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Deirdre Coleman examines the burden of readmissions to the healthcare system and the path to tackling this issue with the help of a technology.

By Deirdre Coleman on Jan 22, 2014

Under the Affordable Care Act's Hospital Readmissions Reduction Program, hospitals that readmit certain patients within 30 days of discharge could face significant penalties. The initial penalties, which took effect several months ago, were only for people readmitted for heart failure, myocardial infarction, or pneumonia. The list has now been extended to include those patients who may be readmitted following hip and knee replacements. This sweeping legislative overhaul will have dramatic effects on the fiscal health of hospitals and intensifies the focus on developing effective strategies to reduce readmission rates which in turn will have positive effects on patient outcomes.

The problem of hospital readmissions is substantial, according to Chris Ellis, Marketing Director of Vree Health, a wholly owned subsidiary of Merck.

“The cost of hospital readmissions is sizeable and it is currently estimated that one in five Medicare patients who are hospitalized will be readmitted within 30 days – that’s about 2 million people a year – and avoidable readmissions cost the government more than $17 billion annually. Technology can be a key enabler in this multi-faceted problem which requires a comprehensive approach to transitional care”, explains Ellis.

Technology-Enabled Transitional Care

There are many ways to address preventable readmissions

·         Patient compliance with medication

·         Coordination across the care team

·         Seamless handoff of patient to Primary Care Physician (PCP)

·         Early warnings to preempt problems

Thanks to advancements in health information technology (HIT), case managers and patients now have access to more tools that not only strengthen communications, but ultimately will contribute to efforts to reduce readmissions. Better patient follow-ups, enhanced education, and personalized care plans are essential in minimizing readmissions and easing patient transitions.

A new white paper, Improving Transitions of Care with Health Information Technology, from the National Transitions of Care Coalition (NTOCC) stresses the importance of improving transitions of care (TOC) through the use of health information technology. "NTOCC believes that for Health Information Technology (HIT) to make a difference in transitions of care, the technology must address several critical steps," the paper states. "The components include standardized processes, good communication, required performance measures, established accountability, and strong care coordination. Without addressing each step, the promise of HIT’s effect on overall transition of care improvement will not be realized."

Roadblocks to Data Flow

A recent report by the Institute for Health Technology Transformation identifies a number of roadblocks to effective population health management. One key challenge is the inability of multiple organizations—or even departments within the same organization—to aggregate data in a manner that allows efficient sharing and use with others. As providers have begun working together to improve patient care quality, it has quickly become apparent that merely having data does not mean being able to use the data in a meaningful way. While disease management programs and other population health management tools offer analytics to identify trends and evaluate opportunities for outcome improvement, the missing piece is the “plumbing” that integrates, aggregates and harmonizes data to ensure “apples-to-apples” data comparisons for all users. Without this step, information cannot flow from multiple sources to provide the most accurate and comprehensive look at a population’s health needs.

Technology-Assisted Transitional Care

As technology improves and the pressure to reduce readmissions continues to escalate due to health care reform, the use of transitions of care and readmission prevention programs will steadily increase and new technologies will emerge to meet the needs of the health care industry.  One example of this technology is Vree Health’s TransitionAdvantage.

The service is based around a cloud-based electronic patient profile, populated initially by the patient’s Electronic Medical Records (EMR), and updated throughout the 30-day post-discharge period with patient health information. The collaboration involved to deliver effective follow-up care is not to be under-estimated: the medical equipment, transportation needs, communication with primary care physicians (PCPs) and discussions with patient caregivers are all considered critical but complicated factors in a patient’s discharge. The extended care team, which typically includes caregivers and PCPs, can help provide the support a patient needs to recover at home post-discharge, but their efforts are likely to be most effective when carefully coordinated.

The service begins with a discharge team member meeting with a patient and their family before discharge. Discharge instructions are sent home with the patient and sent to an information repository that can be accessed by all members of the transition team that will interact with or monitor the patient during the 30-day period. From that point on, post-discharge care can be coordinated through technology—including email reminders, Interactive Voice Response (IVR) and personalized web pages—in conjunction with a dedicated “Transition Liaison” i.e. one-on-one with a real person at the end of the phone.

