Hospitals look to lower readmission rates
Days after she was discharged to her Saugus home from Beth Israel Deaconess Medical Center after being treated for pneumonia, Carol Sewell got a call. A nurse working for both the hospital and her primary care doctor began checking in on her regularly, sometimes three times a week: Did she know about her follow-up appointments? Could she get a ride to the doctor’s office? And had she filled her prescriptions?
“It kept me doing things that I should be doing that I might not have,” Sewell said. “She’d ask questions. I’d have to have the answer.”
The calls made the 69-year-old with a history of cancer and chronic obstructive pulmonary disease feel that someone was watching out for her. Beth Israel Deaconess hopes that such intensive follow-up will help patients like Sewell maintain their health and avoid being readmitted.
Beth Israel Deaconess is one of hundreds of hospitals in the country that will lose money under a new federal program meant to force improvement in the overall care of some of the sickest seniors. Created under the Affordable Care Act, the program docks Medicare payments to hospitals whose patients are most likely to be readmitted within 30 days of treatment for pneumonia, heart failure, or heart attacks. Government officials say readmissions drive up health costs and can be a sign of inadequate care.
In Massachusetts, 54 medical centers will lose some money, according to a Kaiser Health News analysis, and Beth Israel Deaconess is among 10 that will lose the maximum amount — 1 percent of their Medicare payments. Some also face state penalties.
Many hospitals are rolling out new programs in response, hiring people such as the nurse who works with Sewell, installing technology to predict which patients need the most help once they leave the hospital, and forging new partnerships with nursing homes, doctor offices, and social services.
But there has been considerable debate about whether the penalties are fair or will have a real impact on patient care.
Some analysts say the penalties hit hardest the hospitals that serve poor and minority communities and those that do well at keeping the sickest patients alive — and not necessarily those that provide poor quality care. Drs. Karen Joynt and Ashish Jha of the Harvard School of Public Health wrote in the New England Journal of Medicine in April that the policy is “misguided” and may cost critical hospital resources that could be better spent on other patient safety efforts.
Others point to the fact that hospitals, particularly in Massachusetts, are already doing the difficult work of redesigning the way they care for patients with the most complicated medical histories. A state law passed this summer pushes providers into new payment models that reward them for managing patients’ overall health care over time.
Tim Gens, executive vice president of the Massachusetts Hospital Association, said the readmission penalty is unnecessary.
“Does it get attention? Absolutely,” he said. “But I don’t think you need to use a penalty that’s harsh and inappropriate to get attention.”
Dr. Donald Berwick helped to roll out the first stages of the national health law during his year and a half as administrator of the Centers for Medicare & Medicaid Services and previously served as chief executive of the nonprofit Institute for Healthcare Improvement in Cambridge, which has led efforts to reduce readmissions for several years. Since he left his government role in December, Berwick has met frequently with health care leaders around the country.
Berwick said the penalty program needs tweaking — he is troubled in particular about its effects on hospitals that serve the poor — but it is one important tool to encourage hospitals to do better.
“I’m seeing a tremendous amount of attention to this issue now, which I don’t think was there before the stakes went up,” he said.
Beth Israel Deaconess Medical Center expects to lose about $2 million in the fiscal year that started Oct. 1, and the penalty could increase in subsequent years if the hospital’s measurements don’t improve in relation to national averages.
Early results from Beth Israel Deaconess’s intensive follow-up program are promising, said Sarah Moravick, manager of inpatient quality. In about a year of working with up to 30 patients per month, she said, overall readmissions in that small group have fallen, possibly by as much as 20 percent.
Sewell, the pneumonia patient, has been hospitalized several times in recent months, for respiratory problems or complications related to diabetes.
“She’s a tough case,” said her son, Bobby , who has a big hand in her care. “One thing affects the other thing affects the other thing affects the other thing.”
But, he said, the family’s relationship with the nurse has been essential at heading off some problems before they require an inpatient stay.
The goal is to be proactive, said Julius Yang, medical director of inpatient quality. “Patients don’t call us when they are starting to experience problems,” he said.
The hospital plans to expand the program, with help from a $5 million federal grant, to serve 250 patients per month by December, adding seven transition counselors and four pharmacists to work in a large physicians’ group affiliated with the hospital and in several other practices and community health centers.
Helping people to understand their medications is key, Moravick said. The typical Medicare patient might be on 13 or more medications. Adding another during a hospitalization can mean a big change in routine or side effects, she said.
In the hospital’s cardiology department, nurse practitioners are taking on the role of talking with families and with primary care doctors about a patient’s post-discharge plan. And, starting about a year and a half ago, cardiologists began working night shifts in the emergency department, where up to about 7 percent of patient visits are heart-related.
Patients who were recently treated for a heart attack and show up at 10 p.m. in the emergency department with a twinge in their chest often are not comfortable going home without being assessed by a cardiologist, said Dr. Peter Zimetbaum, director of clinical cardiology. Having a specialist working alongside emergency staff can help to get those patients appropriate care without hospitalizing them.
The problem of avoidable readmissions is “a new phenomenon,” Zimetbaum said. It used to be that primary care providers kept in close contact with their patients, visiting in the hospital, treating them when they were discharged, and sometimes paying house calls.
But health care changed. Frontline physicians don’t have the same time for each patient they once did. Specialists filled their roles in the hospital.
“We haven’t figured out yet how to deal with the pieces that I think we’ve lost,” Zimetbaum said.
The Institute for Healthcare Improvement is in the fourth year of a program funded by the Commonwealth Fund, a private foundation focused on health care quality, to work on the issue in several states, including Massachusetts. Dr. Saranya Loehrer, who is a director with the program, said she is hoping this year brings some clarity on what it takes for hospitals to lower their readmission rates.
One challenge, she said, is that the problem — and the solution — is not fully within hospital control. It requires “a community approach,” with other providers, services, and family involvement.
Patients at UMass Memorial Medical Center and its affiliates will begin to see stoplight signals — a red, yellow, or green marker on their chart and in their hospital rooms — to indicate how close they are to being discharged, a reminder for families and physicians to plan for what comes next.
The hospital also has added an automated system to contact every patient within 24 hours after they go home to see if they need a follow-up call from a nurse. And it plans to install software to identify patients who are at highest risk for frequent hospitalization.
The hospital system is set to lose about $1.5 million in Medicare revenue this year because of its elevated readmission rate, said Dr. Robert Klugman, chief quality officer. Regardless of penalties, he said, investing in better care is essential to working within the newer models of paying for health care.
“We’re building the infrastructure, and it’s the right thing to do,” Klugman said.