Cover Story
Slowing the Revolving Door
Minnesota’s hospitals are leading the way in reducing preventable readmissions.
By Kate Ledger
As a pediatrician, William Nersesian, M.D., spent his clinical career focused on young patients at his practice in Minneapolis, but he also was the kind of thinker who liked to tackle big problems in health care. His curiosity was piqued three years ago, while speaking with UCare’s then-chief medical officer Barry Baines, M.D., about one of the costliest issues on the table: the unfortunate return trips to the hospital for some of the sickest and oldest patients in the system. “Those patients, who have conditions like heart failure, diabetes, and COPD, comprise a great majority of all hospital readmissions,” says Nersesian, who now serves as chief medical officer for Fairview Physician Associates.
He began reading up on the topic, consulting the articles that had begun to appear on the problem of hospital readmissions and what was being done to reduce them. The issue was already becoming one of national significance. In July 2008, the National Quality Forum had made readmission rates a measure of hospital performance, and the Centers for Medicare and Medicaid Services (CMS) had posed future penalties for hospitals with excessive avoidable readmission rates.
Nersesian sketched out a pilot program aimed at cutting preventable readmissions at Fairview Southdale Hospital, which he chose for several reasons. “It’s a large-sized hospital, and I needed enough patients to measure statistically whether we were making a difference or not,” he says. In addition, it happens to be a site that serves a significant number of UCare patients, among them seniors on its Medicare Advantage plan.
With the support of Baines, who agreed that UCare would sponsor the pilot, and the hospital’s CEO Brad Beard, the program addressed specific gaps in care, including medication reconciliation and post-discharge follow-ups with primary care doctors, that tend to keep the frailest patients from a steady course of improvement after being discharged. The program launched in February 2009. Even Nersesian was surprised by the results a year later: The readmission rate for the targeted Medicare patients fell from 16.5 to 10.6 percent—a reduction of 36 percent.
Although the experiment at Fairview Southdale was among the earliest efforts of its kind that showed results, an array of similar projects were not far behind, both in Minnesota and nationwide. Amid soaring health care costs, avoiding preventable hospital readmissions has surfaced as the most fruitful way to reduce expenses while simultaneously improving care. President Barack Obama recently called for hospitals to reduce their readmission rates by at least 20 percent, a challenge that’s also become a financial imperative. Beginning in 2013, hospitals with high readmission rates for patients with certain medical conditions will receive decreased reimbursement from Medicare, and the list of conditions is slated to expand in 2015. Recently, the state also put penalties on the line: Earlier this year, Gov. Mark Dayton signed a bill to withhold a portion of payments to health plans that fail to reduce hospital readmissions among patients enrolled state-funded health programs by 5 percent a year until they reach an overall 25 percent reduction. “This is a topic that everyone’s talking about,” says Tania Daniels, vice president of patient safety for the Minnesota Hospital Association (MHA).
Thirty Critical Days
The problem of patients bouncing back to the hospital is all too familiar, both to families and to doctors. Take an aging population with increasingly complex medical conditions, add an ever-widening array of available medical treatments and extremely varied home circumstances, mix in cultural differences, and the result is that it’s trickier than ever to ensure patients follow the steps they need to after a hospital stay. “They’re your parents or grandparents,” Nersesian explains. “They may come in to the hospital with all their medications—they have 17 in a bag—and nobody has sat down with them to review what they’re taking or whether those drugs might interfere with each other. They get treated by numerous specialists, whose names they might not even know when they get discharged. And they may have trouble getting an appointment with their primary, or even getting a ride to that appointment.” At discharge, some patients return home, where they’re responsible for their own care, or they return to nursing facilities, where their hospital discharge information may or may not be integrated into their daily regimen. During the first 30 days following discharge, there are often complications from medications or from poor adherence to discharge advice. Patients can slide back into another episode of the problem they were treated for or even find themselves facing a new one such as pneumonia or the consequences of a bad fall.
