One day last August, Tillie Hawthorne, 67, arrived at Scott and White Healthcare in Temple, Texas, struggling to breathe and swallow. A flare-up of her muscle-weakening myasthenia gravis would keep her bedridden for days, and not for the first time, as a $3,000 course of intravenous antibodies helped restore her strength. But this time, at checkout, Hawthorne got more than her discharge papers; she left with the name of her very own coach.
Chronically ill and on multiple medications, Hawthorne was a prime candidate for Scott and White's new "care transitions" initiative, aimed at saving older patients a quick return trip to the hospital. Hospital readmission rates are getting intense scrutiny now that health reformers have promised to slash spending and improve care by penalizing institutions that overdo it. Nationally, about 20 percent of hospitalized Medicare patients are back within 30 days, according to a 2009 study published in the New England Journal of Medicine. The cost: some $17 billion a year. In half of the cases, patients don't see a doctor between stays, suggesting a dismal lack of follow-up. Sometimes, they develop an infection because the medical staff didn't follow infection-control procedures. A study of heart failure patients published in June revealed that as hospital stays shortened between 1993 and 2006, the readmission rate jumped by 3 percentage points. "There are a lot of factors that can play a part," says Michael Rapp, director of the quality measurement and health assessment group at the Centers for Medicare and Medicaid Services, or CMS. "How completely was the patient evaluated in the hospital? Was the patient prepared for discharge?"
At-home help. Scott and White aims to dot all the i's. Six days after Hawthorne went home, her transition coach, a trained social worker, stopped by to review her medications and advise her on how to recognize worsening symptoms and call the doctor for at-home help. The coach then telephoned twice over the next two weeks to answer questions and make sure Hawthorne had visited her doctor. She was hospitalized for two days in February for pneumonia. But "I haven't had a crisis in almost a year," she says. There won't be hard data on Scott and White readmits before late summer, but the preliminary evidence says they're down.
While the new Medicare penalties won't take effect until October 2012, hospitals have some experience with such a system. Uncle Sam currently doesn't pay for a readmission on the same day as a discharge, unless it's for an unrelated reason. But the new law goes much further, directing Medicare to recover payments made for unnecessary readmissions within 30 days of discharge after a stay for three conditions: heart attack, pneumonia, and heart failure. In the first year, a hospital's total Medicare payments can be reduced by up to 1 percent. The cap rises to 2 percent the next year, and 3 percent the third year. CMS eventually will add more diseases to the list.
Last summer, the agency began publishing rates for the three conditions on its "hospital compare" website. The latest data show, for example, that Florida Hospital in Orlando has a rate of 23.0 percent for heart attack patients, compared to a much-better-than-average 15.9 percent at Sarasota Memorial Hospital. In Iowa, a pneumonia readmission rate of 20.8 percent at Trinity Regional Medical Center in Fort Dodge compares with 14.6 percent at Mercy Medical Center in Cedar Rapids.
While Florida Hospital and Trinity Regional both say they're addressing their rates, they note the particular challenges of serving elderly populations. CMS generally counts all readmissions for any reason. If someone discharged after treatment for heart failure falls, breaks a hip, and is back two weeks later, the hospital takes a hit. That makes sense, argues Harlan Krumholz, director of the Center for Outcomes Research and Evaluation at Yale-New Haven Hospital, which worked with CMS to develop comparative hospital quality measures. Counting only rehospitalizations for the same condition might encourage institutions to game the system by selecting condition codes for the readmissions to avoid a penalty. And hospitalizations that don't appear related actually may be. Heart failure patients are vulnerable to a whole range of risks, Krumholz says. "Was that fall preventable? Were they too weak and not ready to go home? Were they given too much blood pressure medication, so they became dizzy and fainted?" Some planned readmissions—a heart attack patient is readmitted for an angioplasty, say—are excluded.
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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.