Hospitals turn around readmissions woes
From losing money to bonuses in one year
Two years ago University Hospitals’ Richmond Heights (OH) facility and Banner Heart Hospital in Mesa, AZ, were both dinged by the Centers for Medicare & Medicaid Services (CMS) for having too many unplanned readmissions. But just a year later, both hospitals have earned bonuses based on their reduced rates.
The leadership team at Richmond Medical Center knew that they had a readmissions problem before CMS started cutting payments for hospitals that didn’t meet certain standards related to it. "We noticed before then that our readmission rates were higher than they needed to be," says Laurie Delgado, president of the system. "It’s possible that had we not started work on the issue when we did, the penalty may have been greater."
The organization wanted to see what the patients who bounced back had in common, she says. "We have a number of patients who are the chronic, repeat readmissions folks. We needed to get our arms around that group and figure out a new way of managing them." Because the penalties relate to acute myocardial infarction, pneumonia, and congestive heart failure (CHF), those were the initial kinds of patients that were the focus. However, they decided to really concentrate on heart failure patients.
Delgado says they drilled down to look at any patient who had CHF as a reason for readmission, or who had heart failure and was readmitted for some other stated reason. "We wanted to see whether they went home, home with home care, or to a nursing facility. If it was the latter, then we wanted to see which facilities had the most readmissions so we could better improve by partnering with them."
The hospital is relatively small — 50 beds were involved in the effort, of the 101 for the Richmond/Bedford combined facilities. That may have made it easier to dissect the data from the readmissions. They put together a team that included the chief medical officer, the chief nursing officer, nurse managers, unit care coordinators, emergency room staff, the quality manager, the lead hospitalist, a cardiologist, a pulmonologist, and several internal medicine residents. There is also a "sub-team" that meets a week before that committee meets to do a chart and data review, says Delgado, so that more time is spent in discussion than in searching for meaningful data.
While looking at the data is the crux of the committee’s work, the committee also looked at what initiatives were already in place related to readmissions, which had been effective, and whether they could be applied to this specific patient group, she says.
The result of the work the committee did in 2011 and 2012 was the implementation of several initiatives that required some financial outlay on the part of the hospital, all with the hopes that the money could be recouped by reducing readmissions.
For instance, while there is a requirement for a patient to be home-bound to receive home care, the committee felt that some patients who are not home-bound are still at high risk. "We started to send a home care nurse for a free visit to help re-educate patients and go over their medications in a less stressful environment than the hospital," she says. They also make sure that the patient has a follow-up appointment with his or her primary care physician and a means of getting there. One of the key ways this helps is to ensure that patients are taking their medications. Many go home with prescriptions only to find they aren’t covered by their insurance or that they can’t get to the pharmacy. The home nurse helps with that.
The committee also looked at the skilled nursing facilities where there were the greatest number of admissions and readmissions. Now, when a patient returns to such a facility, a geriatric nurse specialist visits within a day or two to review the care plan with the nursing team at the facility.
"The thing that probably helped the most was getting a clear understanding of our patients," Delgado notes. "When we first started looking at reasons, we needed to get a grip on what was the barrier for them that led them back." They developed a tool to collect data identifying the reason for admission, what the plan of care was the last time they were in the hospital, whether they complied with medication regimens, and any other problems they had. That led to the creation of the next discharge plan, with an eye to preventing any of those issues from happening again.
"It also helped the committee to understand the barriers that patients had — access to medication, for example," she says. "We have ways of assisting with those problems, like pharmaceutical company programs or alternative medications."
They still look at the data, and are pleased with the results. Some patients don’t want a home care nurse to come in, even though it’s free, but by and large, Delgado says the plan changes have been exceptionally well received and have paid off.
Not that they are finished: This month, they are starting a project with the internal medicine residency manager for a transition clinic for patients who might not be able to get into their doctor’s office within a week — a risk factor they identified in their initial data mining. It’s free, open three days a week, and staffed by residents who can help with education. A dietitian is available if needed, and all information from those visits is transferred to the primary care physician in time for the eventual office appointment. Concerns are bounced to the cardiologist, as well as the primary care physician. They may implement a voucher system to help the patients get to the transition clinic.
Medicare figures are slow in coming, so they didn’t see a big drop for a while. But they know that they reversed a systemwide CMS financial hit of $128,000 inside a year. And it was great to watch the trend chart move downward, she says. Now they’re looking to do something similar with chronic obstructive pulmonary disease "because we know that getting to a pulmonologist within a week after discharge helps prevent readmissions."
She says that one of the biggest lessons she learned is that it’s OK to try a lot of things at once to evince change. Not all may work, but something will.
A system view, rather than patient view
At Banner Heart Hospital in Mesa, AZ, the journey to lower readmissions started four years ago, with participation in the Heart Failure Accreditation Colloquium (colloquiumhealth.com). The hospital was one of the first to participate and was required to hit various milestones on the path to accreditation, says chief medical officer Mark Starling, MD.
