Ag­ing agencies help cut read­mits

Modern Healthcare - - BEST PRACTICES - By Mau­reen McKin­ney

Three years ago, eight-hospi­tal River­side Health Sys­tem faced loom­ing federal penal­ties for ex­cess read­mis­sions, of­ten the re­sult of in­ad­e­quate tran­si­tions from the hospi­tal to home.

Thirty-day read­mis­sion rates var­ied widely across the New­port News, Va.based sys­tem, with most above the na­tional aver­age. The sys­tem lacked a stan­dard­ized way of en­sur­ing that dis­charged pa­tients had ad­e­quate sup­ports in place, un­der­stood their con­di­tions and saw pri­mary-care physi­cians for fol­low-up care.

“We didn’t re­ally know what was go­ing on in pa­tients’ homes,” said Dr. Kyle Allen, River­side’s vice pres­i­dent for clin­i­cal in­te­gra­tion and med­i­cal di­rec­tor, geri­atric medicine and life­long health. “We missed many of the is­sues that led them to be read­mit­ted.”

Hos­pi­tals such as those be­long­ing to River­side are un­der in­creas­ing fi­nan­cial pres­sure to smooth the post-dis­charge pe­riod and ad­dress pa­tients’ daily-life chal­lenges, both to im­prove out­comes and pro­tect hospi­tal fi­nances. More than 2,200 hos­pi­tals will see their Medi­care pay­ments docked as much as 2% this year un­der the CMS’ Hospi­tal Read­mis­sions Re­duc­tion Pro­gram, which pe­nal­izes hos­pi­tals with higher-than-ex­pected read­mis­sion rates. The max­i­mum penalty jumps to 3% in 2015.

One un­der­used ap­proach to re­duc­ing read­mis­sions in­volves en­cour­ag­ing pa­tient self-man­age­ment and col­lab­o­ra­tion among providers and com­mu­nity-based or­ga­ni­za­tions. Hos­pi­tals that forged such col­lab­o­ra­tions have rapidly re­duced read­mis­sions, ex­perts say.

“Much of the time, people get read­mit­ted be­cause of the chal­lenges they have in daily life, not be­cause of their di­ag­noses,” said Dr. Eric Cole­man, di­rec­tor of the Care Tran­si­tions Pro­gram at the Univer­sity of Colorado and a na­tional thought leader in the field.

Rec­og­niz­ing it didn’t have the tools in place to pre­vent read­mis­sions and avoid the penal­ties, River­side de­cided to try the part­ner­ship ap­proach.

Be­gin­ning with a small pi­lot pro- gram, River­side forged strong col­lab­o­ra­tive re­la­tion­ships with area agencies on ag­ing, which are com­mu­nity or­ga­ni­za­tions whose mis­sion is to help older adults live in­de­pen­dently.

“In health­care, there’s a ten­dency to do things on your own,” said Allen, who be­gan work­ing closely with such agencies in the 1990s in pri­vate prac­tice and later as chief of geri­atrics at Akron, Ohiobased Summa Health Sys­tem.

Un­der River­side’s pro­gram, hos­pi­tals en­roll Medi­care ben­e­fi­cia­ries with chronic ill­nesses. Cases are given to trained tran­si­tion coaches from com­mu­nity agencies who brief pa­tients and their rel­a­tives on how to man­age med­i­ca­tions, watch for signs of wors­en­ing health and set goals to keep them out of the hospi­tal.

A 2012 pi­lot pro­gram with Bay Ag­ing, Urbanna, Va., and three River­side hos­pi­tals led to a 20% drop in all-cause read­mis­sions among 140 pa­tients, and more than $900,000 in es­ti­mated sav­ings.

Based on that suc­cess, in 2013 the CMS funded the East­ern Vir­ginia Care Tran­si­tions Part­ner­ship, which ex­panded the pi­lot to in­clude five area agencies on ag­ing and 11 hos­pi­tals, in­clud­ing five River­side hos­pi­tals. The sys­tem has seen its over­all read­mis­sion rate drop to 16% from 23% in 2012, Allen said. The na­tional read­mis­sion rate hov­ered just be­low 18% dur­ing the first eight months of 2013, ac­cord­ing to the CMS.

Re­cently, Allen said, a 56-year-old man with a his­tory of em­phy­sema and pneu­mo­nia was dis­charged from one of River­side’s ru­ral hos­pi­tals af­ter a stay for re­s­pi­ra­tory dis­tress. Af­ter vis­it­ing the home where the pa­tient lived alone, the tran­si­tion coach from a lo­cal ag­ing agency dis­cov­ered that the man’s heat was not work­ing, he had very lit­tle food, he had not filled his pre­scrip­tions and he had no way to get to and from the doc­tor.

The coach ar­ranged trans­porta­tion, con­tacted a food bank, got fuel as­sis­tance and helped the pa­tient un­der­stand how to man­age his con­di­tion.

River­side is also per­form­ing deep data dives to an­a­lyze tran­si­tions of care that don’t go well. It is mea­sur­ing cri­te­ria such as med­i­ca­tion rec­on­cil­i­a­tion and suc­cess­ful trans­fer of ad­vanced di­rec­tives, said Pat Russo, vice pres­i­dent of care man­age­ment.

Part­ner­ing with out­side agencies and other com­mu­nity-based groups pre­sents chal­lenges, such as con­fu­sion over who does what, re­im­burse­ment and physi­cian hes­i­ta­tion. “Com­mu­nity agencies live in a very dif­fer­ent world and it takes a lot of work to make these part­ner­ships suc­cess­ful,” Allen said.

“River­side’s big­gest suc­cess is cre­at­ing a trust­ing en­vi­ron­ment where people can come to­gether and find so­lu­tions,” said the Univer­sity of Colorado’s Cole­man. “If you want to be a player, you have to be in the room.”

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