Why reducing readmission rates is so difficult

Local hospital readmission data mirror national data in that twenty percent of hospitalized patients are readmitted within 12 days of discharge, and 30% within 30 days. Hospital reimbursement has changed to global, not fee for service payment. Hospitals and physicians need to create effective ways to prevent readmission. Readmissions also portend poorer outcomes. Therefore, it is our task as the physician community, to work collaboratively in this process.

Currently, most patients have no contact with their primary care physician while hospitalized or at the skilled nursing care facility. At discharge, the patient or caregiver is given a few pieces of paper with confusing instructions and a handful of new prescriptions (several are for medications that they already have, and therefore they fill none). Or, a medication sheet is faxed to the skilled care facility with the admission H&P (from the hospitalist who knows little about the patient) and the patient is wished good luck.

Health care providers are now encouraged to reduce readmission rates using proven effective factors, including;

  • A primary care follow-up visit within a week of discharge, with transportation arranged if it cannot be done by family.
  • Demonstration that the patient and or caregivers are fully informed and can show understanding by “teach back” techniques as to medication regimen, “red flags” indicating deterioration, and when to call for help.
  • Regular contact (daily phone or direct visit) with someone (primary care doctor or delegate, nurse, disease manager, or trained member from a community resource) for several days after care transition to home or skilled facility.
  • Meticulous medication evaluation as well as making sure that transition medications are available, affordable, pre-authorized, as well as delivered.
  • Identify “frequent fliers” arriving in the ER, and provide proactive actions to prevent readmission.

Historically, the health care system has relegated most of this as the often uncompensated responsibility of the primary care provider.

Now the reality.

The average primary care provider has 2,000 patients and sees 20 patients a day. Based on a 210 day year seeing patients, the doctor can provide 4,200 visits a year. Yet their panel of 2,000 patients will request 6,000 office visits a year.

Add to this the frail elderly patients with some anxiety or cognitive impairment, typically on 10 prescription medicines, with 8 chronic medical conditions (4 of which are co-managed by specialists), who come in with 2 acute problems. These at-risk patients need 6-10 visits a year, and each requires significantly more time than 20 minutes. The disconnect gets exponentially wider. Even before the post-hospital visit, as the patient arrives home or in an unfamiliar skilled care facility, the primary care provider gets the call after hours, weekends, etc. We are tasked by the patient or concerned family to discuss conditions and prognosis, and review medication changes.

Next, the post-hospital office visit is predictably a schedule wrecker, should the provider take ownership of the process. The typical complex patient takes 90+ minutes, which cannot be pre-planned for in the 15 minute same day access slot. Often, the discharge summary is not available and must be faxed at the time of the visit. The visit agenda: review all the exams, consultations, labs and diagnostic studies and interventions provided during the stay; assess ability to acquire, take, refill, or pre-authorize medications; assess social supports; evaluate emotional, linguistic, or intellectual barriers to compliance; assess access to transportation, nutritional status, fall risk, the patient’s or caregiver’s knowledge of red flags of early deterioration, and the medication regimen through the “teach back” process; discuss and document advance directives and care goals; help coordinate follow up labs/diagnostic testing, specialist visits; review, fill out and sign numerous pages of home visiting nurse, PT/OT/nutritional assessments; correct conflicting medication lists by each agency; and do a physical exam — all in the allotted 15 minutes.

No surprise, then, that the default response to an urgent request of a complex patient for an acute visit or a “red flag” post-discharge concern becomes “go to the ER.”

In conclusion, we need to create a system wide team approach and work collaboratively. Each player needs to be sensitive to the role and needs of their downstream teammates and, if possible, do as much of the processes as can be done at the time they are interacting with the patient. We need to either off-load the downstream expectations of primary care or find ways to vastly improve the resources available to the primary care player’s role in transitions.

Perhaps resolutions through organized medical societies, hospital, and skilled facility associations can put pressure on the payers and Medicare/Medicaid to consider adequate payment or savings to be shared with community based primary care, thereby supporting involvement in admissions and transitions to and from hospital and skilled care facilities even without face to face contact with the patient.

Winslow W. Murdoch is a family physician. 