The process included a site visit that required hard thinking about why providers and the facility did the things they do. "It was very provocative stuff," he says. "And we found out that what we were doing just didn’t serve the patients. We thought we were, but we weren’t."
Starting in 2010, they began a process that mapped the patient experience in the system from the time patients are referred to the hospital. "We wanted to know what decisions they had to make, and whether that impacted the quality of their care," Starling notes.
They learned that pretty much everything flows to the ED, which has only two choices: to admit the patient or not admit the patient. They decided to add another option: A dieresis clinic that could help keep the patients out of the hospital.
Looking further at the system flow to the inpatient portion of the patient journey, they found a system that didn’t engage the patient or put him or her at the center of care. They needed to get patients involved with their care, so technicians trained patients who were able to weigh themselves every day. Getting them to understand why this was important, putting the onus on them to monitor their weight, and knowing what to do if it went in the wrong direction would help them after discharge to better manage their own care. Similarly, able patients were given a card with all their medications, time of dosage, dosage, and route of administration. They go to the nurse station to retrieve their medications, where they are quizzed on the purpose of the prescriptions they take. Again, this is great training for when the patient leaves. "And the patient gets up and walking, which is also good," he says.
Starling says they also trained select nurses as experts to be a resource to new nurses and also to develop patient education. This education is kept consistent throughout the continuum of care, ensuring patients get the same information with the same language whether they are in the ED, an inpatient unit, or at a Banner clinic. Meanwhile, patients were assessed on admission by social work, case management, and the bedside nurse, as well as the clinician. Then the group would do interdisciplinary rounds to share the information on what the patient needed.
This was the third arm, Starling says: getting them ready for discharge from the start. "Before, we were just kicking them to the curb like we were discharging them from the army, with no idea of what happens outside our realm." So they built a transition model that included making an appointment for them to see a clinical pharmacist while they are in the hospital, ensuring they have a timely appointment with a cardiologist post-discharge, and making sure they get into post-discharge heart failure rehabilitation. It’s not covered by Medicare, so for patients who can’t pay, the hospital picks up the tab.
Putting the patient at the center
Further along the continuum, the hospital reduced the number of skilled nursing facilities they work with to three. "To participate with us, they have to be ready to track data, use our teaching tools, and implement our plan," he says. The nursing homes also helped identify three stellar home health agencies. "One thing we did was ask them what they needed from us," says Starling. "They told us that they needed help with cardiac diets. So they came to us and watched our people prepare and plate meals for the patients, and they continue to act as a resource for the nursing homes’ dietary staffs." The nursing home and home care staff are also invited to participate in nursing education provided to the hospital nurses.
Starling says they "turned the care continuum upside down and put the patient at the center." The readmission rates went from 28% to 15% between mid-2011 and the summer of 2013. They keep an eye on data monthly, and any readmission is investigated in detail by a clinical nurse specialist and case manager.
"We are building a model that could work with any chronic illness — post-operative heart patients, chronic kidney disease, COPD — they can all work with this. You just change the particulars. You end up with better quality, better patient functionality, and it costs us less. We are the most efficient building in Banner."
They are sharing the program, and it has been deployed for heart failure patients in other hospitals in the system. "It’s just known as the Program,’" he says.
He says being bold was a key to success. "Sometimes the best slate is the one that’s wiped clean. You have to realize that the care of the patient is more than just the three and a half days a patient is here with us. There were people struggling; we were not helping them. Looking at our system showed us where the gaps were. It doesn’t take a genius to know that if your only choice is to discharge a patient from the ED or admit him to the hospital, a lot will be admitted even if that’s not the level of care they need."
Starling thinks it’s imperative to know exactly what happens when a patient enters your system, and it’s worth the money to pay for an expert to help you do it. "I know what happens to a patient every hour. I know who touches them. Frankly, I was surprised when I did this that anyone ever got out."
Spending $60 for two lessons on self care for patients, or a couple hundred dollars for eight two-hour rehab sessions is a no-brainer compared to spending $6,000 for every readmission, Starling says. "There is less depression, better functionality, and they manage their care. Not all patients need this, but many do. And they aren’t coming back."
The hospital is so confident of its program that it has applied to CMS for bundled payments. "We figure we can get down with our innovations to 10% readmissions. I think when we’re bundled fully, we’ll have money left over. Give me a hunk of money for 90 days care and I’ll make $4,000 on each patient every year. And we’ll do it for heart attacks, for post-op heart patients, for everyone."
For more information on this topic, contact:
- Laurie Delgado, president, MBA, University Hospitals, Shaker Heights, OH. Email: [email protected].
- Mark Starling, MD, Chief Medical Officer, Banner Heart Hospital, Mesa, AZ. Telephone: (480) 854-5177.
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