Health Reform Takes Aim at Hospital Readmission Rates

Health reform gives hospitals a big incentive to send patients home for good.

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[ What Hospital Certifications Say—and Don't Say] Better stats. Like Scott and White, many hospitals are looking at ways to improve their stats. St. Mary's Medical Center near St. Louis is one of 28 sites implementing a program whose key elements include detailed self-care instructions at discharge and follow-up calls within 72 hours. The instructions use a "teach back" method, in which patients must show they understand their diagnosis and treatment plan. Three months after the program was adopted at a 30-bed unit within St. Mary's last year, the 30-day readmission rate had dropped to 7 percent from 12 percent.

Raymond Racette, a retired biology teacher in Phillipston, Mass., who suffers from heart failure, can vouch for the high-tech approach favored by Massachusetts General Hospital. A year ago, Racette, 69, found himself in an ambulance for the third time in two months. Heart surgeons implanted a cardiac resynchronization therapy (CRT) device in his chest, as well as a sensor that records fluid levels in his heart. Twice a day, Racette holds a device similar to a BlackBerry against his chest and pushes a button to initiate a 20-second data download. The information is relayed to a secure website, where medical staffers can access it and get in touch, with instructions, if need be. Racette can see the readings, too, and make changes in his diet to correct course. "This warns me a day in advance if I'm heading for trouble," he says, "so I know to eliminate all salts for a day or so." Besides keeping him out of the hospital, the monitoring has Racette feeling well enough to plan some sailing trips with his grandson.

Doctors eventually will be pushed to do a better job of keeping patients at home, too. Sharp Rees-Stealy Medical Group, a large practice in San Diego, already uses computerized "telescales" to remotely monitor advanced heart failure patients such as Jerri Frost, 78. Each morning, Frost stands on an electronic scale that weighs her and asks a series of "yes or no" questions, which she answers by punching a keypad. Rapid weight gain in heart failure patients can be a sign of dangerous fluid buildup. Occasionally, Frost has to admit to the scale that she's had a salty meal (Mexican and Chinese are favorites), which might trigger a call from a nurse. "If I've lost weight, it says 'Good job,' " she says with a chuckle. Jerry Penso, the group's quality director, says the "all cause" readmission rate for older patients is 13.8 percent, compared with the 20 percent national average.

Reducing hospitalizations by improving care is a no-brainer, but experts caution that not all readmissions are preventable, and some indicate a high quality of care. A zero readmission rate "would be a very bad sign," says Stephen Jencks, a Baltimore-based healthcare consultant and a former director of the quality improvement group at CMS. A cancer patient, for example, may be readmitted several times for chemotherapy; a heart failure patient may return for surgery to implant a pacemaker. Some worry, too, that creating financial incentives to keep people out of the hospital could cause hospitals not to readmit patients, or to discharge them prematurely, not for medical reasons but because they know they may be paid less for such patients.

Clearly, it's more important than ever for patients to insist on clear explanations and to understand their rights while in the hospital. People covered by Medicare who feel they are being discharged too early, for example, can file an immediate appeal; hospitals are required to tell you how to do so upon your arrival. Even the threat of an appeal can mean closer scrutiny of a patient's discharge plan, says Laura Weil, director of the health advocacy program at Sarah Lawrence College. Some states let patients stand up to private insurers, too.