A landmark study published in 2009 in the New England Journal of Medicine found 19.6 percent of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital in 2004 returned within 30 days, and 34 percent were rehospitalized within 90 days. The study’s authors estimated that inadvertent rehospitalizations cost Medicare $17.4 billion. “Rehospitalization is a frequent, costly, and sometimes life-threatening event that is associated with gaps in follow-up care,” they noted. A state-by-state comparison showed Minnesota had a 30-day readmission rate of 18.2 percent, slightly lower than the national average.
A RARE Opportunity
The problem of readmissions was hardly news, as several organizations in Minnesota had already begun taking note of it. In 2009, representatives of the Minnesota Medical Association and the Minnesota Council of Health Plans brought together a group that included leaders of hospitals, clinics, long-term care facilities, state agencies, academic institutions, payer organizations, and quality improvement organizations to discuss the causes of readmissions and ways to address the problem. The topic was also on the table at the MHA, which has been collecting claims data for more than 20 years. Stratis Health, Minnesota’s Medicare quality improvement organization, embarked on its own project to reduce readmission rates at small Critical Access Hospitals beginning in 2010. The Institute for Clinical Systems Improvement (ICSI) was interested in tackling the issue on as large a scale as possible and had been discussing how best to recruit hospitals to work on it. “This is such a big issue, none of the agencies could tackle it alone,” says ICSI president Sanne Magnan, M.D. “None of us had the personnel or the resources on our own to invite the more than 130 hospitals in the state to participate. We knew we needed to bring all the various efforts together in some way.”
Those efforts have now coalesced in the form of a high-energy, forward-thinking program that’s focused on improving the steps involved in educating and discharging patients. Together, ICSI, the MHA and Stratis Health rolled out a statewide campaign in July called Reducing Avoidable Readmissions Effectively, or RARE. The goals of RARE are to rally institutions that haven’t yet started addressing the readmission issue, to further efforts that are already underway, and, ultimately, to cut unnecessary readmissions in the state by 20 percent (about 4,000) over the next year. As of mid-August, 51 hospitals across the state had joined RARE, which offers participants opportunities to learn about improving discharge practices and smoothing the transition from hospital to home or nursing facility.
Each hospital that enrolls in RARE will receive assistance from ICSI, MHA, or Stratis Health. A staff person from one of those organizations will work with the hospital to review its discharge practices, identify areas that could be improved, and design initiatives to solve problems. That may mean instructing hospitals in ways to help patients practice setting up and/or taking their medications before they leave the hospital, or helping them forge new lines of communication with nursing homes to make a patient’s transition smoother. Participating hospitals also will be able to share lessons about what did and did not work with each other.
Using a new software program, the MHA will help identify Potentially Preventable Readmissions (PPRs) and estimate hospitals’ predicted readmission rates. It will then compare the estimate with actual numbers of readmitted patients to determine how well the programs around the state are working and identify those that may need to intensify their efforts. “We’ve provided baseline PPR data to all Minnesota hospitals, regardless of their participation in RARE, but we’re providing quarterly updates for RARE participants,” says Mark Sonneborn, vice president for information services at MHA, who has presented in webinars for hospitals leaders on how to interpret the numbers. The hospitals have to distinguish, for instance, between patients who are readmitted for a condition related to the initial hospital stay and those who return with another, unrelated ailment. “The hospitals seem to understand the data is really just contextual and tells them if they’re making progress or not,” he says.
Multiple Means to an End
What’s evident is that no single fix will work for all hospitals, so hospitals around the state are trying various approaches.
Fifteen Critical Access Hospitals hospitals from New Prague to Virginia, Minnesota, are participating in a national project facilitated by Stratis Health and are employing a strategy known as Project RED (Re-Engineering Discharge) that got its start a handful of years ago at Boston University Medical Center. That program’s approach is to standardize discharge with an 11-point checklist that is reviewed with a patient. The checklist delineates explicit roles and responsibilities of physicians and other caregivers, makes sure that patients receive proper education about their condition and their medications, and spells out how information will get from the hospital to the patient’s primary care physician.