A daily health check—a short series of questions about the patient’s health and adherence to the care plan—is completed by the patient or caregiver each day. To increase patient use of the daily questionnaire, options for completing it accommodate patient preferences and include live phone call, IVR or patient portal. Regardless of response method, however, all of the data moves directly into the accessible patient health record repository where the care team has appropriate access.

A key component of the technology is the Transition Liaison. They are the human voice of support and encouragement to the patient, stepping them through their care plan and their daily health check, monitoring the patient’s progress, reminding them to take their medication, confirming they carry out any follow-up appointments and facilitating any rescheduling. In the case of a worsening of the patient’s condition, they direct them to the appropriate level of care needed. The health check which tracks biometric measures serves as an early warning system and allows for corrective action to be taken before the condition worsens. Transition Liaisons are highly trained in motivational interviewing techniques, helping patients understand their care plan, building rapport with them and working towards the individual’s personal goals whether that means getting back out into the garden or attending their daughter’s wedding. Patient engagement is critical and is often the stumbling block to compliance with the care plan. This involvement with the patient creates ownership of their recovery and motivates them to complete their care.

Looking at the care quality problems that lead to needless additional hospi­tal stays, the list is long. Many patients are discharged without understanding their illnesses or treatment plans, or inadvertently discontinue important medicines needed to stay well.Family members are frequently not included in discharge planning, even though they may be central caregivers to the patient. Sometimes, the physicians caring for the patient do not communicate with each other and fail to develop a coordinated plan for post-discharge care. Patients may not have the right prescriptions or be able to fill them. Appointments with primary care clinicians or with specialists may not occur soon enough after discharge. Without a clinician visit, an opportunity to recognize that the patient is not improving may be missed. Information about a patient’s hospital course does not always go to the appropriate community clinicians. Most importantly is the lack of clarity regarding the clinician who is responsible following discharge; accountability is scattered among hospital staff, community physicians and nurses, skilled nursing facilities, and families. Without clear accountability, problems that could be prevented are missed, leading to emergency room visits and repeat hospitalizations.

Improving the Patient Experience

Patient satisfaction has become a priority for a few reasons: Consumers are being more selective as they look for the most affordable provider; patient loyalty is at a premium due to tough competition among hospitals; and CMS (Centers for Medicare and Medicaid Services) value-based purchasing now factors patient experience into Medicare reimbursements. 

 “In 2013, the Hospital Readmissions Reductions Program withheld up to 1% of regular reimbursements for hospitals that had too many patient readmissions within 30 days of discharge because of three medical conditions: heart attack, heart failure and pneumonia. Under the ACA, the maximum penalty will increase to 3% by 2015 and be expanded to include readmissions for other medical conditions”, Ellis states.

It is of paramount importance for hospitals to master the evolving value-based payment and delivery mechanisms because eventually, their credit ratings and financial health will depend on it. The silver lining is that hospitals that have embraced care continuity, focusing on transitional care, have discovered efficiency savings. Within the next couple of decades, the number of Americans over the age of 65 - the population with the highest readmission risk - will rise from one in eight to one in five. Given the annual per capita medical costs are roughly three times greater for people 65 and over, the need to identify cost solutions and provide higher quality care is critical. A recent study from NEHI, a health policy organization, shows that readmissions could be reduced by up to 12 percent through improved discharge procedures, follow-up care and health information technology.

The US health care system faces many challenges. Quality, cost, access, fragmentation, and misalignment of incentives are only a few. Health care providers must embrace today's user-friendly technologies to improve communication between care teams. Electronic health records were an important first step in creating a single repository of data that can supply a fountain of information. But now it is incumbent on health systems to embrace communication technology that allows EHRs to become more actionable. Today's patients live in a hyper-world of instant gratification. Patient expectations around efficient care delivery are increasing and will put even more pressure on the health care system to evolve to meet expectations. Only with the adoption of new technologies to improve this care coordination will the American health care system be able to keep up.