According to a study published in the New England Journal of Medicine analyzing close to 12 million fee-for-service Medicare beneficiaries, nearly 20% of them who had been discharged from a hospital were re-hospitalized within 30 days, 34% were re-hospitalized within 90 days, and 54.1% within a year. Moreover, of those who were discharged with a medical condition, 68.9% were readmitted or died within a year. Of those discharged after a surgical procedure, the rate was 53%.
What are some of the causes of readmissions and how can they be successfully addressed? Who is at greatest risk for readmission?
These numbers are alarmingly high and data suggests that at least three-quarters of these readmissions are preventable. This trend is wrought with incalculable costs on patients’ physical, mental and financial wellbeing, as well as with high costs for Medicare. In fact, this ‘revolving door effect’ cost Medicare over $17.4 billion in 2004, about 17% of Medicare’s total hospital payments made that year. The new health care law, the Patient Protection and Affordable Care Act aims to reduce these costs by reducing Medicare payments to hospitals with excess hospital readmissions. Yet, to effectively reduce these incidents and costs, hospital administrators must ask, “what are some of the causes of these readmissions and how can they be successfully addressed?” This article examines both of these questions, looks at who is at greatest risk for readmissions and reviews beneficiaries’ rights to discharge planning services and appeals.
Potential Causes for Hospital Readmissions
Many articles and studies note lack of communication between hospitals, skilled nursing facilities (SNFs), providers and patients as a common cause in hospital readmissions. For example, in one study(1) on reducing readmissions for chronic obstructive pulmonary disease (COPD), miscommunication among hospital staff led to occasional mistakes on medication dosages and inconsistent patient education on how to use inhalers (a common outpatient treatment for this condition) and was one of the main causes for high readmissions. In another study which interviewed acute care hospitals and the SNFs where they sent patients, each blamed the other for not providing adequate information. Sometimes medication lists were missing, post surgical care instructions were confusing or not given, little or no communication existed between physicians when a patient was switched from one facility to another, and/or follow up appointments were never made or communicated.
This last item regarding no scheduled follow-up appointments was also noted as a potential cause in the New England Journal of Medicine study where they found that half of nonsurgical patients were re-hospitalized without having seen an outpatient doctor for follow-up care. Study authors strongly recommend hospital physicians increase their efforts to coordinate prompt and reliable follow-up care with their patients’ primary care physicians.
Another potential contributing factor to hospital readmissions is the decrease in numbers of practicing geriatricians serving our elders, according to Harvard Medical School professor, Dr. Lewis Lipsitz. In his article, Caring for the Elderly, he discusses how medications and treatments often require modification for older adults, and ‘mis-treatments’ contribute to the high number of readmissions for elders. Sometimes what’s appropriate for young or middle-aged adults can be detrimental to the health of adults 65 and older, and doctors not trained in geriatrics may be unaware of these differences.
Also, geriatricians are more trained in the social aspects of aging and aging issues, and often work closely with patients’ family members and other doctors, organizing rehabilitative and social services, helping to complete applications for supportive housing, and overseeing the myriad medical and social services patients may be receiving. While geriatricians don’t usually get paid for all these tasks, the comprehensive services and knowledge base they bring to their patients positively affects their health and quality of care, and helps lower the overall medical costs. Dr. Lipsitz states that, “geriatricians actually save health care dollars by planning ahead; avoiding unnecessary hospitalizations (and readmissions into hospitals), tests, medications, and treatments; reducing surgical complications; and facilitating the safe transfer of patients to appropriate rehabilitation settings and care at home.”
Who’s At Risk?
According to the New England Journal of Medicine study, patients with certain medical conditions or surgical procedures are more likely to be readmitted into the hospital within 30 days than other patients. The 5 most common medical conditions include: heart failure, pneumonia, chronic obstructive pulmonary disease, psychoses, and gastrointestinal problems. The 5 most common surgical procedures include: cardiac stent placement, major hip or knee surgery, vascular surgery, major bowel surgery, and other hip or femur surgery.
Patients discharged to a Skilled Nursing Facility (SNF) are also at risk. A study in the Journal of the American Geriatric Society noted a "greater risk of multiple complicated transitions (hospital readmissions) in patients initially discharged to skilled nursing facilities" and "a lower risk of multiple complicated transitions for patients initially discharged to inpatient rehabilitation facilities." Medicare and private insurance companies often admit patients who need rehabilitation services after a stroke, hip fracture or joint replacement to a Skilled Nursing Facility rather than an Inpatient Rehabilitation Facility (IRF). While this choice may appear to be less expensive, it may not be if one considers the readmission factor. The readmission rate to a SNF for a joint replacement is 14.3% while it is only 2-3% for those who go back into an IRF. More striking is the fact that a person who goes to an IRF after a stroke, as opposed to a SNF, is 3 times more likely to go home.
What Can Be Done?
In addition to knowing one’s rights (reviewed below) and being one’s own advocate while in the hospital, comprehensive systemic changes and protocols must change to make a sustained reduction in hospital readmissions and transform patient care and outcomes. One intervention is called Project BOOST (Better Outcomes for Older adults through Safe Transitions), a national initiative led by the Society of Hospital Medicine with guidance from multidisciplinary leaders and stakeholders across the U. S. In California, with additional funding from the California HealthCare Foundation (CHCF), Project BOOST will launch their initiative with 20 hospitals throughout the state this year. The initiative is designed to:
- Reduce 30-day readmissions rates,
- Enhance patient satisfaction,
- Improve the flow of information between hospitals and outpatient physicians,
- Identify high-risk patients and target specific interventions to mitigate their risks for adverse events; and
- Improve patient and family preparation for discharge.
