Framing the Issue

  • Health reform is prompting hospitals to look beyond their four walls to promote wellness and manage patients. That requires a different staffing model.
  • To avoid penalties for readmissions, hospitals are training discharge staff and deploying both nurses and nonclinicians into the community and into patients' homes.
  • Hospitals also need to staff up to handle the millions of Americans gaining coverage under the Affordable Care Act.
  • Allowing nurses and others to work at their maximum skill levels takes the burden off of physicians. Using lay workers, when reasonable, also mitigates some of the burden of a bigger staff.

To help prevent unnecessary readmissions, leaders at Florida's Sarasota Memorial Health Care System decided two years ago to join forces with local nursing homes, creating a working group to brainstorm ways to support each other better.

Traditionally, when a nursing home patient falls or becomes short of breath, "there is the tendency to call 911 and bring the patient to the hospital," says Gwen MacKenzie, R.N., chief executive officer of the Sarasota system, which includes an 806-bed hospital, the only public facility serving a four-county region. But that shuttling back and forth not only boosts hospital readmissions, it also can be difficult for patients, particularly if they're quite ill and nearing the end of life.

These days, nursing home staffers are encouraged to call clinicians at Sarasota Memorial if they have a question or need input on whether hospital care makes sense. The hospital also shares more detailed medication and other clinical information than typically is included in the discharge summary, MacKenzie says. "And vice versa — we're getting more information from them. It's more of a partnership. We're even thinking about some of our nurse practitioners maybe visiting patients in the nursing home, to help supplement some of their staffing to be able to prevent a readmission."

Hospital executives and quality experts predict the health care staffing model will shift to reduce post-discharge complications that can land patients back in the hospital. The only question is how quickly and to what degree that shift will happen. Along with redeploying or retraining existing staff to avoid Medicare readmission penalties, some expect increased hiring for myriad positions from pharmacists to social workers to case managers to translators. Failing to staff beyond the hospital's four walls is no longer a financially viable option, says David Nash, M.D., a health quality expert and the founding dean of the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia.

"We have an economic incentive to not only coordinate care, but to really enhance compliance with care," he says. "The notion of the difficult patient, the poor historian, the noncompliant patient — well, that all now has an economic implication."

The transitional staffing hurdles are numerous. Hiring or retraining staff will come with a financial cost in the short term, and might be unfeasible for cash-strapped safety net facilities, experts say. Hospital leaders also will have to more closely align responsibilities with staff expertise, rather than default so many tasks to the doctors and nurses, says Paula Stillman, M.D., vice president for health care services at Temple University Health System in Philadelphia. Last year, Temple launched a community health worker training program for lay people, and plans to enroll a second group this spring [see Page 45].

Innovative staffing will be needed not only to guard against Medicare penalties, but hospitals also will somehow have to absorb the medical needs of a projected 30 million newly insured people under the Affordable Care Act next year. "As we increase the number of people who are going to be seeking health care, we need to be using the lowest-cost person to work at his maximum level of competence," Stillman says.

Most immediately, the hospital field's drive to reduce unnecessary readmissions is rooted in the 30-day tracking effort incorporated into the federal health reform law. As of March, 2,213 hospitals had been issued a penalty, roughly two-thirds of those whose readmission rates were reviewed, according to a Kaiser Health News analysis. Of those, 276 received the maximum Medicare penalty of 1 percent.

Nearly 20 percent of Medicare patients discharged from a hospital required readmission within 30 days, according to a frequently cited 2009 New England Journal of Medicine study. Those unplanned readmissions cost the federal program an estimated $17.4 billion annually in 2004, the researchers found.

Other studies have scrutinized the problem within specific patient groups. One surgical analysis published last year looked at complication rates for 551,510 adult patients who had undergone some type of general surgery. Overall, 16.7 percent of the patients experienced a post-surgery complication and nearly half of those complications (6.9 percent) occurred after the patient was sent home, an Archives of Surgery analysis revealed.

The hospital system of the future will look like a "care coordination company" with related services that it either owns or closely coordinates with, including home health, infusion services, physical therapy and transportation, Nash predicts. "I think every one of these components cries out for another staff-related job."

Will a hospital system's staff roster expand proportionately? "The jury is out on that," Nash says. "My hunch is that, knowing how our industry operates, yes, it will be a bigger staff. But it might be a bigger staff with folks not making a doctor's salary. We may see fewer physicians [proportionately] and a larger number of helpers."

Trissa Torres, M.D., a senior vice president at the Institute for Healthcare Improvement, isn't so sure. "I'm seeing much more the redeploying than the adding of staff," she says. "The financial drivers lead us, as health system leaders, to be cautious about adding more staff."

By thinking creatively, hospital leaders can maximize the skills of staffers already on the payroll, says Earl Steinberg, M.D., executive vice president of innovation and dissemination at Geisinger Health System in Pennsylvania. A nurse who is lining up transportation for a patient isn't making the most of his clinical expertise. And it isn't always necessary to take a doctor's time. "A pharmacist is pretty darn good at explaining the use of medications and the potential side effects of medications," he says.

