Hospitals are absorbing new penalties from the Centers for Medicare & Medicaid Services for "excessive readmissions" as part of the Hospital Readmissions Reduction Program created by the Affordable Care Act.

In Part 1 of this article, posted on April 25, 2013, we described the long-term implications of the readmissions reduction program and recommended that hospitals implement a multidisciplinary team to address readmissions prevention in an ongoing process rather than one that has a defined end. Part 2 will help hospitals identify high-risk patients and provide recommendations for the strategies presented in Part 1.

Getting Started: Understanding the Problem

It is tempting to start implementing changes in multiple areas simultaneously, but doing so might be a waste of resources. Consequently, the first task for the management team is to understand the scope of the hospital's problem.

One critical task is to evaluate the financial impact of the hospital's current performance (the penalty for excessive readmissions). This analysis not only should measure the effect of this year's penalty, but also consider the impact in future years, as the maximum penalty will triple.

Before assuming the causes of avoidable readmissions, management teams need to learn the hospital's actual experience. Case managers should interview all readmitted patients to gain an understanding of why the readmission occurred. Several questions should be asked:

  • Was adequate clinical information provided to the patient's next care provider?
  • Were the discharge instructions clear? Did anyone assess the patient's or family's understanding of the discharge plan? Did anyone assess whether problems could be anticipated (e.g., the family can't afford medications)?
  • Did the patient have a follow-up visit with his or her primary care physician within seven days of discharge? If not, why?
  • Was the patient educated to identify signs and symptoms that suggest that his or her condition was worsening, and does the patient know what to do in case of problems?

Data gathered from interviews should be analyzed to address multiple hypotheses. For example, are readmissions more frequent at a particular nursing home? Are readmissions more likely following a weekend discharge? Are assessments of patient understanding inaccurate?

When a problem is identified, assemble a work group to address it. These work groups may need to gather and analyze different data before they can develop or implement new processes. Make sure to include in the work group physicians who can address medical staff issues.

In addition to providing insight, the interviews should become an ongoing feedback mechanism to monitor the effectiveness of the discharge process. Every patient who is readmitted should be evaluated by a case manager to determine if the readmission were due to a preventable cause. It is also important to identify what parts of the process are working to ensure that any changes made don't eliminate them.

If the case review suggests a quality of care problem, a physician should perform a second-level review to evaluate the quality of care. Data should be compiled for trend analysis, but each case should be used to provide feedback to caregivers involved in the initial hospitalization. Review information also may be useful for current caregivers to identify factors that might precipitate readmission.

Identifying Patients at Risk

Case management departments should have processes in place to identify high-risk factors for readmission and prioritize discharge planning for patients with those factors. High-risk factors include:

  • mental health diagnoses;
  • substance abuse;
  • showing up in the emergency department more than three times in two months;
  • high-risk medications (anticoagulants or diuretics);
  • polypharmacy (more than six medications);
  • chronic diseases;
  • high or low body mass index;
  • leaving against medical advice.

Data gathered from interviews with readmitted patients should be used to refine risk-screening tools. Interviews may reveal new combinations of factors that might increase the risk of readmission.

After patients are identified to be at high (or moderate) risk for readmission, specific interventions should be included in these patients' discharge plans. For example, when making a referral to a home health care provider, the risk factors and the patient goals need to be communicated so that the patient, hospital and home health provider are working toward the same goals.

Standardizing Discharge Educational Tools

Reducing readmissions is not just a concern for case managers. Because patient education is a primary responsibility of the nursing staff, nurses should be educated on the high-risk factors, as well as on actions that can be taken to avoid readmission. These actions include:

  • educating and re-educating;
  • assessing patients' understanding of their care requirements;
  • assessing patients' awareness of early warning signs that require immediate notification of their physician;
  • beginning discharge education as soon as the patient or family can cooperate;
  • providing a comprehensive plan prior to discharge, including the following components: medication reconciliation; follow-up appointments and tests; post-discharge services set-up; a written discharge plan; instructions on what to do if a problem arises; patient education; and a discharge summary sent to the patient's primary care provider.

In many cases, providing ongoing education throughout the hospitalization and for 24 to 48 hours after discharge has proven to be beneficial for patients. Patients should be educated regarding the importance of keeping their own medical journals to include their medications, test results and hospitalizations. Ideally, a pharmacist should be involved in patient education and medication reconciliation at discharge. Verify that patients have all their medications and that they understand why they are taking those medications; that they grasp the importance of taking the medications as prescribed; and that they understand any potential side effects, as well as the importance of family support.

While the patient is still in the facility, all care providers should ensure that patients and families are educated about the disease process. Patients with acute myocardial infarction, congestive heart failure and pneumonia should receive follow-up phone calls within 24 hours of discharge. During these calls, provide additional education, review discharge instructions with the patient, ensure that a follow-up appointment has been set up in the next week, review medications and provide information about whom to call if issues or problems arise.

Discharge instructions also can be offered on the hospital's website so patients can access this information at home and more fully understand the instructions. Hospitals can also use their websites to promote ongoing communication with patients to answer questions and provide more clinical education. Each of these steps will improve patient outcomes, increase customer and provider satisfaction, and reduce readmissions.

Working with Post-Hospital Care Providers

Given the consequences of readmissions, hospitals should establish stronger working relationships with other providers to extend care beyond hospitalization. Case managers, who work with other care providers on a daily basis, need to redefine these relationships to establish better communication both preceding and following discharge. Working collaboratively with these other facilities is imperative when tracking patients who are subsequently admitted to other hospitals and when developing patient identifiers. This tracking can be used for a hospital's internal quality improvement purposes as well as for validating readmission data.

Develop a transition-of-care work group to include home health care agencies, skilled-nursing homes, long-term acute hospitals and rehabilitation hospitals. Standardize education tools so that the hospital, physician, home health agency and skilled nursing home are all using the same language and documents to educate and instruct the patient. Consider sharing access to medical records to improve clinical data-sharing.

Additionally, hospitals should try to engage home health care agencies and skilled-nursing homes to address some of the causes of readmissions and manage patients to reduce readmission rates. Activities intended to build collaboration and reduce readmissions could include:

  • working with home health care agencies to develop disease-specific programs that track data and create plans to reduce readmission rates;
  • working with skilled-nursing homes to identify reasons patients are sent back to the hospital and the challenges they face;
  • working with the nursing homes to provide advanced cardiac life support training, telemonitoring links, EKGs with quick reads and access to hospitalists to answer clinical questions instead of sending the patient directly to the emergency department;
  • partnering with community agencies to assist them with education and access to other health care professionals.

Although hospitals may not have influence over the clinical practices of other facilities, CMS officials believe that hospitals should communicate effectively with post-acute care providers. Through better post-hospital care communication, discharging hospitals can influence where the patient is reassessed (and readmitted).

Readmissions are becoming an increasingly painful and public problem for hospitals — in both finances and patient care. While no easy fix exists to prevent readmissions, hospitals can take a proactive approach to relieve the pain, starting with taking the time and resources needed to fully understand the problem at hand, and enlisting the involvement of the many different groups that can contribute to a successful readmissions reduction initiative.

Terri Marshall, R.N., M.S., C.C.M., is a senior consultant with Compass Clinical Consulting, Cincinnati.