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A Leap Of Faith

July 10, 2009
by Joe Bormel
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A Leap Of Faith
Discharges, Re-Admissions, and Post-Acute Care

I was chatting with the chief hospitalist at a major medical center yesterday and he reminded me of something I understood all-too-well. As a doctor, you can't keep a sick patient in the hospital forever. There can be a big difference between stabilized and stable enough that you're confident that the patient won't "bounce back" and be re-admitted. Discharging patients is often a leap of faith, faith that they'll continue to improve after hospital care.

There were lots of articles in yesterday's newspapers like this one:

And this one from USA Today and Baylor:

The CMS study of Medicare records showed Baylor University Medical Center in Dallas has the lowest readmission rate for heart failure in the country, at 15.9%. Baylor invested some $20 million in measuring and improving performance at all 15 of its hospitals. Part of the success comes from intensive follow-up after discharge to ensure patients are complying with treatment regimens. USA TODAY (07/09)

The national re-admission rate according to CMS is about 20% within a month of discharge, and readmission rates have been added to hospitalcompare.hhs.gov. Here is an example :

Hospitals, whether the physician involved is a hospitalist or a private physician, are driven to discharge patients who are stable, presuming that their post-discharge care is adequate. Organizations like Baylor, above, have stepped up to the challenge of effectively offering post-discharge care in various ways, away from the hospital.

Last month at the first annual X3summit, Johns Hopkins's CIO Stephanie Reel and her team detailed a variety of dramatic programs to deliver care outside of the hospital.

The implications for CIOs and other readers of these blogs is pretty obvious. The walls of the hospital are coming down. And that's a great thing!

Topics

Comments

Daphne, Do you believe that episode-of-care grouping on the part of CMS is necessary to assure that providers are fairly compensated for care?

Readmission article in WSJ, July 28th, 2009

For those wanting more detail, there's a story "Cutting Repeat Hospital Trips Simple Idea, Hard to Pull Off " which discusses the problem and provides good detail:

http://online.wsj.com/article/SB124873545269485081.html


I've mentioned this in the past, but, here goes again ... half the story is actually in the "Comments" tab.  For example, one commenter provided a reference to a Medicare study where improved home care did not reduce costs.  Like blogs, comenters are often highly knowledgeable professionals in the field being discussed.  They often can and will say important things that the primary authors cannot.


The real story for HCIT is operationalizing the "Discharge to What" issue. If the patient is discharged to an ambulatory care provider system capable of managing the patient at home, that's great ... and it takes information flow. Notification, a C32 interoperable document would be nice, with problems, discharge meds, etc.

If discharge doesn't include a care provider that can detect and intervene early, the readmission cannot be avoided.

Planning for and reducing re-admissions requires good use of information, and access to that follow-up care.

And, is re-admission a sign of poor quality, i.e. an inappropriate discharge? Again, HCIT can document when patient's meet criteria for discharge. Every hospital I know of has this in their care management plan for CHF.

Have you made it easy and efficient for your doctors and nurses to document that discharge critera were met? If so, should the hospital be faulted for "poor quality" when a readmission occurs in the setting of an appropriate discharge?

What did these criteria look like in the paper world?  Here's an example)...


I would love to see lawmakers raise the bar to that kind of a question. Why? Because it leads to meaningful healthcare reform - direct incentives to treat these patients as outpatients aggressively post discharge.




Joe, you know this is my pet topic. Thanks for keeping this dialogue going. I still believe that until our payment models change, we'll always be acting on faith rather than facts.

You bet I do. Rehab and LTC in the loop, too.

Joe,
Excellent! We've been watching these inter-related issues as well — discharge planning and management, reimbursement and the lack thereof for bounce back admissions, increased visibility (thanks CMS), and the fact that we need a much better discharge safety net. Although you didn't say so, I will. This trend toward decreasing readmission rates is being driven by reimbursement. Are we putting a patch on a draconian system here, or is this just pure goodness?

Jack

Since I wrote this post less than 2 weeks ago, I've been informally asking many people expert in HCIT-

What do you think the national or your local readmission rate is?

Basic awareness is not there, in my experience with a small sample.

Like Anthony's post, Adrift in PolicyLand, what this means is that despite the meaningful use discussions going on relative to ARRA-HITECH, we seem to be missing the fundamental quality dimension to healthcare improvement. Granted, readmission rate can be a coarse measure, it does speak loudly about access to post-discharge care and how it's structured. If this is any indication, the extensive policy debate going on is not going well.

Jack,

Thanks for the kind words.

As you know, there is an acceptable rate to take a patient to the OR to discover that they don't have an appendicitis. If 100% of your patients have an appendicitis, you almost certainly were too conservative and missed patients.

With that kind of logic, you have to ask. what is the correct rate of re-admissions? Are they always a sign of poor quality (the number is always too high)?

Conversely, could a low re-admission rate signal other quality problems?

The appropriate rate depends on the medical condition and patient population. Self-pay patients with poor outpatient care access or poor compliance behaviors may have higher re-admission rates than patients with access to excellent out-patient resources. Does this reflect on the in-patient care organization?

The post discharge care may or may not be reimbursed so it may result in cost shifting back to the hospitals that have operating margins insufficient to invest in services and related technology. So, it's complicated. That said, I think it's absolutely the right question.

Once we've assured that the discharge decision was reasonable and the post discharge services are adequate, it doesn't seem fair and reasonable to deny payments for readmission.

Thanks for asking. I think you're thinking about this correctly.

I welcome other perspectives on this important topic.

Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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