It’s been more than three years since Medicare’s hospital readmission reduction plan, established by the Affordable Care Act (ACA), kicked in. The program has set benchmarks for acceptable readmission rates, and was designed to combat what economists have called a “system of perverse incentives” – meaning that hospitals have, in the past, made more money when a patient develops a complication and lands right back in the hospital. Hospitals are now penalized financially for high rates of avoidable readmissions, defined as those that occur within thirty days of discharge and relate directly to the health issue that caused the original hospitalization. There are six conditions that hospitals are specifically targeting for follow-up care that can prevent unnecessary readmissions: heart failure, heart attack, pneumonia, COPD, coronary bypass surgery, and coronary angioplasty.
Reducing unnecessary readmissions is an important way to improve quality of care, lower overall spending, and keep patients safe. According to the Centers for Medicare & Medicaid Services (CMS), hospitals are making good progress: the national readmission rate has fallen to 17.5 percent, after many years of hovering at 19.5 percent. So what have we learned from our ongoing efforts to keep patients at home and out of the hospital? Here are a few of the lessons that have emerged.
- Widespread initiatives like preventing readmissions have the ability to change the organizational culture and reach beyond hospital walls, possibly preparing the healthcare industry for a broader role in society. In their efforts to keep patients at home, leaders have sought solutions for fragmented care, promoted multi-disciplinary teamwork, improved communication and sharing of expertise, and applied technology in innovative ways. It has potentially changed our view of what is possible in healthcare.
- Despite our best efforts, readmissions are sometimes driven by factors beyond hospital control, both clinical and non-clinical. For example, CMS reports that Medicare beneficiaries with multiple chronic conditions have a readmission rate of 25 percent, as opposed to only 9 percent for those with one or no chronic condition.
- Disparities exist in the community resources that can help patients avoid readmission. These resources include public transportation, availability of primary care providers, proximity of pharmacies, grocery stores that support a healthful diet, and social agencies that support the elderly or financially disadvantaged. Safety-net hospitals in particular tend to see higher readmission rates. As a result, some hospitals have worked to broaden their reach within the community by employing case managers and patient navigators to help coordinate follow-up care.
- Discharge planning is everything. A recent study in the American Journal of Surgery found that 65 percent of the patients studied did not have the reading skills required to understand the printed discharge instructions provided to them. Outreach and follow-up care can help to correct problems like this—including simple solutions like daily phone calls from a nurse, setting an appointment with the patient’s primary care provider at time of discharge, and helping to arrange transportation. Effective medication reconciliation also must become a routine part of discharge planning. Technology can support both patients and providers during the discharge process and the 30-day period after discharge. Patients can use mobile apps and patient portals to interact with nurses, clarify instructions, receive reminders and remain engaged with their own care.
Are you interested in working to improve outcomes and manage seamless transitions of care? There are currently no national standards that address hospital discharge, so hospitals will be looking for their own solutions in reducing readmissions. Case management is an expanding field for nurses wanting to play a leadership role in this area. 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.