The Hospital Readmissions Reduction Program, a component of the Affordable Care Act (ACA), financially penalizes hospitals that have higher-than-expected readmission rates for certain conditions. There have been worries that these penalties would lead to longer stays in observation units, or a failure to readmit patients who return for care.
However, a recent study shows that hasn’t happened at all. Instead, readmission rates are going down without compromising care.
The authors compared monthly, hospital-level rates of readmission and observation-service use within 30 days after hospital discharge among Medicare elderly beneficiaries from October 2007 through May 2015 for 3,387 hospitals. They found “readmission rates for targeted conditions declined from 21.5% to 17.8%, and rates for nontargeted conditions declined from 15.3% to 13.1%,” particularly shortly after the ACA was passed. There were no statistically significant changes in observation-unit stays.
So how are hospitals doing it? Here are three strategies.
In busy inpatient departments, there are a lot of moving parts to manage: physicians overseeing care, nurses monitoring patients, pharmacies dispensing drugs, diagnostics, allied health professionals and more are all working to efficiently move patients through to appropriately ordered discharge without compromising quality of care. Certified medical scribes can be tasked with delivering messages between providers, and to patients and their families, from the physician. In addition, a scribe can help the physician keep track of tasks to be completed during rounds by recording notes from the tech, nurse, or another department. This lets the doctor manage new requests in order of actual priority, rather than the order in which they are delivered — and ensures the care plan for the patient in the room is executed in a timely manner. The scribe can also play a critical role in keeping the physician on track to revisit patients or follow up on test results — or to ensure a nurse visits a patient to provide care directed by the physician. Furthermore, the scribe can collect reports from the lab, track time and provide notes to patients from the physician. All these efforts enhance teamwork and keep the communication within and between departments flowing, so that there aren’t missed messages or miscommunications, which could delay discharge or lead to discharge in which the patient goes away ill-equipped to manage the care regimen at home.
Improving communication between clinicians and patients, and instituting follow-up communications after discharge is critical to ensuring that patients can manage when they are discharged to home or another facility, such as a nursing home. The Re-Engineered Discharge (RED) toolkit is a free set of resources, developed in a safety-net hospital with Association for Healthcare Research and Quality (AHRQ) funding, to help hospitals enhance these patient-communication pathways.
The RED toolkit recommends the use of discharge educators (DEs) to “educate and advocate for patients in order to best prepare them and their caregivers for discharge and success following discharge from the hospital.” The DE is the key stakeholder in RED, collaborating with patients’ multidisciplinary medical teams (e.g. physician, social worker, case manager, pharmacy) about what happens during the hospital stay and what needs to be done for a safe transition home, including:
- Reviewing the discharge plan that has been developed by the medical team and identify service gaps.
- Addressing gaps by arranging for appropriate services (e.g., diabetic education, visiting nurse).
- Identifying barriers to the discharge plan and strategies to overcome these barriers (e.g., transportation issues, cost of medicine, anticipated medicine side effects).
- Creating an easy-to-understand discharge plan, and teaching it in a way that allows patients to understand how to care for themselves once home.
Making the most of telemedicine
Telemedicine is a huge benefit to patients in remote locations, those with chronic diseases, and those who require — or think they require — follow-up consultation. Tele-consultation can let a physician or nurse review any postoperative issues a patient may be having, provide education, continue to monitor progress or even prescribe other treatments (e.g. physiotherapy) or medications where patients might otherwise go to the ER, desiring to be readmitted. Each of these benefits has great potential to reduce waiting times, costs and travel, and improve the quality of post-discharge care patients receive as well as their access to care. Cameras for home computers and mobile phones are very advanced, and by instructing the patient or carer how to angle it, a medical professional can, in most cases, visualize any issues. Using a telemedicine solution is often cheaper than or near enough to the patient’s co-pay that, combined with speed and convenience, it’s a pragmatic option for post-discharge care that prevents readmissions.