AMA details plan for cutting hospital readmissions

Most rehospitalizations happen within two weeks of discharge. Experts say primary care doctors can help keep patients healthy at home.

By — Posted Feb. 18, 2013

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Outpatient physician practices can play a key part in ensuring that patients have safe transitions in care and avoid preventable hospital readmissions, according to an American Medical Association report released in February.

About two-thirds of U.S. hospitals will see their Medicare pay cut by up to 1% under the Hospital Readmissions Reduction Program, stated an unrelated research letter published in the Jan. 23/30 issue of The Journal of the American Medical Association. The program was authorized by Congress as an incentive for hospitals to decrease the number of patients who need to come back to the hospitals within a month of discharge.

Much of the attention given to the readmissions problem — about 20% of Medicare patients are rehospitalized within 30 days of discharge — has focused on how hospitals can improve discharge planning. Another study in the same issue of JAMA concluded that the vast majority of readmissions are for reasons unrelated to the prior hospital stays, suggesting that optimal follow-up in the outpatient setting is essential to preventing rehospitalizations.

The AMA report, based on the recommendations of a 21-member expert panel, says outpatient practices have a responsibility to conduct comprehensive health assessments, set care goals with patients, support patient self-management, manage medications and coordinate care with other settings.

“When patients leave the hospital to go home, they are transitioning back into the care of their outpatient primary care and specialty physicians,” said AMA President Jeremy A. Lazarus, MD. “These physicians play integral roles in helping patients fully recover, and coordination between inpatient and outpatient teams is key to ensuring success. Physicians in ambulatory care settings must first have access to information about their patients' hospital stays to ensure continuous, high-quality care. The lists of actions recommended in this report can then serve as a guide as physicians care for recovering patients.”

Why follow-up is critical

Outpatient follow-up with patients should focus on more than the conditions for which they were admitted, said Harlan M. Krumholz, MD, director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation in Connecticut. He is the lead author of the JAMA study showing that 65% of patients hospitalized for heart failure subsequently were readmitted within 30 days for another reason. That study also found that 78% of pneumonia patients were rehospitalized with a different principal diagnosis. The wide range of reasons why patients are readmitted suggests a “posthospitalization syndrome,” Dr. Krumholz said.

“[Doctors] need to appreciate that once people go home — not just the frail, elderly patients, but across the entire population of patients — their risk of adverse consequences is high,” he said. “Their immunity's down, their hematologic system is not working well. They may be susceptible to falls or trauma that are the result of bad judgment. … The next month is a critical time for them.”

About three in five readmissions occur within 15 days of discharge, said Dr. Krumholz's JAMA study. That research highlights how important a steady continuum of care is to safe transitions in care, said Matthew K. Wynia, MD, MPH, co-author of the AMA report, titled “There and Home Again, Safely.”

“These are patients who started as outpatients in the ambulatory world, walking around being normal human beings and then they became inpatients. And there are things that the ambulatory clinic can do to mitigate the posthospital period of risk even before the patient is admitted to the hospital,” said Dr. Wynia, the AMA's director of physician engagement for improving health outcomes. “Then there are things that can happen soon after the person goes home to mitigate that risk. We're trying to bookend both sides of that.”

Help with self-management

Primary care doctors can help patients and family caregivers monitor and measure the patients' health status and progress, recognize signs of deterioration, and make the right choices about when to seek care. Just asking patients and their loved ones to do that is not enough, the AMA report says. Successful practices reinforce the patients' role, use standardized health assessments to track changes, provide health coaching to patients and caregivers, and offer ongoing support.

These are some of the approaches used by the 55 primary care practices that are taking part in the Better Health Greater Cleveland initiative in Ohio. The Robert Wood Johnson Foundation-funded venture estimated that from 2009 to 2011, about 2,900 fewer patients than expected were hospitalized in Cuyahoga County — home to the Cleveland metropolitan area — saving about $20 million in medical expenses. The estimates are based on comparisons of hospitalization figures from other populous Ohio counties such as the Cincinnati and Akron areas. Participating clinics care for nearly 140,000 patients.

A majority of Medicare patient readmissions are for reasons unrelated to the prior hospital stays.

Greater use of electronic health record capabilities to track patients with chronic conditions and ensure that they get preventive care is another key to preventing hospitalizations, said Randall D. Cebul, MD, director of the project, which was launched in 2007. Twice a year, clinic leaders meet to share best practices in detail.

“You can see that some practices do better than others,” Dr. Cebul said. “Sometimes, we find that the top 10 or dozen practices on a quality metric are all from one system. So you say: 'What's up with this? What did they do?' We've created a safe space for collaboration and competition to come together.”

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9 ways doctors can lower readmissions

An American Medical Association report highlights the critical role that office-based doctors play in helping their patients make safe transitions after being discharged from the hospital. To help avoid rehospitalizations, physician practices should:

  1. Keep organized information on patients' medical issues, health goals, functional and psychological status, and behavioral and social issues.
  2. Consider patients' acute, intermediate and long-term care goals.
  3. Be explicit with patients about social, economic, cultural and other factors that may impede their care.
  4. Use reader-friendly tools such as checklists and “red flag” lists to help patients and caregivers with self-management tasks.
  5. Use motivational interviewing and teach-to-goal methods to support self-care.
  6. Use pharmacy, patient and hospital discharge lists to ensure a fully reconciled and accurate medication list after discharge.
  7. Reinforce medication changes made in the hospital with patients, as appropriate.
  8. Use “pill cards” to help patients track drug changes.
  9. Allocate time to address care coordination tasks, using templates and checklists for specific tasks.

“There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions,” American Medical Association, February (link)

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External links

“Characteristics of Hospitals Receiving Penalties Under the Hospital Readmissions Reduction Program,” The Journal of the American Medical Association, Jan. 23/30 (link)

“Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia,” Journal of the American Medical Association, Jan. 23/30 (link)

“Better Care, Better Health, Lower Cost; It Takes a Community; Executive Summary 10th Report,” Better Health Greater Cleveland, January (link)

“There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions,” American Medical Association, February (link)

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