Is the whirl of hospital revolving doors slowing?
Federal health officials are now reporting that the rate of preventable and costly hospital readmissions is down for the first time in more than five years, which meant about 70,000 fewer hospital returns nationally in 2012 for the Medicare program alone.
With a strong push from the federal health reform law, scores of medical and social service workers around Kansas — like thousands of their counterparts in other states — are working together on projects that officials say show promise for reducing avoidable readmissions.
If they succeed, hospitals could be spared some of the Affordable Care Act penalties they face in the form of reduced Medicare payments and federal health care spending could be trimmed $8.2 billion by 2019, if projections from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) prove accurate.
Starting in October 2012, almost 30 of the 46 non-exempt Kansas hospitals were punished for relatively high readmission rates in the first year of the ACA program, according to information from CMS compiled by Kaiser Health News, a partner of KHI News Service.
Because of the potential financial sting attached, nobody wants to be on that penalty list when it’s redrawn for this year, especially since last year’s maximum penalty of a 1 percent reduction will grow to a maximum 2 percent and then 3 percent for 2014.
“Almost every hospital is looking at this, because they stand to gain or lose,” said Ken Mishler, chief executive of the Kansas Foundation for Medical Care, a Topeka-based, non-profit organization that is the federal government’s sole designated contractor in Kansas for improving health care quality. In federal parlance, the foundation is known as a Quality Improvement Organization or QIO.
Mishler’s group was directly involved with organizing projects in four locations - Hays, Topeka, Kansas City and Wichita – but there are others underway, too, including one by the Kansas Healthcare Collaborative, a 2008 creation of the Kansas Hospital Association and the Kansas Medical Society.
There is evidence the various efforts, some of which predate the ACA, may be working. The readmission rate in Kansas was already lower than the national average, but recent numbers show even that somewhat lower rate has dropped.
Patients who return to the hospital within 30 days of being discharged cost Medicare, the government health care program for the elderly, about $12 billion a year in avoidable expenses, according to the Medicare Payment Advisory Commission. They cost the U.S. health care system overall as much as $25 billion a year, according to the PriceWaterhouse Cooper Health Research Institute.
According to the Kansas Foundation for Medical Care there were 49.4 per 1,000 Medicare fee-for-service patients readmitted to Kansas hospitals within 30 days in 2011 versus 52.5 in 2010. That compares favorably to the national average of 56.8 per 1,000 in 2011 and 58.2 per 1,000 in 2010. Foundation officials say the ultimate goal is a 20 percent reduction.
The efforts to make that happen in Kansas vary place to place but among the things they have in common is the involvement of multiple types of medical and social service providers or agencies, not just hospitals.
The reason for that, experts say, is that one of the best ways to reduce readmissions is to make sure that patients get proper follow-up care or attention after they are discharged whether they leave the hospital to live alone at home - where they may receive limited assistance from a variety of outside sources - or a skilled nursing facility where they get more-or-less 24-hour attention.<a name="continued"></a>
‘A community problem’
“It’s not just a hospital problem. It’s a community problem and you have to get all the providers together. It’s not easy work. It’s hard work,” said Laura Sanchez, the project director for the Kansas Foundation for Medical Care. “It took several months (to get the projects going) and in some communities it was easier to build than others.”
In Topeka, for example, the collaboration involves more than a dozen local organizations including the city’s two major hospitals, nursing homes, home health agencies, the regional Area Agency on Aging and Midland Care Connection. The aim is to assure that no matter where a Medicare patient goes after leaving the hospital that there is a “seamless” transition to the next service provider so, for example, the person continues to take the proper medicine or is able to make follow-up appointments with a doctor.
One of those involved in the Topeka project is Eileen McGivern of Brewster Place, a retirement community that offers services to the elderly ranging from minimal help with housekeeping to full care for dementia.
McGivern said she had been involved in a fledgling pilot program with the two hospitals that involved about 60 discharged patients, each of whom had been diagnosed with at least one of the six conditions most likely to result in an otherwise avoidable readmission.
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“I did some pilot coaching on the people with those six diagnoses as a way of getting our feet wet to identify some of the challenges we might face,” as part of the larger collaborative project, she said. “It was really pretty beneficial.”
McGivern said she tailored her “coaching” to meet the needs of each of the 60 patients.
