Most im­por­tant best prac­tice? Read­ers say part­ner­ships tar­get­ing read­mis­sions


Hos­pi­tals are con­clud­ing they have to work very closely with health­care providers, com­mu­nity or­ga­ni­za­tions, fam­i­lies and pa­tients them­selves if they’re go­ing to keep peo­ple out of hos­pi­tal beds—the new man­date un­der Medi­care and fast-grow­ing mod­els of value-based payment.

Col­lab­o­ra­tive ap­proaches to cut­ting read­mis­sion rates gar­nered by far the most votes in our reader sur­vey on the most im­por­tant ef­forts we’ve pro­filed in our reg­u­lar Best Prac­tices fea­ture. Mod­ern Health­care con­ducted a se­ries of reader sur­veys in con­junc­tion with the pub­li­ca­tion’s 40th an­niver­sary to gauge where health­care is headed next.

Us­ing col­lab­o­ra­tion to cut hos­pi­tal read­mis­sion rates gar­nered 323 votes, sig­nif­i­cantly more than the 176 votes re­ceived by the sec­ond-place choice— boost­ing patient out­comes with tele­health.

Un­der the Af­ford­able Care Act’s Hos­pi­tal Read­mis­sions Re­duc­tion Pro­gram, hos­pi­tals have to keep read­mis­sion rates be­low the na­tional av­er­age to avoid Medi­care penal­ties of up to 3%. Only 799 of the more than 3,400 hos­pi­tals sub­ject to the pro­gram avoided penal­ties for fis­cal 2016.

One way hos­pi­tals are tack­ling the is­sue is by work­ing with out­side or­ga­ni­za­tions to im­prove patient tran­si­tions.

“The whole sys­tem is shift­ing to a model that has more shared risk and ac­count­abil­ity,” mak­ing it more crit­i­cal “to man­age pa­tients out­side the four walls of the hos­pi­tal,” said Beth Feld­push, se­nior vice pres­i­dent of pol­icy and ad­vo­cacy at Amer­ica’s Es­sen­tial Hos­pi­tals, which rep­re­sents the na­tion’s safety net providers.

Col­lab­o­ra­tion rep­re­sents an evo­lu­tion in think­ing about read­mis­sions. When penal­ties were first in­tro­duced, providers fo­cused on clin­i­cally ad­dress­ing the ill­ness that landed the patient in the hos­pi­tal. The fo­cus on med­i­cal man­age­ment alone “proved to be naive as it largely ig­nored how broader so­cial fac­tors con­trib­ute to read­mis­sions,” said Dr. Eric Cole­man, head of the Univer­sity of Colorado’s health­care pol­icy and re­search di­vi­sion.

Cre­at­ing part­ner­ships with spe­cialty providers, such as skilled-nurs­ing fa­cil­i­ties, as well as or­ga­ni­za­tions

such as the area agen­cies on ag­ing, a group of com­mu­nity or­ga­ni­za­tions pro­vid­ing sup­port for se­niors na­tion­wide, “is prov­ing to be a win-win so­lu­tion,” said Cole­man, who won a MacArthur Foun­da­tion “ge­nius” grant for his work on tran­si­tional care in 2012.

Bun­dled pay­ments and ac­count­able care or­ga­ni­za­tions also en­cour­age these col­lab­o­ra­tions be­cause they give providers an in­cen­tive to care for a patient through­out an episode of care even though it might in­volve mul­ti­ple set­tings and ex­tend be­yond the acute pe­riod of ill­ness, Cole­man said.

He noted that a col­lab­o­ra­tion is more likely to suc­ceed when there is a trusted con­vener, all par­ties have agreed on the goals and data are used to iden­tify op­por­tu­ni­ties for im­prove­ment. “Even more promis­ing is to invite pa­tients and fam­i­lies to share both pos­i­tive and neg­a­tive ex­pe­ri­ences.”

Al­though telemedicine was a dis­tant sec­ond for read­ers, its show­ing con­firms that the use of re­mote tech­nol­ogy con­tin­ues to gain trac­tion as a le­git­i­mate means of aug­ment­ing face-to-face vis­its with clin­i­cians. Last year, Com­mu­nity Health Sys­tems, one of the largest hos­pi­tal op­er­a­tors in the U.S., ex­panded its tele­health ser­vices to of­fer 24/7 ur­gent care in at least four states. Mean­while, the Cleve­land Clinic has part­nered with CVS Health’s Min­uteClinic to give cus­tomers in Ohio vir­tual on-de­mand ac­cess to their providers for con­sul­ta­tions.

