Connecting with Post-Acute Care to Reduce Hospital Readmissions

Readmissions are not ideal for patients or for healthcare organizations, so it is encouraging news that hospitals and health systems are working diligently to address how to reduce readmission rates. A CMS report shows a drop from a 19 percent national 30-day readmission rate between 2007 and 2011 to 18.4 percent rate in 2012.1 

With CMS penalties for readmissions reaching 3 percent in 2014, it is critical that healthcare organizations implement innovative strategies to decrease readmission rates. 

The reduction in readmissions can be attributed to a number of initiatives focused on enhanced patient education and clearly written discharge instructions. Although these strategies recognize the importance of ensuring compliance with recommended treatment plans, healthcare organizations lose much of their impact once the patient is discharged. Without a sustainable strategy to follow discharged patients for the first month, hospitals will continue to struggle to with reducing readmission rates.

One ongoing strategy that directly improves readmission rates is partnering with post-acute care organizations. When hospitals work with post-acute care facilities to monitor care and support compliance with medication or therapy recommendations, the post-acute care provider can intervene to allay concerns or treat new symptoms before the patient and family caregiver seek emergency department care. An ongoing relationship with post-acute care can also enable access to data that enhances overall knowledge that can be used to address the risk of readmission for different patient populations.

Several hospitals and post-acute care providers have successfully established collaborative relationships, which begin with a post-acute care liaison working at the hospital to streamline the transition from acute care to post-acute care settings. An onsite liaison enables the post-acute provider to get to know the patient before discharge, ensuring that all patient needs are fully understood and enabling the provider to have the right staff, right services and right equipment in place for the patient's transition to post-acute care.

Although the personal contact among post-acute staff, hospital employees and patients creates a seamless hand-off from one care setting to another, there are three other executive strategies that hospitals can take to optimize the relationship between acute and post-acute care, ultimately leading to reduced readmissions and improved patient outcomes.

1. Share data to enhance knowledge. The first hours following hospital discharge are the most critical for patients who need home health services, home medical equipment or hospice care. Although an onsite liaison provides initial admission information for the post-acute care provider, the ability to electronically transfer patient information directly from the hospital electronic health record to the post-acute care provider's EHR system enhances this transition. The information exchange is not only necessary at the start of care, but throughout the entire episode of care. When post-acute care providers can access up-to-date medication records and changes in therapy made after physician follow-up exams, the level of care provided to the patient increases.

The value of shared information benefits physicians and other acute care providers in the health system as well. The ability to review post-acute care clinician notes, track patient progress and evaluate new symptoms reported by patients to post-acute providers enables all providers to have a holistic view of the patient's progress — a true longitudinal patient record. Integrating disparate systems to create a record that follows the patient throughout the healthcare continuum — from physician office to acute care to post-acute care and back to physician office — provides the knowledge that clinicians need to optimize care plans to enhance compliance and to identify appropriate interventions to prevent hospital readmissions.

2. Use technology to support care protocols. Post-acute providers can implement interventions in a timely manner because they conduct patient assessments at each visit to document progress and evaluate physical and mental health status. For example, screening for and treating depression following hospital discharge can prevent readmissions. Research has shown that older patients who screen positive for depression following hospitalization are three times more likely to be readmitted.2 Post-acute providers that use a screening and treatment decision tool developed by Weill Cornell Medical College as part of a National Institutes of Health funded study reduced readmission rates for depressed patients by 40 percent.3

Working with post-acute providers that use technology-supported protocols to guide decisions increases the likelihood of ongoing, sustainable readmission rate reductions. For example, over 20 percent of patients with chronic obstructive pulmonary disease are readmitted to the hospital within 30 days of discharge.4 HME providers minimize the risk of COPD readmission by providing oxygen equipment that fits the patient's lifestyle, such as lightweight portable equipment for active patients who need oxygen during the day. Tailoring the choice of equipment to the patient's needs improves the likelihood of compliance with treatment protocols because daily activities are not negatively affected by use of the equipment. Also, HME providers who monitor a patient's use of oxygen and prompt patients when it is time for refills can document compliance or can work with the patient to address reasons for non-compliance.

Also, the data collected with the use of technology-supported protocols contributes to collaborative development of care improvement initiatives that positively affect patient care before and after discharge.

3.  Leverage data and analytics to improve quality. Establishing a collaborative relationship with post-acute care providers, rather than a simple referral relationship, provides valuable opportunities to improve quality throughout the healthcare continuum. By sharing information about quality metrics for which the hospital is responsible and setting similar expectations for the post-acute provider, both organizations can work together to collect data that documents achievement of performance goals.

Integration of acute care and post-acute care systems not only enables the collection of data but also provides the patient care overview that supports development of new protocols that focus on the needs of specific populations. Identifying the most common reasons for readmission of patients with conditions such as chronic obstructive pulmonary disease, congestive heart failure or diabetes leads to enhanced patient education, more specific discharge instructions and improved care protocols for both acute care and post-acute care settings.

Technology challenges can be overcome
Although most acute-care organizations have addressed the interoperability challenges among hospitals, physicians, diagnostic services and clinics, integrating a post-acute care provider's EHR system does present additional challenges. While standards for health information technology systems are still emerging, the use of HL7 for the exchange, integration, sharing, and retrieval of electronic health information and open web-based systems by post-acute vendors, along with software vendor partnerships and growing health information exchanges expands the opportunities for tighter integration.

Even with the interoperability challenges, the benefits of integrating post-acute care systems with acute care systems can be significant. The opportunity to reduce readmissions, minimize penalties, improve the financial bottom line and improve patient care ensures valuable, long-term benefits throughout the healthcare continuum.

Chris Watson is Chief Operating Officer at Brightree, a provider of cloud-based clinical, billing and business management software solutions for the post-acute care industry.

More Articles on Hospital Readmissions:
Patient Navigation Services Cuts Readmission Rates, Costs, Pilot Program Finds
Quality Improvement Organization Communities See Decreased Medicare Readmissions
Study: Primary Care Follow Up Reduces Readmissions for High-Risk Vascular Surgery


Gerhardt G, Yemane A, Hickman P. et al. Data shows reduction in Medicare hospital readmission rates during 2012. MMRR 2013: Volume 3(2). Centers for Medicare and Medicaid Services, Office of Information Products and Data Analytics. http://www.cms.gov/mmrr/Downloads/MMRR2013_003_02_b01.pdf   Accessed April 13, 2014
 
2 Kartha A, Anthony D, Manasseh C, et. al. Depression is a risk factor for rehospitalization in medical inpatients. Prim Care Companion J Clin Psychiatry. 2007; 9(4): 256–262.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2018837/
 
3 Bruce ML, Raue PJ, Sheeran T, Reilly C, Pomerantz JC, Meyers BS, Weinberger MI, Zukowski D. Depression care for patients at home (Depression CAREPATH): Protocols and implementation.Part 2 Home Healthcare Nurse, 2011, 29(8):480-9.

Elixhauser, A., Au, D., Podulka, J. Readmissions for Chronic Obstructive Pulmonary Disease, 2008 . HCUP Statistical Brief #121. September 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb121.pdf

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