Reducing readmissions will be uniquely challenging for America's 5,724 hospitals. Some are part of large health care systems that include home health care, nursing homes and physician practices. Some are rural or urban institutions with very little community support. "There's wide variation in how much control a hospital may have in influencing readmission rates," says Akin Demehin, Senior Associate Director of Policy at the American Hospital Association. The AHA is concerned, he says, that some hospitals will be unfairly penalized if they are in areas with few physicians and other community-based health services.
It is those community services that have helped EvergreenHealth become one of the most successful hospitals in the country at reducing avoidable readmissions. Hospital personnel noticed a decade ago that too many patients were soon back in the beds they had recently vacated. To find out why, administrators started talking to doctors and home health workers. Were physicians seeing their patients within the first week after discharge? Did they make sure patients had easy telephone access to discuss medications? Were home visits done to make sure patients understood instructions for their care, had the proper medications and were not using expired drugs? "Readmissions are nobody's fault," says Neil Johnson, COO of EvergreenHealth. "They're largely a communication issue."
Without enough hands-on support after discharge, patients, nursing home workers and family members can get confused about home treatments or nervous about changes in condition. Before you know it, someone is calling 9-1-1, and the patient is back in the hospital.
To stop the cycle, hospitals have to be more than brick-and-mortar institutions. That's one reason most now call themselves health care systems, because only a coordinated system can attempt to corral all the players a discharged patient needs.
To make it work, it's as though the hospital's services go home with the patient. That, too, costs money, but less than hospital care. The Geisinger Health System compared 85,000 of its patients covered by its coordinated care network, ProvenHealth Navigator, to 150,000 patients not enrolled in ProvenHealth. Those enrolled saw a 40 percent reduction in readmission rates over three years and a cost reduction of 7 percent compared to those without the benefit of the care network.
"When someone comes out of the hospital, we make sure we call them within 24 hours of discharge. We get them back in their primary care doctor's office within three to five days. If they're in a skilled nursing facility, we get a nurse practitioner or physician assistant into those facilities," says Thomas Graf, Chief Medical Officer of Population Health and Chairman of Community Practice at Geisinger Health System.
EvergreenHealth Home Care is the Kirkland, Wash., institution's home health care network . "In the 1980s and 1990s, a lot of hospitals dropped their home health care systems," says Johnson. They weren't very profitable, and they were heavily regulated, making them more of a headache than some hospitals wanted. But EvergreenHealth stuck with its home health system, and now it is proving to be a vital piece of the puzzle in reducing readmission rates.
For congestive heart failure, EvergreenHealth's readmission rate was already low at 14 percent in 2003, compared to a national average of nearly 25 percent. As part of a Medicare demonstration project in 2009, they got that rate down to 6 percent. And today, says Johnson, only 2 percent of patients receiving the system's home health care are readmitted to the hospital.
Slowing the revolving door to hospitals might actually be simple, if all the players in the health care delivery system start doing what hasn't traditionally come naturally: Talking to one another. Only that way, experts agree, can providers make sure patients, their families and caretakers know what to do when they leave the hospital and that patients get the follow-up medical attention they need.