Reducing Readmissions to Reduce Penalties: Where to Begin?

There is no doubt that the Patient Protection and Affordable Care Act has created waves in the country's health system. The new legislation is affecting every American, be it for better or for worse. Hospitals and health systems are also adjusting to the new law, which has catalyzed a refocusing on hospital metrics, a key one being readmission rates.

The PPACA created the Hospital Readmissions Reduction Program, which penalizes hospitals with high readmission rates. When the program began in October 2012, the penalty rate was up to one percent of every Medicare payment, and the rate will continue to rise.

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So how can hospitals ensure their patients leave their facilities without needing to return?

"A little bit of communication and proactivity goes a long way in helping a patient after they leave the hospital," says Barbara Michael, MD, TeamHealth's facility medical director for Saint Francis Hospital in Charleston, W. Va.

These two elements, communication and proactivity, are the backbone of two hospital readmission reduction interventions, one at Saint Francis and the other as part of a joint effort between two healthcare providers in Abbeville, S.C. These slight but effective changes to hospital operations could bring hospitals and their patients the successful readmission reduction strategies that they need.

Interdisciplinary rounding at Saint Francis Hospital
When TeamHealth took over Saint Francis' hospitalist service a year and a half ago, they implemented the process of interdisciplinary rounding in efforts to reduce readmissions.

Interdisciplinary rounding requires all the healthcare providers involved in a patient's treatment to holistically discuss that patient's needs.

"The physician, the charge nurse, the case manager, the social worker, the utilization review nurse, dietary and physical therapy, we all sit down together every day and go over each patient that is on the floor," Dr. Michael says. "We identify roadblocks or special needs the patient will have before they're discharged home, so the discharge process actually starts the day they are admitted to the hospital."

Many of these roadblocks and special needs are social, such as a lack of a support system at home, financial issues and needing assistance setting up an appointment with a primary care physician after being discharged, Dr. Michael says, adding these red flags are common in older patients.

"A lot of these elderly folks do not want to give up their independence even though some of them are having trouble taking care of themselves at home. Those are the social needs and social aspects of caring for these patients," she says.

Since implementing the interdisciplinary rounding program 18 months ago, Saint Francis has already significantly reduced its readmission rates. Its hospital-wide Medicare payments went from a 0.48 percent penalty the first year of implementation to a 0.08 percent penalty the following year.

Dan Lauffer, COO of Saint Francis, attributes the program's success to the clear and direct communication it fosters between healthcare providers.

"I think the dialogues of having the two groups talk with each other through interdisciplinary rounds improves that kind of communication, so it's clear what is actually happening with the patient," Mr. Lauffer says. "Those interdisciplinary rounds have improved communication and improved the sense of urgency and accountability to get the patients the best care they can."

Saint Francis has also reduced its average length of stay since implementing interdisciplinary rounding from 5.31 days to 4.69 days, an 11.6 percent reduction. Whether the drop is linked to interdisciplinary rounding is impossible to tell, but it is a beneficial side effect nonetheless.

"[Patients] are spending less time in the hospital, get better faster, and they go home and they don't come back," Dr. Michael says.

Community paramedics at Abbeville Area Medical Center
The Abbeville Area Medical Center in rural South Carolina serves a patient population that often encounters barriers to healthcare access.

To address concerns regarding healthcare access, the Abbeville Area Medical Center and Abbeville County EMS created a community-based joint Community Paramedic Program, a readmission reduction program where paramedics perform home visits and initiate proactive interventions with the goal of reducing readmissions by 20 percent over the next two years.

Physicians order a home visit for discharged patients who they believe will benefit from this type of assistance. Community paramedics then perform home checks to ensure the patient's needs are being met and intervene in any situation that could potentially turn into a readmission.

"By community paramedics being proactive and seeing patients on a regular basis, we're able to recognize issues and actually get that patient the right care at the right time before it can become an emergency or a crisis that might develop into a 9-1-1 call," says David Porter, director of Abbeville County Emergency Services.

Not only does the Community Paramedic Program aim to avoid readmissions, it also hopes to reduce the use of the emergency department as a safety-net service.

"We want to make sure we are using our resources as effectively as possible," Mr. Porter says. "If this is a patient that is frequently receiving care at the emergency department and they're constantly getting there by ambulance, we can get ahead of this and we can go see that patient on our schedule when we're not as busy or when the paramedic has that time freed up in his day."

The Community Paramedic Program was launched in October 2013, so there is not yet any concrete data on how it may be affecting readmission rates. However, Mr. Porter anecdotally says the program has already helped high-risk patients avoid an unnecessary trip to the emergency room.

Similar to efforts at Saint Francis, the Community Paramedic Program identifies social factors that can contribute to readmission. Mr. Porter says the majority of their patients are affected by some socioeconomic factor restricting their access to healthcare, such as financial constraints, healthcare literacy or a lacking family support structure.

The three community paramedics involved with this program are full-time paramedics who volunteered to undergo specialized training to prepare to serve the community in a more clinical manner. Training includes a 15-week online course, hands-on lab sessions and 100 hours of clinical rotations, including primary care, emergency department and home health care, Mr. Porter says. Paramedics in the Community Paramedic Program are providing a different type of care than they may be used to.

"Historically, [paramedics] interact with the patient in one of two ways. You call 9-1-1 and you either go with us to the hospital or you sign a sheet saying you don't want to go to the hospital and we leave," Mr. Porter says. "There are a lot of patients in the middle who call 9-1-1 because they don't know who to turn to. We need to be able to offer them a little bit more."

Mr. Porter also emphasizes that the Community Paramedic Program is not about restricting emergency room access, adding that when community paramedics are doing a home visit they sometimes end up calling an ambulance.

"We're not denying people the right to go to the ER," he says. "Our goal is to try to improve patient health and wellness, improve quality of life, and make sure they're getting the right level of care at the right time."

The Community Paramedic Program incorporates another element Mr. Porter says is paramount to its uniqueness and success: being community-based. Mr. Porter says this root in community services allows community paramedics to provide better patient care.

"The healthcare community is kind of segmented," Mr. Porter says. "Everyone operates in their own verticals. They communicate with those they are forced to through necessity rather than actively going out and networking. Having community paramedics who spend time in clinics, spend time in healthcare, spend time in private sector organizations, they're almost like a bridge between all these different verticals. It really allows for a better continuity of patient care."

More Articles on Readmissions:

High Volume Hip and Knee Hospitals Also Have Highest Readmissions
ACC's "Hospital to Home" Initiative Reduces Readmissions, But Slowly
Secondhand Smoke Raises Readmission Risk for Children Admitted With Asthma

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