Already, at least 11 state legislatures are looking at expanding a nurse's clinical autonomy, in part to assist with the anticipated influx of newly insured patients. Depending upon the legislation, nurses, particularly those with advanced degrees, might be able to handle a variety of tasks — from prescribing medication to interpreting diagnostic tests — without a doctor's supervision, according to a Washington Post article in March.

Moving forward, hospital leaders will need to educate all staffers about the importance of the discharge transition, not just those directly involved, says Joanne Lynn, M.D., who directs the Altarum Institute's Center for Elder Care and Advanced Illness in Washington, D.C. When a patient comes out of surgery and is moved to a recovery room, "you would think that it was just outrageous if there were no continuity there," Lynn says. "Here we're taking people who are increasingly fragile, because we are getting them out of our hospitals so quickly, and we're moving them to home very often without any of the same attention. Of course, things fall apart."

Supporting discharge

Lynn co-authored a study published in January in the Journal of the American Medical Association that looked at 14 Medicare Quality Improvement Organizations and the intensive patient support they provided, including following up after discharge. The average 30-day readmission rate in the 14 QIOs declined, from an average of 15.21 per 1,000 in the 2006–2008 period to 14.34 per 1,000 in 2009–2010. Readmission in the 50 comparison communities also improved, though more modestly, dropping from 15.03 to 14.72, respectively.

The QIOs did not identify a single solution; instead, they provided a variety of transitional and discharge support, from a follow-up visit to intensive health coaching. The common theme, Lynn says, was better educating individuals and their caregivers on post-hospital care, as well as when they should seek medical help. With a well-trained patient "you always have a safety expert on the job," she says.

Leaders at Inova Alexandria (Va.) Hospital decided to better assist patients with chronic illnesses by introducing a transitional care management program in 2011. The program, which includes 13 full-time equivalent positions, roughly half of them new hires, helps vulnerable patients get the follow-up care they need after leaving the hospital, says Christine Candio, R.N., chief executive officer of the 318-bed hospital.

The program even has an attached clinic for follow-up appointments. A heart failure patient, for example, typically will be seen there within 48 hours after discharge, Candio says. By early 2013, more than 3,000 patients had been enrolled with various chronic diagnoses, including diabetes and pneumonia. "It's too soon to tell," regarding return on investment, but hospital readmission and other data are being closely tracked, Candio says.

Given that its older population is vulnerable to chronic conditions like congestive heart failure, Sarasota Memorial long has focused on readmission prevention, MacKenzie says. But the risk of incurring Medicare penalties has heightened vigilance, she acknowledges, leading to the nursing home project and a steady ratcheting up of case management hours.

Case workers used to work primarily weekdays, outside of 24/7 coverage in the emergency department. More recently, the hospital has been beefing up coverage for the weekend hours, MacKenzie says.

Weighing trade-offs

The socioeconomic factors that can foster readmissions have made social workers a hot commodity, at least for hospitals that can afford to hire them, says Karen Joynt, M.D., an instructor at Harvard Medical School and Harvard School of Public Health. Joynt, who studies readmission patterns, is interviewing safety-net hospitals as part of a federally funded research project.

For cash-strapped facilities, there can be trade-offs, she says. "Some of the hospitals are saying, 'We are having a hard enough time keeping things going within our own walls. We have to keep the patients that we have in here safe.' So our choice is, do we fire a bunch of floor nurses to hire social workers?"

Will hospital investments in hiring or retraining pay off by avoiding Medicare penalties? The answer to that equation will depend on myriad factors, including a hospital's percentage of Medicare patients and its bed occupancy, among others. "I would assume that it [the ROI analysis] is happening with chief financial officers all over the place," Joynt says.

But she worries that readmissions will create a spiral effect for already struggling hospitals. A study she helped to author, published in January in JAMA, found that safety net hospitals were more likely to incur Medicare penalties. Of those projected to be highly penalized, 44 percent were classified as safety net and 30 percent were not.

Hospitals that can align with accountable care organizations may be able to implement the investments needed in the new Medicare reimbursement world, she says, and others will have a difficult time trying to catch up.

Charlotte Huff is a freelance writer in Fort Worth, Texas.

Executive Corner

Three things to consider when expanding and revamping discharge-related staffing:

1. Maximize your docs

With more patients flooding the health system, physician time is anticipated to be at a premium in the years ahead, says Paula Stillman, M.D., Temple University Health System's vice president for health care services. "You want to save the physician to be the head of the team and to use her to her maximum skill set," she says, "and have her delegate other responsibilities to people that she's trained to work with her."

2. Bolster the team safety net

As hospital leaders tap nonclinical people to assume discharge-related roles, there is "always a risk that somebody is going to exercise poor judgment," says Earl Steinberg, M.D., executive vice president of innovation and dissemination at Geisinger Health System in Danville, Pa. "I'm a big believer in [working in] teams. I do think it helps people stay within their comfort zone — not just their comfort zone, but their appropriate zone."

3. Retrain existing clinicians

To better understand patient challenges, hospital clinicians need to be trained to listen more and talk less, says Trissa Torres, M.D., a senior vice president at the Institute for Healthcare Improvement. "What we as clinical people tend to do is tell people what they need," she says. "And that doesn't work. We have to retrain [clinicians] so they are reoriented to listen to the patient's agenda and not promote their own agenda."