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Get Out - And Stay Out

June 26, 2009
by Daphne Lawrence
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With readmission penalties on the horizon, CIOs are laying the groundwork for post-discharge solutions

Stephen Jencks, M.D.

Stephen Jencks, M.D.


A recent study published in “The New England Journal of Medicine” reported that 20 percent of Medicare patients are readmitted to hospitals within a month. Bills being introduced in Washington suggest that hospitals may soon be held accountable for these costly readmissions - which in 2004 alone cost Medicare a whopping $17.4 billion.

“A lot of people see this as a ‘right now’ issue,” says Stephen Jencks, M.D., a Baltimore-based consultant and principal author of the study. “This topic is of as much interest for its ability to leverage real change as it is for the benefits to the patient.”


Rich Temple

Rich Temple


That real change means a paradigm shift in the business model of care delivery from incident-based to episode-based, and thus, to keeping patients out of the hospital. “In the current model, there's absolutely no incentive for a hospital to reduce readmissions,” says Rich Temple, former CIO of St. Clare's Health System in Denville, N.J., and currently CIO of AristaCare Health Services, a network of long-term care facilities based in South Plainfield, N.J. “It's a very perverse system,” he adds.


Robert Wachter, M.D.

Robert Wachter, M.D.


But as politicians nationwide jump on the healthcare reform bandwagon, most agree that sweeping changes will pass, as bill after bill is submitted in Washington. Sooner rather than later, many say, hospitals will be penalized for these costly readmissions through lower Medicare reimbursements.

“I think cuts in reimbursement for readmission are inevitable,” says Bob Wachter, M.D., a San Francisco-based consultant and author, who believes the timeline will hinge on overall healthcare reform. “There are savings that they need to find under a rock somewhere, and there is a decent sized budget line that says we're going to save a lot of money by preventing excessive readmissions.”

If health reform happens, most agree some aggressive tactics to promote better transitional care at the time of discharge has to be part of the package. “This is one of those targets that seems so right in so many different ways, it's hard to figure out who will argue against it,” says Wachter.

Candidates for the opposition include hospitals and doctors, who stand a good chance of losing valuable Medicare money if penalizing legislation is passed. But many ask why hospitals should be held accountable for patients' compliance once they leave the facility. “Is it fair for a hospital to get dinged for public reporting on its mortality rates because a patient had a certain lifestyle?” counters Wachter. “That's not fair either, but nobody thinks twice about that.”

And though any post-discharge interventions like remote monitoring (and the FTEs to read those monitors) will cost strapped hospitals money, they may have to bite the bullet. “Hospitals do all sorts of stuff they can't afford if it's mission critical,” Wachter says.

The data that shows many readmissions are preventable is strong, particularly for some chronic conditions like congestive heart failure (CHF). Often, steps to prevent readmissions are not that expensive or complex - and some CIOs are already preparing for what seems to be inevitable.

“What we're seeing now is a more global approach to patient care, and that's where technology is really going to play a role,” says Mrunal Shah, M.D., vice president of Physician Technology at the five-hospital Ohio Health system in Columbus. “We know there are limited resources for patients once we discharge them, but there are ways to get involved.”

The technology that Shah is leveraging at Ohio Health is a Web-based, patient-specific education tool from Chicago-based Emmi Solutions that the hospital is using as part of a pilot program around post-discharge care. Most agree some enhanced attention to patients' engagement and education at the time of discharge is a key factor in preventing readmission. Shah is currently establishing baseline measures for the pilot, which targets CHF patients - one of the CMS measurables for readmission.

As part of the program, patients access education modules specifically tailored for them both in the hospital and back at home; Shah says the hospital gets a report on whether patients accessed the education and watched it in its entirety. Nurses document that content was provided, and Shah says he has the ability to report and follow up on that data. “Part of our baseline is what we expect from people,” says Shah, whose pilot began in May. “We hope to show an impact within 90 days.”

Many activities, in addition to patient education, have been demonstrated to decrease readmissions, and like so much in healthcare, interconnectivity is a big stumbling block. “A great many organizations believe that the health record begins and ends at the walls of their organization,” says Jencks. “But this is a place where effectiveness rests in the ability to share information.” He says sharing can be as simple as sending a prescription to a local pharmacy on behalf of a patient, or as complicated as having a multilevel record that different people can access when authorized.

