Tools for physicians to reduce hospital readmissions

Of every six Medicare patients admitted to the hospital for nonsurgical reasons, one will return within 30 days. Every year the estimated 2.3 million readmissions among seniors not only take a toll on the patients and the health professionals who care for them, but they also add up to about $17 billion in Medicare costs.

The government is taking steps to curb such rehospitalizations. On Oct. 1, 2012, the Centers for Medicare & Medicaid Services began reducing pay to hospitals on readmissions within 30 days for Medicare beneficiaries for heart failure, acute myocardial infarction and pneumonia. In the last quarter of 2012, CMS said the readmission rate fell to 17.8% — down from a rate of between 18.5% and 19.5% — prompting CMS officials to say the hospital readmissions reduction program is making an impact.

Yet plenty of hospitals are expected to be penalized for excessive readmissions through the program. Two-thirds of U.S. hospitals will get their Medicare pay reduced by up to 1% in 2013, according to a research letter in the Jan. 23/30 issue of The Journal of the American Medical Association.

Many readmissions are avoidable, health professionals say. There are initiatives, such as improving discharge planning, taking place in hospitals to prevent patients from being readmitted. But some patient safety experts say more focus should be put on the outpatient setting and what roles physician practices play in ensuring safe transitions in and out of inpatient settings.

The American Medical Association is doing just that. The AMA convened a panel of 21 experts in 2011 and 2012 to examine care transitions of patients from hospitals and other facilities. The findings were released in February in the report “There and Home Again, Safely” (link). It is available free online on the AMA's website.

Upon leaving the hospital, patients can be at risk of harm or a medical error during handovers of care when responsibilities shift among health professionals. The AMA report seeks to improve the safety of such care transitions by offering practical guidance on the responsibilities and roles of ambulatory practices. Many studies on patient discharges from hospitals examine readmissions from the inpatient perspective; the report looks at patient transitions through the lens of the ambulatory setting.

The report's panel developed a set of five responsibilities for outpatient practices for safe care transitions: Conduct a comprehensive health assessment for the patient; establish care goals with patients; support patient self-management; promote safe and effective medication use; and coordinate care with all members of the care team.

To carry out these responsibilities, the report said, medical practices should be guided by five core principles: Focus on the needs and goals of patients; collaborate with all team members, including the inpatient care team; use clear protocols and processes; make adjustments as a patient's care needs and goals evolve; and be flexible to address the unique needs of each patient. The principles emphasize the importance of communicating and focusing on patient-centered care throughout the process.

The report clearly spells out practical approaches for carrying out the five responsibilities for medical practices. For instance, the panel recommends that doctors and their teams conduct a comprehensive health assessment in the outpatient setting on every patient to gather information necessary to determine a profile of a patient's risks and strengths that can help guide their care. Physicians also are advised to use a uniform and structured assessment tool that is easy to update. It said the Comprehensive Geriatric Assessment instrument is consistent with the report's five principles, and its components are useful for all primary care settings.

The recommendations on conducting an assessment are just one of many examples of how office-based physicians can help prevent rehospitalizations and other problems. Additional guidance includes keeping organized information on medical issues and health goals, using reader-friendly tools to help patients with self-management tasks, and considering a patient's acute, intermediate and long-term goals.

Putting the report's ideas into action won't happen without overcoming some systemic obstacles. For instance, changes in a patient's health insurance can disrupt continuity of care. Electronic health record systems are not always interoperable across multiple inpatient and outpatient settings.

Even in a health care system marked by fundamental disagreements at every turn, there is no disputing the wisdom of avoiding unnecessary readmissions. The AMA report provides physicians with practical tools to make sure that patients have safe transitions from inpatient to ambulatory settings.