Accountable Care and the Need for Better Discharge Planning

This is Part 2 of a two-part series, examining how accountable care organizations will most likely expand the role of nurse case managers, making them both more visible and more accountable. (Read Part 1 here.)

One of the goals of accountable care organizations will be to reduce unnecessary hospital readmissions – those defined as occurring within 30 days of a discharge and being directly related to the original complaint. Often, readmissions within this 30-day window are the result of avoidable complications.

Heart failure alone has a readmission rate of 27%, according to a 2009 study in the New England Journal of Medicine. And according to the Medicare Payment Advisory Commission (MedPAC), in 2005, 17.6% of all Medicare patients were readmitted within 30 days, for a cost of $15 billion.

A mandate to reduce readmissions

The Patient Protection and Affordable Care Act (PPACA) establishes a hospital readmission reduction program, with defined benchmarks for acceptable readmission rates. The program kicks in next year and will apply to all Medicare patients discharged on or after October 1, 2012.

Here’s a quick rundown of how it will work:

  • Initially, the program will track readmission rates for three key conditions that account for high readmission rates: heart failure, heart attack, and pneumonia.
  • Hospitals that have readmission rates over a set benchmark will lose 1% of their pay.
  • By 2014, the list will be expanded to include three more conditions that have typically seen high readmission rates: COPD, coronary artery bypass surgery, and coronary angioplasty. Penalties for high readmission rates will also expand, up to 3% of a hospital’s reimbursement rate.

Better discharge planning

A healthcare blogger recently estimated that a floor nurse spends only eight minutes per patient on discharge instruction. In very complex cases, a case manager may be involved in discharge planning, to help the family arrange for durable medical equipment, home health aides, etc. But is this enough? With their economic viability on the line, hospitals will be searching for ways to ensure their patients recover uneventfully at home, rather than suffering complications. And almost certainly they will conclude that more thorough, focused discharge planning is the answer, with nurse case managers taking the lead.

Let’s look at the factors that drive high readmission rates:

  • Fragmented data, with poor communication between specialists, hospitalists, primary care providers, and patients/caregivers.
  • Medication issues. The patient may be confused about how to take a new medicine, or there may be interactions between drugs. If Medication reconciliation doesn’t occur at discharge, new medicines might duplicate existing medicines.
  • No patient follow-up within the 30 days following discharge.
  • Low patient compliance or health literacy, resulting in confusion or an inability to follow discharge instructions.
  • Inappropriate end-of-life care that doesn’t include hospice or support for the caregiver.
  • Lack of technology that can help track readmissions and examine trends.

All of these factors could be eliminated (or their effects drastically reduced) if there were one central coordinator with the authority to pull all loose ends together and demand cooperation from all clinicians involved – in other words, a super-hero version of today’s case manager, with an expanded skill set and expanded responsibilities in discharge planning.

What’s ahead for case managers?

In tomorrow’s healthcare system, where discharge planning takes on an urgency not seen before, skilled case managers will be in demand. At most hospitals, a squadron of case managers will be involved with all patients, assessing them in person and beginning the process of discharge planning as soon as a patient is admitted.

Because readmissions will be tracked, tomorrow’s case managers will be held accountable for the results of their discharge plans. In turn, they’ll need the authority to hold hospitalists accountable as well, and to bring primary care providers into the discharge process. Other interventions they’ll likely use include:

  • Making sure primary care physicians have immediate access to discharge summaries.
  • Having office staff schedule follow-up appointments for patients before they are discharged.
  • Overseeing medication reconciliation.
  • Coordinating patient coaching, so patients and caregivers understand their roles in the care transition.
  • Calling patients on the day after discharge and once a week afterward, until the next healthcare provider takes over.
  • Conducting readmission assessments that are patient-specific, and formulating a customized prevention plan.


Case management appears to be an excellent career path for nurses wanting to play a leadership role as healthcare reform evolves. Online nursing degrees like American Sentinel’s MSN with a case management specialization can make you attractive to employers, provide you with case management knowledge and skills, and give you the academic background you’ll need to pass the credentialing exam.