NOVEMBER 1, 2012

Welcome to the Medicare Readmissions Update eNewsletter
Editor: Philip L. Ronning
This issue sponsored by the Dual Eligibles Summit

Thinking Outside the Pillbox: Improving Medication Adherence and Reducing Readmissions
The New England Healthcare Institute (NEHI) has released an Issue Brief entitled Thinking Outside the Pillbox: Improving Medication Adherence and Reducing Readmissions. The Brief, which is in part a response to the October 1, 2012 initiation of readmission penalties, argues that advanced discharge planning and transitional care are central to reducing readmissions, and medication management is a core function of discharge planning. This is based on the fact that adverse events are a major cause of avoidable hospital readmissions: more post-discharge adverse events are related to drugs than other causes, and lack of adherence to medications prescribed at discharge has been shown to be a driver of post-discharge adverse drug events. The Brief examines four models for discharge planning found in the literature. All of the models share five principles in common: 1) designation of a lead coordinator, 2) the facilitation of teamwork, 3) medication reconciliation and clinical management of medications, 4) patient education, counseling and engagement, and 5) follow-up by clinicians. (NEHI, October, 2012)

Need Surgery? You Might Have to Get Healthier First
This New York Times piece highlights a range of activities providers are undertaking to improve the results of surgeries and to minimize the likelihood that patients will be readmitted. These efforts are part of an increasing trend exemplified by the Strong for Surgery program being implemented in Washington State. (The link will provide access to related programs such as SCOAP and CERTAIN.) The principles are based on the checklist theme and the recognized fact that healthier patients are less likely to produce the complications that result in a readmission. At the same time, providers are examining all aspects of the perioperative process. (New York Times, October 22, 2012)

Are Social Factors Tied to Hospital Readmissions?
Reuters reports on a new Journal of General Internal Medicine study which analyzed data from 72 previous papers examining the reasons people died or were readmitted to the hospital and found that age, race, employment status, living situation, education and income levels are just some of the factors that may play a role. Linda Calvillo-King, MD, assistant professor of internal medicine at the University of Texas Southwestern Medical Center in Dallas and lead author of the study, said, "We don't yet know how to accurately measure (the factors), but I think we found enough information to say that they are important and that they should continue to be studied and accounted for." (Reuters, October 19, 2012)

4 Discharge Tactics to Reduce Senior Readmissions
"The Centers for Medicare and Medicaid Services estimates $15 billion is spent annually on readmissions for Medicare patients, with $12 billion of that amount being preventable," said Jeff Huber, president and COO of Home Instead Senior Care. He recommends four steps to reduce the readmissions of seniors: 1) Inquire about the post-discharge environment, 2) Implement an integrated approach to post-discharge care, 3) Provide clear discharge instructions, and 4) Continue to adjust the post-discharge plan. (Healthcare Finance News, October 28, 2012)

How Avoidable Hospital Readmissions are Hurting the Economy, the Health Care System and the Patient
In this consumer-oriented piece Lily Sarafan, President and COO of Home Care Associates, explains the high costs of healthcare and the problems driving the costs up (e.g., "inefficiencies" cost the public $300 billion, etc.) and draws particular attention to readmissions (e.g., 1 in 5 Medicare patients is readmitted within 30 days). She suggests that patients and families can help minimize this problem. Her recommendations, which are summarized below, can be included in patient education materials.

  • Write a list of your loved one's prescription drugs, over-the-counter drugs, supplements and vitamins, including your regular dosage and medication times.
  • Obtain a list of home medical equipment, such as a walker or hospital bed, to facilitate recovery at home.
  • Write down a schedule of the follow-up appointments, including relevant contact information.
  • Ask the hospital staff to demonstrate any tasks that require special skills, such as changing a bandage.
  • Ask the discharge team about common issues for patients in similar circumstances.
  • Understand your loved one's physical limitations and areas where he or she will need support.
  • Create a regular schedule with your loved ones and any professional care providers involved in your loved one's post-hospitalization care.
  • Ask to speak with a social worker if have concerns about coping with your loved one's illness.
(Huffington Post, October 17, 2012)

A Trigger for Hospital Readmissions ID'd by Geriatric Experts
The condition of elderly patients must be more clearly understood prior to discharge in order to reduce the likelihood of readmissions. For example, older patients' brains often aren't working as sharply as they were prior to their admission, or they can't walk as far or manage steps as they did before. Edgar Pierluissi, MD, medical director of the San Francisco General Hospital Acute Care for Elders (ACE) unit, says that this insidious process is a fact of life for about one-third of patients 70 and older after hospitalization. "If you're really interested in reducing readmissions and hospital complications, you have to face these facts," he notes. Often, it means they can't return home and must spend the rest of their lives in skilled nursing care. He and colleagues described this in an article in the Journal of the American Medical Association last year. (The article "Hospitalization-Associated Disability: 'She Was Probably Able to Ambulate, but I'm Not Sure'" is available to subscribers or for purchase). The authors concluded that units such are their ACE unit "...can reduce hospital length of stay and the resulting cost savings may be greater than the added costs of the unit" as well as improving patient and provider satisfaction. Pierluissi says that there are only about 70 to 100 focused ACE units in the country, the first of which were at Virginia Mason in Seattle and Case Western in Cleveland and Summa Health Akron, OH. (HealthLeaders Media, October 15, 2012)

Risk Factors in Hospital Readmissions among General Surgery Patients Identified in Study
A recent study by Georgia State University's Experimental Economics Center and conducted by a team from the Emory University School of Medicine published in the Journal of the American College of Surgeons identified characteristics of surgical patients associated with readmissions. The study of 1,442 surgical patients from Emory University Hospital found 163 patients (11.3%) were readmitted. Three primary causes of readmission were isolated: pre-existing conditions, complications developed in the hospital and complications developed post-discharge. Research is continuing with experts in decision-making at Georgia State University's Experimental Economics Center to develop decision support software that will help improve outcomes. (EurekaAlert, October 24, 2012)

Improve Outpatient Management to Cut Readmissions
According to research form the American Journal of Transplantation, hospitals should target kidney transplantations, as 33% of them are readmitted within 30 days. Factors such as age, race, body mass index, diabetes and heart disease were associated positively with the readmissions. These examples were cited: African-Americans had an 11 percent greater risk of readmission, obese patients had a 15 percent increased risk and diabetic women had a 29 percent greater risk. "Some patients just need more intense monitoring," said study leader Dorry L. Segev, MD, an associate professor of surgery at the Johns Hopkins University School of Medicine. "We need to be aware that kidney transplant recipients have an extremely high risk of returning to the hospital in the first 30 days after discharge and that readmissions may very well be prevented by putting in place better systems for outpatient management." (FierceHealthcare, October, 16, 2012)

Target Conditions to Reduce Readmissions

Source: 2012 Healthcare Benchmarks - Reducing Hospital Readmissions, June 2012

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The Road Ahead -- The Transition from Volume to Value-Based Payment

Richard Clarke, DHA, FHFMA
President and CEO, Healthcare Financial Management Association (HFMA), Westchester, IL