Re-Hospitalization is a Major Medicare Healthcare Problem: Is it Solvable?

 

I have written about this in the past, but this is too important to let lie. One in five Medicare elders who are hospitalized and discharged end up back in the acute hospital within 30 days! These readmissions or failed transitions in care lead to substantial increases in costs, morbidity, and mortality. It has been estimated that this readmission problem costs Medicare over $15 billion each year.

Avoidable readmissions and patient dissatisfaction with discharge care are growing problems nationwide. Of those Medicare beneficiaries who are readmitted within 30 days, 64% received no post-acute care between discharge and readmission. Combine that with mismanagement of medications and other causes for re-hospitalization, the leading experts believe that a total of 76% of readmissions may be preventable. Furthermore, research from the Centers for Medicare & Medicaid Services (CMS) shows beneficiaries report greater dissatisfaction in discharge-related care than any other aspect of care CMS measures. For Nevada, a readmission costs Medicare an average of $9600 and Northern Nevada has about 4,314 readmissions a year. You figure the cost benefit of reducing these!

Additional research shows that the majority of readmissions were medication related (66%) and 50% had lab results that were still pending at discharge (Roy, et.al., 2005). Clearly, this returning to acute care hospital is a major Medicare healthcare problem, but it is solvable.

In the 1980’s, Medicare started to reimburse hospitals to cut costs by diagnosis related groups (DRGs). This meant that hospitals would not be paid based on number of days the patient was in an acute bed, but by episode or DRG. The hospitals accommodated this method of reimbursement by getting the patients in out of the acute bed as fast as possible, usually “quicker and sicker.” Unfortunately, the hospital care would only include services up to discharge AND if the person came back within 30 days they could not get reimbursed again if the diagnosis was the same. However, for the normal Medicare person coming into the hospital, they would have several chronic illness problems, so when readmitted, the hospital would use another diagnosis and they would get reimbursed again. Therefore, the hospital had no incentive to provide post-acute care or any transitional care that would keep the person in their community or home.

This has all changed with the health reform law, the Affordable Care Act (ACA) Section 3026, signed in 2010. The law requires hospitals to change their discharging practices to include more thorough processes in transitional post-acute care to prevent readmissions to the acute hospital within 30 days. Several research and healthcare organizations have developed evidence-based services that are very effective in curbing the readmissions.

I have personally been working in the area of integrating acute and chronic care for years by establishing continuums of service and  employing a care coordinator or “transitional health coach” to help the frail, chronically-ill elder Medicare beneficiary and the family or caregivers.

The problems associated with poor transitions of care and 30-day hospital readmissions are not solely the responsibility of a community’s hospitals. They are often the result of a breakdown in the transfer of information and communication between providers and patients at the time of discharge or transition, a failure to assure the patient and/or caregiver can manage their disease(s), and a lack of standard known processes to effectively manage patients’ transitions from one setting to another.

The Partnership for Patients Community-based Care Transitions Program (CCTP) under CMS is focusing on processes of care at a community level that engage providers and stakeholders across the continuum of care, not just in the hospital. This includes home health and hospice agencies, nursing homes and physician offices, as well as patients, families and other social or health service community stakeholders.

I am very excited to report that the Center for Healthy Aging has been designated by the Senior Coalition and a group of Northern Nevada hospitals, physicians, home health, and other health and social services as the Community Based Organization (CBO) to link the at-risk, chronically-ill Medicare elders to the “Transitional Care” services to keep them out of the acute hospital. We are working with Geriatric Care Specialty, Care Management Associates, and IntegriCare Clinical Associates, and several other medical, health, and social service organizations in seeking funds to develop this transitional care program, including a CMS application to provide this service for Northern Nevada Medicare beneficiaries.

The CCTP provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk elders hospitalized for common medical and surgical conditions. For the millions of Americans who suffer from multiple chronic conditions and complex therapeutic regimens, the program emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management – all accomplished with the active engagement of patients and their family and informal caregivers and in collaboration with the patient’s physicians.

The goal is to reduce acute readmissions by 20% in two years (2013). This will be done by employing Transitional Health Coach nurses and assistants to work with the patients and family members or caregivers to empower them to be accountable for changes in their own health, communicate to the their primary care and specialty physicians when appropriate, have their medications be reviewed and appropriate for their conditions, and secure the needed services in the community or home when appropriate.

In short, the Center for Healthy Aging and the established partnerships offer Northern Nevada the best combination of expertise and experience that will succeed in providing a CBO for the Community-based Transitional Care Program. We look forward to providing a community wide organization and service that will reduce the acute recidivism and improve the quality of life to our elders, “Adding Life to Years”.

Lawrence J. Weiss, Ph.D. is CEO of the Center for Healthy Aging. Dr. Weiss welcomes your comments on this column. Write to him at larry@addinglifetoyears.com or c/o Center for Healthy Aging, 11 Fillmore Way, Reno, NV 89519.