s also hoping to recoup some of the estimated $18 billion a year it pays in avoidable hospital readmissions. This year, the Medicare penalties are expected to cost hospitals $280 million.

Only a couple of area hospitals face the highest 1 percent penalty, but most face a small deduction in reimbursement (see sidebar). Although for some the penalties are minor, all hospitals reached for comment have made reducing readmissions a major priority.

“We spend a lot of time thinking about readmissions. We have been actively working on it for three or four years. It does take a village. It is a slower path because a lot of it is outside the hospital’s control,” says Diane Frndak, vice president of quality and safety for Allegheny Health Network (formerly West Penn Allegheny Health System). AHN measures readmission rates every day. “We have a daily report that is down to a patient-specific level, hospital level and goes into a monthly report.” The penalties, she says, are “significant but not overly significant.”

Keenan adds: “Readmission is a symptom of a larger problem. Before, we were treating chronic conditions in an episodic way. We as a health system are now pushing that care pendulum back to prevention. We want to keep people as healthy as possible.”

Over the past couple of years, 328-bed St. Clair Hospital in suburban Mt. Lebanon has focused on reducing its relatively high readmission rates for congestive heart failure. Its efforts have paid off, shaving eight percentage points off its 26-percent readmission rate reported for 2008-2011, the time period for which the first round of Medicare penalties are assessed.

At Excela Health’s Latrobe Hospital, “We have seen a drastic decline in heart failure readmissions,” says Holly D’Amico, director of medical resources for the three-hospital Excela Health based in Greensburg.

So what are hospitals doing to reduce repeat patients? Lots. Although many are addressing the issue in unique ways, there are two major themes: making sure patients are adequately prepared before leaving, and coordinating with the next level of care, whether a primary care provider or nursing facility.

“We always had patient education, but over the past two or three years we put a lot more focus on it and made sure our education materials were as up to date as possible,” says Holly Hampe, St. Clair’s vice president and chief quality officer.

Todd Pollock, a quality improvement specialist with UPMC, says, “A big problem we discovered was that we need to speak differently to our patients about their diseases and don’t assume they understand what we say.” UPMC has its patient education materials down to a fifth-grade reading level and, like other area hospitals, employs the “teach-back method,” asking open-ended questions to make sure the patient understands their care instructions, including how to take their medications.

Studies have shown that 40 percent to 80 percent of the medical information patients receive is forgotten immediately and nearly half of the information retained is incorrect. Teach-back is a way for a nurse or physician to confirm that the patient actually understands what they say.

Hospitals are now calling patients within 24–48 hours of discharge to make sure they’ve fulfilled prescriptions and made follow-up doctor appointments. “UPMC Health Plan noticed that patients who didn’t see their primary care provider within five days of discharge were more likely to be readmitted,” says UPMC’s Pollock. “So now there’s a dedicated call center to call those patients whose chief complaint was chest pain and shortness of breath to help them set up those appointments.”

Excela’s D’Amico has been on the frontlines of this issue at a national and local level since 2008. Excela Health operates Latrobe, Frick and Westmoreland Regional hospitals. It was chosen by the Centers for Medicare & Medicaid Services as one of 14 demonstration sites nationwide because of its high readmission rates. “At Latrobe, we had a higher-than-desired readmission rate for heart failure. On the Hospital Compare website (www.hospitalcompare.hhs.gov), we stood out as not good. And now we’re right where we need to be,” D’Amico says.

Excela’s secret was taking advantage of free tools from The Joint Commission (accrediting agency for hospitals) and partnering closely with the Westmoreland County Area Agency on Aging (AAA), local nursing homes and even restaurants (see sidebar).

In 2011, Excela rolled out Project RED (Re-Engineered Discharge), a program created in Boston that Excela made its own. The project includes a one-page uniform document that Excela gives to the next provider within an hour of a patient’s discharge. “Ambulance drivers want one, too, so they can have a synopsis of the patient. We started with heart failure patients and now the program includes patients with diabetes and COPD,” D’Amico says.

Excela has weekly calls with four nursing homes, including those at Redstone Highlands Senior Living Communities, which now has a nurse practitioner or physician’s assistant on site until 9 p.m. Excela also takes advantage of four coaches, employed by Westmoreland’s AAA. Each month, these non-clinical coaches go into the homes of about 125 patients with heart failure or complex medical conditions. They make sure the patients are doing well and, when not, connect them to medical or non-medical resources. “We work really closely with the Area Agency on Aging. They come to the hospital every day. We have weekly calls with them. They’re integrated into our family,” D’Amico says.

Of its 12 acute care hospitals, UPMC has the area’s only two hospitals that were able to avoid Medicare penalties (UPMC Hamot in Erie and UPMC Bedford Memorial in Everett). “As a general rule, we have seen our readmission rates come down,” says Linda Harvey, director of UPMC’s Donald D. Wolff Jr. Center for Quality, Safety & Innovation. “Some of our hospitals have decreased their rates to 13 percent and have managed to sustain it.”

But Harvey admits that UPMC still struggles with higher rates at its Mercy and McKeesport facilities, which see a large number of elderly patients with socioeconomic issues and homeless patients who tend to use emergency services for primary care. Even so, the Medicare penalties for these higher rates are still “very, very minor,” Harvey says.

Over the past year, UPMC has implemented the Emergency Department U-Turn pilot project at Shadyside and Presbyterian hospitals and plans to expand the program to Mercy Hospital and Hamot, in Erie. The goal is to make sure that when patients with certain diagnoses (heart failure and lung disease) leave the emergency department, they will get a visit from a UPMC HomeCare provider within 24 hours. “This will also help give the ED physician more confidence if they’re on the fence about ‘Should I admit this patient or not?'” Harvey says. “This way, the physician will know that if they send the patient home, they’ll receive efficient, reliable care.” Next year, COPD (chronic obstructive pulmonary disease) will be added to the Medicare penalty list, so St. Clair is putting “considerable attention” on these patients, says Hampe, making sure they are meeting with a dietitian, being connected with a homecare agency, and being referred, when appropriate, to a pulmonary rehabilitation program.

Hampe adds that the penalties for readmission rates are “not as great” because they have been offset by St. Clair’s favorable core measures (such as patient satisfaction and mortality).

Eva Mae Larva, 84, was newly diagnosed with congestive heart failure during a stay last December at UPMC St. Margaret Hospital in Aspinwall. She was sent home with several new medications to help her manage a complex diagnosis. Two weeks later, Isabel MacKinney-Smith paid Larva and her husband a home visit. As a UPMC chronic disease care manager, MacKinney-Smith spent a little more than an hour explaining a number of things: what Larva’s medications are for and when to take them; the importance of checking her weight daily; when a weight gain should prompt a call to her PCP; the importance of a low-sodium diet; ways to avoid a flareup of her condition; and what to do if her health goes downhill quickly.

MacKinney-Smith then followed up with weekly phone calls. She typically stops calling 30 days after discharge, but if patients ask for a regular check-in she will continue to call them.

Larva has had no re-hospitalizations and has been getting regular physician follow-up ever since the home visit. “I couldn’t have been more pleased with Isabel. She really helped me greatly,” Larva says. “I keep the [education] materials by my bed and anytime I have questions, I read them.”