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  • http://twitter.com/puttd Debra Van Putten

    I think that simply using some commonsense and care would go along way. One

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I have a concierge practice which gives me and the patients sufficient time to re evaluate their needs post hospitalization. Having the time to stay on top of this sea of data greatly reduces the rate of inpatient admissions, unnecessary inpatient testing and bounce backs. I see my patients daily in the hospital. I understand the economic realities of caring for 3000 patients and the benefits of only doing outpatient medicine but I was trained to provide in patient and outpatient care and I will be damned if I will give up caring for my patients when they are sickest and need an advocate the most. I see my patients in the nursing home. The nursing staffs are under trained, stretched thin with a high number of patients per nurse, caring for elderly chronically ill individuals with long problem lists and poly-pharmacy from multiple doctors. When a patient gets ill in that setting there is very little nursing or care they are actually allowed to perform.. The facilities mantra is ” call 911 and copy the chart for transfer.” It doesn’t help that if the patient bounces back to the hospital at or near the end of their Medicare covered stay when funding will be reduced on a per diem basis,, the facility can get them back four days later at the original higher rate of pay. It doesn’t help when every bus in town, newspaper, evening prime time news show and magazine is carrying full page ads advocating contacting a trial attorney about ” elder abuse” at these facilities. Last week a NY law firm took a full page ad in the three largest south Florida periodicals ( the Miami Herald, The Sun Sentinel and the Palm Beach Post) looking for victims of elder abuse in South Florida. ER’s, specialty physicians, ambulance services, skiiled nursing facilities all do far better with the bounce backs . Lack of continuity of care and multiple docs who do not know the patient exacerbate an already dysfunctional heartless system. To fix the system , primary care docs need to be compensated for providing and directing longitudinal care of patients in multiple settings. Nursing homes must be given the economic and legal freedom to provide care on site and only send out those patients who are truly emergent. Independent seniors and the children of the frail elderly need to rise up and demand a more compassionate system for their parents but must except some type of tort reform so that the facilities feel comfortable treating illness on site instead of just calling 911 for minor problems to cover their legal butts.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Strangely enough I’ve been running into lots of community docs lately who seem offended when I ask if they admit their own patients because “of course!” they do. And these are not even concierge physicians. They have a full load at the office, but somehow make it through, and not all of them are “older generation”, so I guess that’s encouraging, but we do need more primary care doctors. I am a bit ambivalent about this team stuff and the confusion of coordination with continuity.

      • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

        The physicians who carry a full compliment of patients and still see their inpatients and patients recuperating at SNF’s are few and far between. I view them as extraordinary heroes and hope their patients’ appreciate their doctors unique dedication.

  • http://twitter.com/jlchasin Lauren Chasin

    I agree, the reality for family physicians is far different than the “ideal”. It is extremely difficult due to time constraints and numerous other issues to give patients all that is necessary to prevent readmissions and ER visits. My hope is that with theories like the Patient Centered Medical Home, the responsibility will not fall solely on the family physician, but the whole team of caregivers.

  • http://www.facebook.com/cliff.martin.148 Cliff Martin

    This is a great article. I am an infectious diseases physician in private practice, with a practice that is about 90% hospital based, 10% outpatient. I am often in on conversations about how to reduce readmission rates from the hospital perspective, and unfortunately the information shared by Dr. Murdoch is largely lost in these conversations. The solution has been to implement electronic medical record solutions, which do very little to coordinate care in their current form – and they certainly don’t solve the problem of the primary care physician. Indeed, I suspect that they add to the time requirement, since I constantly hear complaints from community physicians regarding the reams of paper they receive, generated by hospital the hospital EMR to meet compliance issues. The common experience I hear is that in a stack of paper 10 to 15 pages thick of required content, about 5 lines are actually useful to the outpatient doctor. I will bring your article to the next meeting and share it with the group.

    The ACO model aims to address this problem in theory, but I am doubtful that it will. No matter what system we design, there is no substitute for 1) being reimbursed for the time you spend working with the patient, including extended visits for post-hospital discharge care, and 2) physician to physician communication. Perhaps an over simplification, but I have often said that if doctors would just talk to each other, we wouldn’t need an ACO.

  • JasonEC

    This is a great article. As a full-time hospitalist for the last 11 years, these are some of the most common struggles we encounter. (Of course patient satisfaction is another that never seems to get a lot better no matter what we do.).

    In a small, economically-depressed community like ours, the post-discharge resources are so slim, it’s just plain hard to help the patients, even though it is our full-time job. And while we can and do identify frequent fliers early (often shortly after they move into the area and/or start utilizing hospital resources) the lack of available resources combined with several psychosocial factors which are usually present really take the control out of our hands.

    Specifically, despite time and attention to educating the patients about the importance of outpatient follow-up, home health, therapy modalities, and taking their medications as prescribed, they frequently ignore the medical advice we give. So many of the patients in this area are only concerned with their pain medication and don’t even look to get their antibiotics or other discharge meds filled. They’re just not important to them. The patients have their own agenda.

    And while there is significant disincentive for the hospital to readmit a patient, and I’m sure that will be passed along to physicians shortly as well, there is little or no disincentive for the patient. I believe that in any system where a person will receive benefits with little or no negative impact to them personally and immediately, those benefits will be abused. And it’s not the hospitals doing it for their profit. Frequently it is patients who benefit with IV pain meds, free meals, air conditioning, and attention from family members. There is a great deal of secondary gain.

    So why should patients follow their doctor’s instruction and advice? It doesn’t matter to them that nobody gets reimbursed if they come back. And all those readmissions culminate in bad outcomes for the patient. But they refuse to look ahead to that just as they refuse to contemplate the effects of their smoking, obesity, and other lifestyle choices that directly effect their health. As long as the resources are there, it’s somebody else’s problem. And if there is a bad outcome, it’s the doctors’ fault, not the patient’s decision(s).

    To me, this is yet another area where there is no way any unilateral measures will change outcomes.

    In summary, everyone in the system must be FULLY responsible. Doctors and hospitals must do their part. But they cannot possibly bear the full burden. Patients have to be responsible for themselves and following through with the advice and direction they are given. Perhaps the government could bother to incentivize the patients to do so.

    • winslow murdoch

      Jason,Thanks. I do think that at least for some of these tough patients, there is real value to hospitalists in collaboratively working with primary care providers who are willing to be available for doctor to doctor communication. We in primary care might know a patient well, what makes some people tick and what motivates certain tough patients. We also may know who, no matter what, will most likely only want symptomatic issues addressed. Now the reality of how community primary care is treated in my community. At my hospital, the hospitalists (one group of hospital employed doctors, whose average census is 15-20 with a separate intensivist hospitalist for ICU /CCU /Trauma) have largely given up (ever started?) trying to call the primary care providers on admission or at discharge, even upon the death of a patient in the hospital. They repeatedly state at our department meetings that it is too inefficient to get a primary on the phone, and if the primary does call back, the admitting hospitalist may no longer be working that shift, or the primary “on call doctor” doesn’t know that patient. I rarely even get a call back from our ER after I have sent a patient there, called and signed the patient out to the ER doctor, given them my cell phone and requested a call back, and faxed over the patient’s medical history. If the patient is being admitted, they usually just call the on call hospitalist, who often cannot find the patient history or problem/med list that I faxed to the ER as the triage nurse (or someone along the process) has usually thrown it out after pulling the basic info to complete their work on the computer as our hospital is totally electronic, CPOE etc. There is no easy existing place to put the outpatient doctors medical history in the hospitals electronic record, Now the hospitalist sees our patient in the ER cold. At our department meetings, and to the hospital administrators, the hospitalists complain that there is almost never any baseline medical history made available from the primary care doctors, which makes their jobs harder, and excuses their higher readmission rates. This dysfunctional process has been institutionalized for more than 15 years at our local hospital system, as well as the large academic hospital system competitor. We bring up these care and quality concerns monthly at our outpatient primary care department meetings to the local and system department chairs (Primary care, Hospitalist, ER,) as well as hospital presidents who all claim they will get to the bottom of the issues and will fix it. After decades of learned helplessness, the primary care doctors don’t really seem to care much anymore. They focus more on fine tuning the Microsystems what they have control over in the immediate office environment, for which an entire separate book could be written on learned helplessness. Time for a paradigm change, as well as looking at patient care as a continuum of care not just through the lens of Microsystems that we have all created in our daily work flow.

  • buzzkillersmith

    Schedule-wrecker–nicely put. As for taking ownership of the process, always remember that no good deed goes unpunished.

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