For more information, see CHCF’s program description for Project BOOST.
Another intervention that makes systemic changes and has been successfully applied in hospitals throughout Pittsburgh, Pennsylvania and now is in other health care centers nationally and internationally, is referred to as “Lean Healthcare” (2) or “the Pittsburgh Way.” Lean Healthcare applies industrial principles from one of the most efficient companies, Toyota, to health care. While this may sound a bit unorthodox, case after case among hospitals and their staff who apply these principles have produced dramatic and sustained results.
One example is with UPMC St. Margaret Hospital in Pittsburgh, Pennsylvania. Their goal in using Lean principles was to reduce hospital readmissions for chronic obstructive pulmonary disease (COPD) by an aggressive 40% in one year. An intervention based on Lean principles helped find areas contributing to these readmissions, organized and established new protocols to prevent problem areas and strengthen efficiency, and established systems to sustain and maintain these changes. For example, the intervention team found that different doses of the same drug (.63 mg and 1.25 mg of Xopenex, a drug commonly used with COPD patients) were in identical containers side by side in the same drawer. To address this problem, the team moved the different doses to different drawers with highly distinctive labels to call special attention to the dosages. While this is a relatively simple fix, the effect on patient health and readmission was substantial. After finding other such areas for change and implementing new systems of efficiency and safety, within one year, UPMC St. Margaret reduced readmission rates for COPD patients by 48% and produced an estimated savings to the hospital of over $85,000.
Interventions such as this one and Project BOOST may spread quickly to hospitals nationwide as the new health care law mentioned above will reduce Medicare payments to hospitals with excess hospital readmissions as a way to reduce health care costs.
Researcher Jan Eldred found 4 stages of care that allow for effective intervention to reduce readmission.
In addition to these interventions, California researcher, Jan Eldred found 4 stages of care that allow for effective intervention to reduce readmission, documented in the paper, "Homeward Bound: Nine Patient-Centered Programs Cut Readmissions." Eldred examines 9 successful programs from Boston to San Diego with creative hospital transition solutions and found the 4 stages of care to include:
- Preparation for discharge, a process that can start even as patients are being admitted, to make sure hospital staff is aware of the home environment.
- Patient hand-off to their outpatient physician.
- Medication reconciliation to make sure new prescriptions are filled and patients are not falling back on their old medication routines.
- Home visits and/or phone calls, daily or weekly for the first 30 days.
Know your rights
In addition to hospitals and providers doing their part to implement systemic changes as described in the above interventions, making sure Medicare beneficiaries and their families know their rights to receive hospital discharge planning services and their rights to appeal a notice of discharge is another essential factor in reducing readmissions. All Medicare beneficiaries receiving care in Medicare-certified hospitals are entitled to discharge planning services. Medicare’s publication, Your Discharge Planning Checklist (PDF) provides a helpful checklist of questions and actions to take with one’s doctors and nurses to ensure that all the basics of one’s care needs are met and accounted for before leaving the hospital.
Also, upon admission and right before being discharged from the hospital, hospitals must give beneficiaries an Important Message from Medicare. This notice states beneficiaries’ right to an appeal if they feel they’re being discharged too soon and how to make that appeal. If talking with one’s doctor and/or other hospital staff about extending one’s hospital stay is unsuccessful, a beneficiary should follow the instructions on the notice and file an appeal by calling Health Services Advisory Group (HSAG) at 1-800-841-1602. HSAG is California’s Quality Improvement Organization (QIO), an organization that contracts with Medicare to handle certain appeals and other matters.
Once HSAG is contacted, the organization will review the beneficiary’s case independently and issue a decision usually within 24 hours. If HSAG finds that the beneficiary:
- Is not ready for discharge, Medicare will continue to cover his or her hospital stay.
- Is ready for discharge, Medicare will continue covering services until 12 noon of the day after HSAG notifies the beneficiary of its decision.
HSAG must notify beneficiaries of its decision by telephone and in writing. The written notice will describe additional steps for further appeal.
Beneficiaries can also file complaints about quality of care concerns by calling HSAG at 1-800-841-1602. They can also file complaints with California’s licensing agency by calling the Department of Public Health Licensing and Certification Division at 1-800-236-9747.
See the California Advocates for Nursing Home Reform (CANHR) fact sheet, Challenging Hospital Discharge Decisions , for more information.
Reducing hospital readmissions requires action on several fronts. In addition to educating beneficiaries on their discharge planning and appeal rights, providers and hospitals must engage in new innovative interventions to improve patient care, efficiency, safety and must promote successful hospital-to-home transitions. As discussed, several interventions such as Lean Healthcare are producing substantial results and present some exciting options for health care reform.
Challenging Hospital Discharge Decisions – A CANHR factsheet that reviews beneficiary rights to discharge planning services and reviews how to file an appeal if one feels s/he is being discharged from the hospital too soon.
Your Discharge Planning Checklist (PDF) – A Medicare publication that provides a helpful checklist of questions and actions to take with one’s doctors and nurses to prepare for leaving the hospital and ensure that the basics of one’s care needs are met and accounted for before leaving the hospital.
- Grunden, Naida. “Applying Best Practice in Chronic Obstructive Pulmonary Disease,” unpublished paper for Healthcare Performance Partners, concerning their joint venture with the Pittsburgh Regional Health Initiative at UPMC St. Margaret Hospital of Pittsburgh. June 2010.
- For more information on Lean health care, see: www.leanblog.org, www.leanhealthcareexchange.com, www.naidagrunden.com and www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm.