As hospitals get penalized for readmissions, more attention is paid to the handoff from acute to outpatient care
Keeping their patients out of the hospital – particularly those patients who have been recently discharged – has never been more important to healthcare providers.
That’s because, since October 2012, hospitals have been penalized for readmissions within 30 days of discharge of Medicare patients with pneumonia, heart attack and heart failure. Effective October 2014, the Centers for Medicare & Medicaid Services was scheduled to add elective hip/knee replacement and chronic obstructive pulmonary disease to the list.
The regulation could have profound implications for how physicians regard their role in patient care.
“It brings us back to our roots,” says Tina Shah, MD, MPH, pulmonary and critical care fellow, University of Chicago, and a health policy researcher, speaking of the readmission penalty. “The readmissions policy is reminding us that no matter what kind of doctor you are, you’re responsible for seeing the big picture,” that is, the patient’s overall health, not just the condition that caused him or her to be admitted to the hospital.
The readmissions penalty program has drawn attention to so-called “transition of care” services, that is, services provided to patients in the hours, days and weeks following their discharge from the hospital. That in turn has caused office-based physicians to take another look at how they communicate with their counterparts in the hospital, and how they communicate and treat recently discharged patients.
The Journal of Healthcare Contracting spoke with several primary care physicians and specialists about the potential impact of the readmissions penalty policy and the new emphasis on care transitions.
Robert L. Wergin, MD, FAAFP, Milford, Neb., president-elect of the American Academy of Family Physicians
The discussion about “care transition” hits at the patient-centered-medical-home concept, toward which many AAFP members are moving, says Robert Wergin, MD, FAAFP. “The key element is relationship-based, coordinated care,” he says. “There’s someone who knows you, who understands these transitions of care, who ensures early follow-up with the patient following discharge, and who ensures that the communication process takes place following discharge but before the follow-up visit.”
Wergin insists that his patients come to the office within seven days of discharge. Prior to that face-to-face visit, his office obtains a discharge summary from the hospital. What’s more, a nurse is on the phone soon after discharge to see how the patient is doing, to check to make sure he or she understands the medications, and to answer any questions. “Studies have shown that early contact, clarification of medications, and making sure the patient and doctor are on the same page, can reduce readmissions,” he says.
Working as he does in a rural setting (Southeast Nebraska), Wergin believes that his patients’ transitions of care are probably smoother than they might be in a larger urban setting.
He knows the patients; he’s the one to discharge them; and in most cases, he discharges them to his own practice. There’s even a good chance he knows where the patient lives, and what durable medical equipment they might have or need in their home. He probably knows if the patient lives alone or with someone else, and who might be available to help the patient recover following a hospital stay.
The transition-of-care CPT codes are a benefit for doctors, says Wergin. But in the end, they don’t really change the family physician’s traditional role. “The care part is something we’ve always done.
“The early follow-up with someone who has been sick enough to be in the hospital is important,” he says. “Many times, when you look at the people who are readmitted, it’s because they didn’t have the resources [to care for themselves after discharge], or it’s because they didn’t have early follow-up with their physician [after discharge] to coordinate care.
“That comes down to a key phrase – communication – between the hospital and the patient’s family physician, in my case,” he says. That includes communication about the medications the patient is on, so care can be coordinated with the doctor in the outpatient setting. “In many ways, that ensures they have the things they need to reduce or avoid readmission.”
“What we’re getting away from is this fragmentation of care,” he says. The patient may see several doctors in the hospital, and be unsure of their unique roles. That’s why the family physician is crucial to reducing readmissions. “They might ask me, ‘What’s the next step?’” says Wergin, referring to recently discharged patients. “I’ll tell them, ‘Keep that appointment with that cardiologist” or whomever they need to see. “Family physicians know the whole person.”
Lee R. Goldberg, MD, MPH, medical director, University of Pennsylvania Heart Failure and Transplantation program; associate professor of medicine at the Hospital of the University of Pennsylvania; and chair of the American College of Cardiology Heart Failure Council
These days, cardiologists are playing a larger role than ever before in care coordination with home care and hospital-based clinics, says Lee Goldberg, MD, MPH. “The hospitals have a strong financial incentive to reduce readmissions, and are partnering with both employed and private practice cardiologists to improve care processes and transitions.”
The readmissions penalty “has focused the attention of both hospitals and clinicians on improving transitions of care as well as ensuring that patients receive guideline-mandated care,” he says. “This has led to increased resources, including discharge planning nurses, social workers and home care, all working together with clinicians, patients and families. Many hospitals are creating their own follow-up clinics to provide early post-discharge follow-up appointments with the goal of identifying and intervening early if problems occur.”
But the readmissions policy has its share of flaws too, he adds. “It is not clear that focusing on 30-day readmissions is the correct metric to use as a proxy for hospital quality. The concept is that if a patient is readmitted, something must have not been done correctly during the hospitalization or at the time of transition to home. Although this may be true some of the time, there are no data to support that most readmissions reflect poor quality of care. In fact, some readmissions may be unavoidable. In addition, the penalties may impact safety net and smaller hospitals disproportionally, as they may serve populations with more needs or less access to care.”
Cardiologists recognize that early follow-up after discharge is critical for patient success, and there has been a shift to providing an appointment within seven days of discharge, he says. “In my experience, medication adherence is the main reason patients get readmitted. Other causes include difficulty understanding how to monitor weight and other symptoms, failure to have early follow-up to identify problems and the need for medication adjustments, and failure to make lifestyle changes, such as diet.”
Hospitals have employed a variety of methods – including post-discharge phone calls by nurses or pharmacists, and even home visits – to improve care in the transition period, says Goldberg. “The challenge of all of these interventions is to decide which ones impact outcomes and how to generalize successful interventions at one center to others.”
Greg Maynard, MD, MSc, SFHM, clinical professor of medicine, Division of Hospital Medicine; director, Center for Innovation and Improvement Science, University of California San Diego; and CMO of the Society of Hospital Medicine.
There is perhaps no one in the hospital more crucial in ensuring a smooth and successful transition of care for the recently discharged patient than the hospitalist, that is, the doctor responsible for the patient’s care while he or she is an inpatient. “The Society of Hospital Medicine – and hospitalists in general – feel that even though the regulation [that is, the penalty for readmissions] isn’t perfect, they welcome the attention to transition of care,” says Greg Maynard, MD, MSc, SFHM, who is an instructor of hospital medicine and director of UC San Diego’s program. There are about 45,000 hospitalists in the United States today, and about 14,000 are Society of Hospital Medicine members, he points out. “They’re taking care of a lot of patients who are affected by these regulations.”
Some complaints about the readmission penalty are justified, says Maynard. “It doesn’t control for psychosocial risk factors, or that the penalties might disproportionately penalize those in hospitals that deal with the underserved. But others discount those [misgivings], believing that the positive attention to the issue far outweighs the negative part.”
Healthcare reform has had the effect of encouraging providers to take a broader look at patient care, he says. “It’s no longer just about taking care of the patient in the hospital. The emphasis is now on fostering more cooperation among such entities as skilled nursing facilities, rehabilitation facilities and other community resources. That’s been a very positive thing.”
What’s more, at UC San Diego, hospitalists and staff aren’t limiting their attention to those patients currently affected by the readmission penalty (e.g., heart attack or heart failure patients), nor to Medicare patients only. “We look at the transition of care for all patients,” says Maynard.
San Diego County and UC San Diego are particularly active in the Community-based Care Transitions Program, created by the Affordable Care Act, which tests models for improving care transitions from the hospital to other settings, Maynard points out. Its purpose is to provide a safety net for discharged patients who might be at high risk for readmission. UC San Diego also uses transition-of-care tools, including the Society of Hospital Medicine’s Project BOOST® [Better Outcomes by Optimizing Safe Transitions], to help reduce readmissions.
“Hospitalists are especially sensitive [to readmissions],” says Maynard. “They realize their mere existence as a hospital-based provider is a potential threat to continuity.” That’s true because they don’t take an active role in the patient’s care after he or she has been discharged. “They know that if they’re not part of the solution, they are part of the problem. What we’d like to see are good lines of communication between inpatient and outpatient providers.
“At many medical centers, hospitalists often take the lead in transition-of-care programs, acting as leaders in building this infrastructure [of communication], but it’s obvious that no one discipline can do it alone,” he continues. “Unquestionably, more hospitals are paying attention to this issue [of readmissions]. CMS numbers show improvement in readmission rates. But we still have a long way to go. And then there’s the whole problem of, how do we handle patients with psychosocial problems,” for whom the inpatient hospital might be the default provider, though not necessarily the most appropriate one.
Tina Shah, MD, MPH, pulmonary and critical care fellow, University of Chicago; health policy researcher looking at COPD readmissions among Medicare beneficiaries; and American Thoracic Society member.
Many hospitals will no doubt be looking to their pulmonologists for help in reducing readmissions of patients with chronic obstructive pulmonary disease, or COPD, given that the Centers for Medicare & Medicaid Services was set to begin penalizing hospitals in October 2014 for excessive readmissions of these patients, notes Tina Shah, MD, MPH. (Pulmonologists already play an important role in minimizing readmissions of pneumonia patients.) But the regulations leave some important questions unanswered.
“There’s a lot of heterogeneity among hospitals,” she points out. For example, pulmonologists may or may not be the primary providers of care for hospitalized patients with COPD or pneumonia. “It’s hard to generalize pulmonologists’ role in the hospital, because we’re not always the primary service provider.” That begs the question, “How can pulmonologists effectively impact and lower readmissions if they are not the primary provider?”
Even as CMS was considering extending the readmission penalty to COPD patients, the American Thoracic Society raised questions about it. In July 2013, the society raised this question in its “Coding and Billing Quarterly” newsletter: “The ATS is concerned the proposed measure has not been validated and that available data do not show a correlation between hospital readmission rates and low quality care for COPD. The ATS is further concerned that COPD exacerbations are not accurately described in Medicare’s administrative claims data, making implementation of this policy off of existing claims systems problematic.”
Says Shah, “Overall, we’re trying to adopt best practices, since there isn’t much literature to guide us [in terms of] what we can do in our practices to improve the transition to outpatient care.” That said, few would disagree that just about any patient would be better served by an improved medication reconciliation process, which essentially means matching up – and clearing up confusion about – the medications the patient was taking upon admission with those he or she is prescribed upon discharge.
In her research, Shah has learned that only about a third of COPD patients are readmitted for COPD. Other reasons include heart failure, pneumonia and generalized respiratory failure. For that reason, it’s important for the pulmonologist to adopt a more holistic approach to the post-hospital care of the COPD patient, she says. It’s important the patient knows prior to discharge to be tuned to how he or she is feeling in a general way. “We say to them, ‘If you feel like you are worse than your normal, do you know who to call?’” she says.
Nitin Damle, MD, FACP, South County Internal Medicine, Wakefield, R.I.; member, Board of Regents, and chair of the Medical Practice Quality Committee of the American College of Physicians
There’s a good chance that a member of the American College of Physicians has been managing the healthcare of any given hospitalized patient for months or years, says Nitin Damle, MD, FACP. “We’re familiar with them.” But that familiarity can be compromised when the patient is admitted to the hospital. “What we need to do is set up a seamless transition from discharge to the follow-up visit in the office,” he says. “The American College of Physicians has been very active in that.”
In fact, the College’s High Value Care initiative focuses on two priorities: helping physicians provide the best possible care to their patients, while reducing unnecessary costs to the healthcare system. Reducing readmissions fits that strategy well, he adds.
The patient-centered-medical-home model of care lends itself to the seamless transition that Damle speaks of. “A central part [of the patient-centered medical home] is team care, and part of that team is the nurse case manager. He or she is the point person, coordinating activities between the hospital and the practice, and the practice and the patient.”
Years back, when primary care physicians were still routinely making rounds at the hospital, the need for an office-based case manager wasn’t as acute as it is today, he says. But as inpatient care has increasingly been handed over to the hospitalist, gaps can occur.
The office-based case manager tracks ER visits, hospital admissions and discharges of the practice’s patients. Upon the patient’s discharge, he or she picks up the ball by ensuring the practice receives a discharge summary, knows what medications he has been prescribed, and contacts the patient with 24 to 48 hours after discharge. Patient confusion about medication changes, important symptoms and the complexity of their medication regimens can lead to patient instability and potential hospital readmission, points out Damle.
Care transition calls for a team approach and some practice redesign, he says. Systems and personnel must be set up, and that costs time and money. The care-transition CPT codes help defray some, though not all, of those costs.
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Nick Sears, MD, executive vice president and chief medical officer, MedAssets
You buy a car, you get a warranty. Something goes wrong during the warranty period, you get it fixed at no charge. The federal government has asked, “Why shouldn’t healthcare work the same way?” Its answer? It should. Hence the readmission penalty provision.
Rather than getting paid for caring for readmitted Medicare beneficiaries, hospitals instead are being penalized, points out Nick Sears, MD. It’s part of the government’s attempt to move away from fee-for-service, to fee-for value, and it’s part of a trail the government has been blazing for some time, beginning with its refusal to pay for certain hospital-acquired conditions or so-called “never events.” But it’s more than that.
“If I were to give a two-minute elevator speech on the Affordable Care Act, it would be, ‘It is an attempt to link pre-acute, acute and post-acute care under one umbrella, so everyone shares in the risk and reward,” says Sears. “Across the country, all healthcare stakeholders are placing increased focus on value and starting the journey to document variables in outcomes and clinical practices. We’re shifting from traditional fee-for-service to what we would consider a bundled payment,” that is, payment for an episode of care, however “episode” is defined.
Still, unless the office-based physician is financially tied to the inpatient facility, the readmissions penalty program won’t directly affect that doctor in his or her practice, points out Sears. That said, physicians might ignore the readmissions program at their own peril, he continues. That’s because hospitals could choose to exclude from their networks those doctors who fail to provide care-transition services and help avoid readmissions.
The dynamics change if the IDN acquires the physician practice, or if the hospital and its physicians form an accountable care organization, he says. In those cases, the doctors would share the hospital’s pain if it incurs penalties for excessive readmissions, and hence would be motivated to alter some of their practices in the office.
“There are many types of value-based reimbursement models that exist in the market today, and each methodology has multiple considerations and moving parts,” says Sears. “But ultimately, it will lead to better care.”