By Debra Wood, RN, contributor
March 3, 2010 - Nearly one-fifth of Medicare patients, equaling 2.4 million older adults, are rehospitalized within 30 days of discharge from an acute-care facility. Ninety percent of those readmissions are for acute, potentially-preventable problems, and end up costing the health care system billions of dollars.
Anne-Marie Audet, MD, MSc, said preventing readmissions can be done without having to invest in expensive technologies.
“It’s not good for the patient, costly and a sign of a fundamental problem in the health care system,” said Anne-Marie Audet, M.D., MSc, vice president of quality improvement and efficiency at The Commonwealth Fund in New York. “It’s something we need to look at and prevent.”
Stephen F. Jencks, M.D., MPH, and other experts in this field reported in 2009 on their study of fee-for-service claims for nearly 12 million Medicare beneficiaries who had been discharged between 2003 and 2004 from a U.S. hospital. They found 19.6 percent were readmitted within 30 days, 34 percent within 90 days and 56.1 percent within a year. Those unplanned readmissions accounted for $17.4 billion in payments by Medicare to the hospitals.
The team also found that half of the medical patients readmitted within 30 days had not seen a physician between admissions.
“Many rehospitalizations result from care system failures in the transition from hospital to the next source of care,” said Jencks, a consultant, during a press briefing. “These care failures allow, and sometimes cause, the clinical deterioration that leads to rehospitalization. The failures reflect a lethal system-design flaw.”
The Medicare Payment Advisory Commission has recommended changes to reimbursement to provide incentives for lowering readmission rates, and Jencks believes there is a high likelihood those changes will occur. He reported between 250 and 400 hospitals are conducting projects to reduce rehospitalizations.
The Health Research and Educational Trust (HRET), an affiliate of the American Hospital Association, released in January 2010 a publication, Health Care Leader Action Guide to Reduce Avoidable Readmissions. The paper cites the results of a clinical trial of the Transitional Care Model, developed by Mary D. Naylor, Ph.D., RN, FAAN, a professor at the University of Pennsylvania School of Nursing, that demonstrated a $4,845 per patient savings by implementing an advanced practice nurse-delivered discharge planning and home visit intervention.
The Transitional Care Model is one of four interventions the report highlights as having strong evidence of reduction in avoidable readmissions. The others are the Re-Engineered Discharge developed by Boston Medical Center; the Care Transitions Program, pioneered by Eric A. Coleman, M.D., MPH, a professor of medicine at the University of Colorado at Denver; and the Evercare Care Model, a nurse practitioner-led program developed by the insurer UnitedHealthcare.
Many of the models require a transition coach or nurse practitioner to coordinate the discharge and teach the patient self-care. Re-Engineered Discharge creates a personalized after-hospital care plan. It began with nurses educating patients and is now testing an interactive, electronic teaching tool. Boston Medical is developing an online tool that would reinforce the discharge plan once the patient arrives home.
The HRET action guide does not recommend one model over another. Instead, it focuses on an approach all hospitals can take to reduce avoidable admissions. Those steps are to examine the rate of readmissions, to assess and prioritize improvement opportunities, to develop an action plan, and to monitor progress.
Audet recommends hospitals start by identifying two or three patients that had been readmitted, then talk to them and their families about what occurred from the first stay until the second.
“That is a powerful way of starting to understand [the reasons for readmission],” said Audet. “Then you can start to begin the solutions and how you are going to reconfigure care and the discharge process, so these problems don’t arise.” She explained that patients often live alone and don’t know what to do with the medications prescribed in the hospital.
Nurses should assess a person’s risk of readmission when they first enter the hospital, Audet said, and every day the person remains in the facility. Age, multiple chronic diseases, dementia or mental illness, living alone, and prior readmissions all contribute to the risk.
“Education has to start the minute they walk through the door,” added Pam Rudisill, MSN, RN, MEd, NEA-BC, president of the American Organization of Nurse Executives. “The nurse is the coordinator and makes sure everyone is on the same page with the patient.”
Jencks indicates four goals for discharge, which include patients and family knowing about medications, signs of danger, follow-up appointments and how to follow a self-care program.
Nurses have long provided discharge teaching, but rushing through the instructions or handing patients a piece of paper is not sufficient. Audet suggested teaching take place every day, for instance with medications when the nurse gives the patient the drug.
Audet also recommends using the “teach-back” method, asking the patient to tell you what they would do in certain situations to check that they truly understand what has been taught. With an older person, teaching and teach back should include the caregiver.
Many older patients are discharged to a skilled nursing facility or home with home nursing, but communication is often lacking. Audet adds that hospitals are just now beginning to sit down with long-term care and home-health providers and plan smoother transitions.
“Coordination between these parties is not happening as well as it should,” Audet said.
Integrated electronic medical records accessible to all clinicians providing care to the patient might prove helpful, but for the most part, those systems do not exist.
“We’re trying to change a culture,” Jencks said. “If we can make it easier with technology, it will be a lot quicker and less traumatic. It takes a community of people to take care of a patient, and those people need to communicate.”
Meg Doherty, MSN, ANP-BC, MBA, executive director of Norwell VNA and Hospice, anticipates more care will move into the community, and nurses will assume more responsibility for keeping patients healthy.
“The goal is to reduce hospitalizations and rehospitalizations [which] will rest on new and emerging roles that will leverage nurses in different ways,” Doherty said. “Our goal now is to assist people in reducing exacerbations, teaching them in the community, so factors that influence rehospitalization and exacerbations of disease do not occur.”
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