Pilot program focuses on congestive heart failure. Jefferson Regional joined Highmark’s readmissions pilot in fall 2009, choosing as its target patients with congestive heart failure. At the hospital, we collected and reviewed data to identify barriers, chose interventions and tested their effectiveness. The hospital will have a chance this year to earn extra funds based on interventions in 2009.
Payor policies are on the horizon. Congress’ health reform legislation includes a readmissions program, but even if the health reforms don’t pass, CMS already intends to create a similar program, penalizing hospitals for patients who are readmitted within 30 days of discharge. It is not clear when CMS would start the program and how it would operate. Even Highmark has not yet proposed a permanent program to follow up on the pilot.
Dealing with readmissions requires coordination. Reducing readmissions is not just a hospital issue. The hospital controls only part of the patient’s care. Hospital discharge planners and physicians can direct patients to seek care after discharge, but they have no control over what happens next. And even if the hospital worked closely with the doctor, the nursing home and the home health agency, no one can force patients to take their medications, make an appointment or follow a diet.
We reach out to caregivers outside of the hospital. We have been successful lowering readmissions by reaching out to physicians and nursing homes. But it requires a lot of talking and cajoling, visiting physicians offices and nursing homes to help them understand the alternatives to readmitting patients to the hospital.
Nursing homes are a big factor in readmissions. A high percentage of patients who have been readmitted could easily have been treated in nursing homes rather than the hospital. That’s because the physicians who serve the nursing homes are often more comfortable admitting patients to the hospital than treating them there.
We try to work with home health agencies. Home health agencies’ interest in working with us on readmissions varies widely. We have less leverage with agencies that are not integrated with us. Although we co-own a home health agency, less than half of our patients go there and federal law prevents us from directing patients there.
We check in with our patients. Our case managers and nurses contact patients with congestive heart failure to see if they attended our congestive heart failure clinic. If the patient can’t get an appointment soon enough, the case manager contacts the doctor’s office to try to get in earlier. We have even considered making an appointment for the patient before discharge to ensure a timely appointment.
Policies cannot be doctrinaire. Even if you could control all the variables, readmissions polices can’t be doctrinaire. For example, a clinically conservative spine surgeon on staff at the medical center often uses a staged approach when treating patients for spinal stenosis. He may treat with medications or physical therapy or prescribe a spinal injection, discharge the patient and see if these non-surgical measures will work. If they don’t work, he admits the patient for surgery. But that would be considered a readmission within 30 days, even though the doctor did the right thing by first trying the less invasive approach.
Clinical integration makes the policy easier to carry out. Even our employed physicians are somewhat independent, administering and managing their own practices. This can make it difficult at times to coordinate policy with them but this arms-length relationship is necessary because they are paid based on what they earn and have no guaranteed salary. But we can expect them to be “good citizens” and cooperate with our initiatives. We measure individual physicians’ readmission rates and these findings may well affect their reimbursements in the future.
It’s hard to integrate physicians working at several hospitals. Many doctors, specialists in particular, have privileges at numerous hospitals, which can make it difficult to gain their cooperation for particular projects. They are not naturally aligned to one hospital.
Contact Leigh Page at leigh@beckersasc.com.