Vir­tual vis­its are “one of the fastest-grow­ing ar­eas” in health­care, and they’re be­ing used in an ar­ray of med­i­cal spe­cial­ties, from op­tom­e­try to emer­gency care, said Jonathan Link­ous, CEO of the Amer­i­can Telemedicine As­so­ci­a­tion. The trade group’s mem­ber­ship grew ap­prox­i­mately 15% in the past year.

Patty Mechael, ex­ec­u­tive vice pres­i­dent of the Per­sonal Con­nected Health Al­liance, a part­ner­ship be­tween the Health­care In­for­ma­tion and Man­age­ment Sys­tems So­ci­ety and other health­care tech­nol­ogy or­ga­ni­za­tions, said de­mand for telemedicine is com­ing from pa­tients who “want to ac­cess health ser­vices in a way that is both con­ve­nient and ef­fec­tive.” Tele­health also pro­vides tech­nolo­gies that can help with on­go­ing patient en­gage­ment, which can “mit­i­gate risks in­her­ent in value-based care de­liv­ery.”

Pri­vate health in­sur­ers ap­pear to agree and are be­gin­ning to jump on the tele­health band­wagon by cov­er­ing more ser­vices.

Tele­health is also pop­u­lar among in­vestors, who ex­pect adop­tion to grow. A Fe­bru­ary re­port from Ac­cen­ture noted that in­vest­ments in tele­health com­pa­nies are ex­pected to climb from $200 mil­lion in 2014 to $1 bil­lion by the end of 2017.

Thwart­ing the spread of drug-re­sis­tant bac­te­ria took third place in the sur­vey. It re­ceived 172 votes, just one more than the tally for the use of med­i­cal scribes, who en­ter in­for­ma­tion into elec­tronic health records to give physi­cians more time to fo­cus on pa­tients.

But the fact that pre­vent­ing the spread of deadly bac­te­ria edged its way into the top three doesn’t sur­prise Dr. Ar­jun Srini­vasan, an an­tibi­otic-re­sis­tance ex­pert at the Cen­ters for Dis­ease Con­trol and Preven­tion.

Ac­cord­ing to Srini­vasan, there’s never been more fo­cus on beat­ing back drug re­sis­tance—in large part

be­cause it’s be­com­ing im­pos­si­ble to ig­nore. “You’d be hard-pressed to find a doc­tor that went through a whole day with­out en­coun­ter­ing an or­gan­ism that posed some chal­lenge (re­gard­ing) an­tibi­otic re­sis­tance,” he said.

The CDC has pri­or­i­tized rein­ing in the use of an­tibi­otics over the past few years.

In 2006, the agency re­leased guide­lines call­ing for the con­trol of mul­tidrug-re­sis­tant or­gan­isms in health­care through “at­ten­tion to ju­di­cious anti-mi­cro­bial use.”

Two years ago, the CDC is­sued a doc­u­ment iden­ti­fy­ing the key el­e­ments of an ef­fec­tive hos­pi­tal an­tibi­otic stew­ard­ship pro­gram—adding to ex­ist­ing guide­lines from or­ga­ni­za­tions such as the In­fec­tious Dis­eases So­ci­ety of Amer­ica and the Amer­i­can So­ci­ety of Health-Sys­tem Phar­ma­cists among oth­ers.

Stew­ard­ship pro­grams re­quire a strong com­mit­ment from hos­pi­tal lead­ers as well as reg­u­lar track­ing of an­tibi­otic pre­scrip­tions and re­sis­tance pat­terns.

Some smaller hos­pi­tals have used telemedicine-based part­ner­ships that tap into the re­sources of larger health sys­tems.

But even though cer­tain strate­gies have proved suf­fi­ciently ef­fec­tive to be deemed best prac­tices, “an­tibi­otic re­sis­tance is not a prob­lem that can be solved by one so­lu­tion,” Srini­vasan said.

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