“A lot of them just needed some empowerment in terms of how to communicate with their physicians or ask questions about medication,” she said. “It was kind of like taking all the good discharge information they received from the hospital and reinforcing it once they got home and helping them problem solve what the next steps would be.”
People who haven’t been seriously sick or don’t work in the health care industry may not fully understand how disjointed or fragmented the so-called “continuum of care” for an ill person can be and so some of the steps being taken to minimize hospital readmissions – such as telephoning a patient or visiting them in their home and talking with them - may seem deceptively simple at first glance.
But those who know the business say it takes concerted effort and/or special planning and training before medical workers responsible for a certain type of care can break free of their busy and sometimes harrowing routines to communicate with someone providing another type of assistance for the same person but perhaps across town or two counties away.
Regina Borthwick is director of inpatient services at Hays Medical Center in near west Kansas and also is involved with the Northwest Kansas Care Transition Collaboration, which includes among others organizations the Hays hospital, a few smaller, outlying critical access hospitals and the local Area Agency on Aging.
One of the first steps taken, Borthwick said, was to make sure that all the collaborating agencies were using the same information so that a patient wouldn’t hear one thing from the hospital and perhaps something else from a worker at a home health agency who might deal with the patient after the hospital discharge.
“We looked to make sure our education material was consistent,” she said. “It was good for us to go out and review the information to be consistent with the doctors, the hospital, clinics…and even the nursing homes. That's kind of what we started with.”
‘A code word’
The various collaborators then agreed to use a standard term when communicating with one another to help meet the goal of making sure that every patient who needs a follow-up appointment after leaving the hospital gets one within five days.
“We use kind of a code word - post hospitalization,” Borthwick said, “so that the clinic knows that a person needs a priority appointment in that five-day time frame. Home health will use those same words, so it moves the triaging of that patient to the top. You want them to be triaged very fast to address any clinical change in order to avoid the readmission.”
The collaborators are trying other things, too, some of which are more technically sophisticated.
“We're trying lots of different things,” Borthwick said. “We’re also trying to give some of the collaboration members access to our (Hays Medical Center’s) electronic medical records” through secure web access.
That could allow, for example, a home health agency with a new patient referral to access the hospital’s lab results and health history for the patient as part of its assessment of the patient’s needs.
She said the collaboration also has people from the different agencies in the region talking about commonly recognized problems, a good step in perhaps finding solutions.
“Everyone within the collaboration has identified transportation as a huge issue,” Borthwick said. “Typically, when we have someone dismissed (at Hays) we’ve always found transportation. Obviously there’s family, but we now have a taxi service and we pay for that, if we have to. Sometimes ambulance is how you transport. In Ellis County, we have a little more resources. But in (more rural) northwestern Kansas, transportation is a challenge and one of the things we identified as a need.”
For some rural medical providers reducing hospital readmissions is something of a two-edged sword, especially since the push to lower them is coming ahead of the much anticipated but still uncertain mothballing of the traditional fee-for-service payment system still used by Medicare and most private health insurers. The current system for the most part still rewards quantity of services rather than quality.
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Greeley County Health Services in far western Kansas, like many in the state's remote or rural areas, is an "integrated" system that provides clinic, hospital and nursing homes services. Without its multi-county, clinic-based network, patients would have no place local to go for care. When patient readmissions to the Greeley County Hospital are reduced that means reduced revenue for the facility and by extension the entire integrated system.
"It's an interesting scenario," said Chrysanne Grund, a project director involved with quality improvement efforts at the Greeley system. "If we would gain $50,000 in perhaps insurance prospective payments (as a reward for prevention) through our primary care side and then see $70,000 in lost revenue on the hospital side, that's difficult to make pencil out. We can't very well work at cross purposes."
Grund said the Greeley system already has seen reduced use of its hospital beds compared to 10 years ago because "we've been so aggressive in prevention. And that makes it more difficult for the hospital's financial situation."
She said most rural health systems in the state are trying to figure out how to best prepare for the future.
"I think this is a pretty pivotal time for rural health systems," she said, "and i think that there's a lot of good ones across the state of Kansas really watching things. You've got to work at what you have been doing and try to keep that going as much as possible and you have to be really ready to respond to what's right around the corner. As long as the system is based on quantity, we have to keep that in mind as we're at work, too."
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