CMS seeks ideas to improve patient transitions, reduce rehospitalizations

January 15, 2011


WASHINGTON — Frequent rehospitalizations can be costly to hospitals, private payers, the government and patients. A recent conference from the Centers for Medicare and Medicaid Services looked at efforts to improve patient care and curb rehospitalizations by improving communication and care continuity during patient transitions to home care or nursing home care.

CMS estimates that Medicare spends about $12 billion annually on avoidable rehospitalizations. Policy experts believe that many rehospitalizations could have been avoided if there were better follow-up care between the hospital and the next setting of care, either a long-term care facility or private home.

Two provisions of the Patient Protection and Affordable Care Act aim to address the problem of avoidable rehospitalizations. First, the carrot: The legislation funds a Community Based Care Transitions demonstration program to improve the quality of care a patient receives after having been released from a hospital. It strives to do so in part by forging relationships with community based organizations. Those organizations will be defined by the agency's rules, but could be an Area Agency on Aging or other organization with the goal of coordinating care.

Then the stick: Starting in the fiscal year that begins Oct. 1, 2012, CMS will begin deducting financial penalties from Medicare reimbursements to hospitals with excessive rehospitalizations of Medicare patients within 30 days of their discharge.

"We must achieve better care, better health and lower costs," Dr. Don Berwick, CMS administrator, told the audience at the Dec. 3 conference. He said that the Affordable Care Act provides tools and opportunities such as the demonstration program, to improve care and lower costs.

The law gave CMS $500 million to implement the Community Based Care Transitions Program and test and support models for improving care transitions for medically high-risk Medicare beneficiaries. It seeks to lower the rate of hospital readmissions, improve quality care and achieve savings for the Medicare program.

When Catholic Health World went to press, CMS had not yet released details on the demonstration project or how to apply for funding. When that work is finalized, an announcement will be posted on the agency's website and in the Federal Register, according to CMS.

Meanwhile, questions can be directed to [email protected].

The framework for the Community Based Care Transitions Program set out in the health reform law states that participating hospitals must have a high readmission rate and work in partnership with a community-based organization that provides transition services across the continuum of care. These community-based organizations must have a governing body with multiple health care stakeholders, including consumers.

CMS will require health care providers participating in the demonstration projects to initiate transition services for patients within 24 hours of discharge and provide timely, culturally and linguistically competent post-discharge services that include medication management and support for patient self-management.

"Nobody likes rehospitalizations," said Dr. Robert Pryor, chief medical officer and chief operating officer of Scott and White Healthcare in Central Texas. For consumers, rehospitalization means expensive co-payments, added treatments and worsening daily functioning. Hospitals that reduce rehospitalization can open up beds to more acutely ill patients and payers with more favorable payment structures.

The conference showcased hospitals that have been successful in reducing readmissions. Some common themes from these programs include:

  • Starting discharge planning at the time of admission.
  • Identifying patients most at risk of discharge failure.
  • Having a team approach, with good communications among physicians, nurses and others.
  • Involving patients and their caregivers through teaching and coaching to assure they understand and can carry out the post-discharge plan.
  • Monitoring and managing medications.
  • Contacting discharged patients within one or two days. The preference is that someone who is authorized to prescribe medications make this contact.
  • Following up with patients who were readmitted and finding out what went wrong.
  • Offering case management services, including palliative care, in emergency departments.

Transitions involving hospitals, skilled nursing facilities and patients' homes should not be treated solely as medical events, said Kathy Greenlee, Assistant Secretary for Aging at the U.S. Department of Health and Human Services. "These are life events and cannot be managed by hospitals alone."

Greenlee said that trying to classify aging services as either medical models or social models has led to "false distinctions and a confusing array of services for seniors."

She urged hospitals to work with Area Agencies on Aging to reduce hospitalizations. These agencies do three things well, she said: information and referral, case management and providing community-based services — all necessary for successful transitions.

Presenters described an 18-month CMS project reviewing readmission data from hospitals across the U.S. The project found that most rehospitalizations were related to:

  • Poor interface between provider and patient, resulting in unmanaged conditions and suboptimal medication regimes.
  • Unreliable support systems, including the lack of standardized processes at health care organizations and inadequate systems for transferring information.
  • A lack of a community infrastructure for addressing post-discharge goals.

Dr. Eric Coleman, creator of a nationally recognized transitions intervention program, said that it is important for patients and their caregivers to take a more active role in transitions. By default, he said, "patients and families perform a significant amount of their own care coordination, but they do this without the skills, tools and confidence to be effective."

An intervention model Coleman developed calls for using a "transition coach" who, at a minimum, visits the patient in the hospital, conducts one home visit and makes three follow-up calls. At the conference, Coleman described four pillars of this intervention: medication self-management, following up with physicians, knowing what warning signs deserve attention and having a patient-centered record.

Mary Naylor from the University of Pennsylvania School of Nursing described a model she pioneered through which advanced practice nurses are available 24 hours a day, seven days a week to serve as the primary point person for patients. The result of the model has been increased time between a discharge and the next hospital admission or death, improved patient qualify of life and physical functioning, higher patient satisfaction levels and a decrease in total care cost.

CHRISTUS Health of Irving, Texas, is among ministry members with programs aimed at improving patients' transitions between care settings, such as between an acute care facility and home, and between long-term care and skilled nursing. Jean Dols, senior system director of nursing and research at CHRISTUS, said it is important that such transition programs be evidence-based and customized to patients' needs.

She added that it is important that the programs include a home visit — such visits provide helpful insights into patients' daily lives and into their support systems.

Drivers of rehospitalization

  • Fragmentation of patient information
  • Inappropriate end-of-life care
  • Medication issues
  • At-risk patients not properly identified at discharge
  • Lack of post-discharge follow up
  • Lack of disease-specific protocols
  • Patient non-adherence to the plan of care
  • Patient knowledge deficit

Source: eQHealth Solutions, Baton Rouge, La.


Copyright © 2011 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 2011 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.