Although small, rural hospitals with Critical Access Hospital designation are not threatened with the same Medicare penalties as larger facilities, Jane Pederson, M.D., director of medical affairs at Stratis Health, says those hospitals still wanted to work on improving their readmission rates. “They didn’t have the same financial incentives as the larger PPS [Prospective Payment System] hospitals, but they certainly realized it was a quality-of-care issue and wanted to do the best for their patients,” she says. According to Pederson, most started making changes this spring and do not yet have data on the impact of that work on readmissions.
The program Nersesian helped formulate for Fairview Southdale Hospital began with the reassigning of a nurse case manager to help patients at discharge. The hospital also provided for a dedicated pharmacist to review each patient’s medications and make sure there were no drug interactions or duplications. Another key element of the program, Nersesian notes, was expediting discharge paperwork. The medical records department agreed to get all discharge summaries transcribed within two business days. That way, primary care physicians would have all the paperwork in hand when a patient came in for a follow-up appointment. “Hospital administration helped back me up on all that stuff,” Nersesian says.
But as he’s quick to point out, the program extended beyond the hospital. Hospital staff worked with physicians in the community and asked them to agree to fit discharge patients into their schedules for follow-up appointments. UCare’s Baines came up with the idea of offering physicians what Nersesian calls a “bounty”: $50 for each patient seen within five business days of discharge. “Many physicians when they heard about the money kind of chuckled because it isn’t very much,” Nersesian acknowledges. “But typically Medicare pays $60 or $70 to get a patient in for a post-hospital check-up. Most physicians’ offices are losing money on Medicare patients and aren’t in any hurry to bend over backwards to get these patients in. Fifty dollars is not a lot extra. But the idea was to incentivize the follow-up and offer a significant increase over what they’re getting now.” UCare is continuing to pay physicians the additional dollars.
Money from UCare was also used to create an incentive for the hospital, which stood to lose funds from decreased readmissions. UCare invested approximately $100,000 to implement the program but realized gross savings from it on the order of $300,000. About a quarter of that went back to the hospital as a reward for reducing readmissions. (The hospital has since entered into similar shared-savings contracts with other major payers including Blue Cross and Blue Shield of Minnesota and Medica.) Nersesian says UCare was pleased enough with the savings that they continued the program and extended it to Fairview Ridges Hospital in Burnsville and are considering offering it at the University of Minnesota Medical Center, Fairview.
Other hospitals and health systems also have taken significant steps to improve communication both within the hospital and with patients’ primary care physicians. One is HealthPartners, which owns Regions Hospital in St. Paul. Regions is striving to achieve an avoidable readmission rate of 10.7 percent by the end of 2011 and to reduce that figure even more by the end of 2014.
One area of focus has been patients with heart failure. Their strategy for reducing preventable readmissions among those patients has centered around the design of a comprehensive care plan prior to discharge. The care plan takes shape during a predischarge conference that involves physicians, care managers, social workers, mental health professionals, pharmacists, dieticians, diabetes specialists, and other providers. It also involves taking steps to bridge the information gap between the hospital and a patient’s primary care physician. When a patient with heart failure is admitted to Regions, the patient’s primary physician receives an electronic alert. Then, when the patient is discharged, a care manager, patient care coordinator, or nurse follows up with the patient by phone, making sure he or she is scheduled for an appointment. The patient’s primary care physician and a cardiac specialist from HealthPartners’ heart failure clinic then co-manage the patient, using the electronic health record system to facilitate communication. Since beginning this work in late 2009, Regions has started to see a reduction in readmissions among patients with heart failure.
Other programs have focused on communicating with the patient at home. Essentia Health’s St. Mary’s Medical Center in Duluth has slashed its readmission rate for cardiac patients to less than 7 percent (the rate for heart patients is nearly 40 percent nationally). Heart patients in their program receive a scale in their homes that helps them take note of sudden weight changes that indicate heart failure. The scale is also telemonitored by a cardiac nurse, who can help adjust medications. In a study conducted in partnership with Blue Cross and Blue Shield of Minnesota, Essentia found that for the 29 patients who’d been participating for six months, the home scale system saved $1.25 million by avoiding unnecessary hospital readmissions.