Temple agrees that links, especially to the pharmacies, would help. “When I was at St. Clare's, we actually built a tool that would follow up on ED patients to see if they were taking their meds.” Temple says the tool involved setting up formal worklists that took feeds from the EMR tracking discharges; 72 hours later, that patient would be assigned to someone's worklist who would call and check up. “You can improve on that if you have an HIE getting feeds from the local pharmacies, because you'll know if they filled the prescription,” says Temple.

But these days, who is following up on the worklists, or even spending time with the patients at discharge? For many CIOs, there just isn't enough staff to go around. That's an area where many believe IT can help, starting with identifying the patients who are ready for discharge and making sure they have the right education. And while it's expensive to have FTEs spending an hour with every patient at discharge, intensive counseling can be designated for the patients at highest risk. Identifying those risky populations is another area where IT tools can play a key role.

“A robust BI tool can provide leaders of healthcare institutions rates of readmission by condition,” says Temple. “That should be relatively low hanging fruit.” He says it's easy to measure against an industry or regional benchmark to see if a hospital's readmission rates for cardiac patients are too high, for example, and to identify where something is wrong and changes need to be made.

And now that Temple is working on the long-term care side (at AristaCare), he is experiencing firsthand the effects of hospitals' poorly managed post-discharge care. “We lose money when we have to readmit to the hospital because they come back sicker,” says Temple. Most agree the solution is a full set of electronically exchanged information coming from the hospital into the long-term care facility. “You are so much more likely to do the right thing when you have a full set of information, and the best way of ensuring that is having it seamlessly transferred.”

But for most, that dream of interconnectivity is still a long way off. And although electronically exchanged information can help, says Jencks, it is far from the only solution. Communication and understanding the needs of post-discharge providers can improve the process. Other providers, like long-term care and rehab, may have a completely different view of the post-discharge needs, and, according to Jencks, many hospitals don't know what those needs are. One simple solution is to invite representatives from the post-discharge facilities the hospital utilizes most to find out what they need to effect a smoother transition.
Russ Rudish

Russ Rudish


Many agree that the most important period of the post-discharge process is the time between discharge and the first visit with the outpatient provider. It is at this meeting, or before, that the physician should have access to all hospital-generated data. Unfortunately, that isn't the case. “Why can't we get the discharge summary to the primary care doc quicker?” Jencks asks. “The answer is that we have a system which is perfectly designed to produce the results that it produces,” meaning hospitals function as if the purpose of a narrative summary is to satisfy the Joint Commission. “And if that's the purpose, you ought to stop doing them,” says Jencks. “The real purpose needs to be to help the patient get better care.”

According to Wachter, “There's no reason a discharge should take two weeks to move to an outpatient provider,” he says. “IT needs to facilitate this.” He says that at discharge, patients should be handed a copy of the discharge summary, and it should ideally also go electronically to whomever will see them next. “You need to get someone to follow up with that patient, and you need an IT system that prompts whomever is following up and gives them the right questions to ask. There's a lot to do, but it's not that complicated. This is one of those unusual circumstances where the stakes are really high and there's not that much controversy over what needs to be done.”

Change in this area is inevitable, and most agree that CIOs definitely need to be prepared - that is, if it's not too late. “Most people will say this train has left the station,” says Russ Rudish, a senior healthcare consultant with New York-based Deloitte LLC. “Some of the first movers are starting to say, ‘I've got to get some of that aftercare money,’” he says. “Right now, 60 to 90 percent of hospital revenue comes from inpatient care, but that's not going to be the case five years from now.”

Rudish believes hospitals need to figure out how to capture some of that aftercare revenue, particularly as inpatient revenue streams dry up. Some of the first movers in hospitals are getting into the retail healthcare business through e-commerce, he says, where they are the provider of aftercare, both products and services. “CIOs have to start thinking about what's happening outside the hospital walls. For many of them, that is a sea change.”

And that sea change is already on the radar screen. “It's beyond me to say what the sausage is going to look like when it comes out of the factory, but I can tell you that there are multiple approaches,” says Jencks, referring to the way healthcare reform legislation will deal with readmissions. One way, he says, is to rate or score a hospital and then tweak its payments. The second is to make the discharging hospital responsible for some or all of the costs of a re-hospitalization. A third is to actually do some public shaming.

“My feeling is, if we want things to change, we've got to do all of the above,” says Jencks. “Paying attention to how patients do after they're discharged is a game changer.”

Healthcare Informatics 2009 July;26(7):30-32

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