At Mayo Clinic in Rochester, the effort to reduce readmissions is evolving. It started with a highly successful pilot program two years ago in the Division of Hospital Internal Medicine. The small-scale pilot, initiated by division chief David Klocke, M.D., began by teaching physicians which patients were at high risk for readmission and helping identify the causes of readmission, such as a patient not understanding exactly how to take a medication. Physicians went on to audit their own patients’ readmissions, noting causes such as inadequate medication review and poor identification of a patient’s psycho-social circumstances. After educating physicians about which patients were most at risk and why, rates improved: In a 14-month period, the division reduced readmissions by 50 percent.
That success led to a program involving hospital nursing units in Rochester and at other Mayo hospitals in Florida and Arizona as well as those in the Mayo Clinic Health System. That program, which focused on patients with heart failure, myocardial infarction, and pneumonia, has led to a reduction in readmissions by as much as 88 percent in some facilities. “Overall, we had approximately a 20 percent decrease, which was our goal,” Klocke says.
The next step is to use Mayo’s electronic medical record to identify high-risk patients and flag those who may need more guidance and follow-up at discharge. Those patients may be taking numerous medications or may have already indicated that they’re opposed to the recommended treatment regimen. “We try to identify them as early as possible, not only based on how high the risk is but what risk factors they have,” Klocke explains. “We then engage the patient and family in discussions about their own self-care, and we do that in the patient’s room.” Among strategies Mayo clinicians use at the bedside is a teach-back system, in which physicians and caregivers educate a patient and then have the patient explain specific details of their care, including what the diagnosis is, what the doctor’s name is, and how they’re going to get to their follow-up appointment. The highest-risk patients get a phone call within the week to make sure they see a primary care doctor.
One of the most surprising changes Klocke has seen has been in the attitudes of physicians in his division, with whom he conducted before-and-after surveys. Before focusing on readmissions, Klocke says, “The surveys indicated that most physicians believed there wasn’t much we could do to help the situation. The general feeling was these patients are so sick, they’re noncompliant, and there’s not much we can change.” But Klocke continually posted data—graphs showing the number of readmissions steadily declining. In a second survey, as physicians noted they were doing more discharge instruction and medicine reconciliation, they also showed an overall change in their perspective. “What they said in the survey was they now believed they could make a difference,” he says.
Enlisting the Village
Making a significant dent in preventable readmissions will require many to think differently about interactions within the health care system. Some also point out that it will take a village. Nersesian, who’s on the RARE steering committee, puts it this way: “You can’t just have hospitals change their practices and affect the problem, and you can’t just have the clinic doctors out there on their own hoping to cut down on readmissions. It’s got to be a collaborative effort with everybody involved.” Hospitals are finding that the effort can sometimes be bumpy. Some institutions are still learning to use their electronic medical record systems, and often those systems aren’t compatible with the ones at nearby primary care clinics. Others are working out how best to collaborate with nursing homes that receive high-risk patients after discharge.
But many are clear about the importance of aiming for a 20-percent reduction in readmission rates over the next year. “We believe the stretch goal is appropriate, and we believe it’s achievable,” says ICSI’s Magnan. “What we’re beginning to build is an infrastructure. We know we’ve got a fragmented medical system right now in how care is coordinated, delivered, and followed up. If we work on things like medication management for people who are readmitted to the hospital, we’re going to learn from this subset of patients. Eventually, the procedures will be usable for other patients, and throughout the health care system.”
Meanwhile, the clock is ticking. Medicare will begin taking stock of readmission rates in October 2011. Yet Magnan thinks that’s not what’s motivating most hospitals to tackle this issue. “Most places aren’t involved because of the penalties and the savings, they’re doing it because it’s the right thing to do.” MM
Kate Ledger is a St. Paul freelance writer.