Reduction Of Hospital Readmissions

Hany Salama, MDDiplomat ABIM IM

Hospice and Palliative Care

Sleep Medicine

FACTS FROM NATIONAL HEALTH INTVIEW SURVEY 2010

38.1 Million persons were limited in their usual activities due to one or more chronic health conditions

Prevalence of activity limitations due to one or more chronic conditions increases with age (7% under age 12, 17% age 45-64 and 43% of people age 75% or older)

• One in five discharged patients will be re-hospitalized

within 30 days

• 50% will not have interaction with a clinician prior to readmission*

*Jencks S., et al. “ re-hospitalizations among patients in Medicare fee for service Program” New England Journal of medicine 2009

Geriatric population has the highest readmission rate

The critically ill constitute 35% of readmission in one month.

CHF and COPD exacerbations are the leading causes of readmissions by diagnosis

Patients discharged to nursing home are less likely to be readmitted in one month compared to those who go home

Inappropriate Care During Hospitalization

Resolution of main problem Increase temperature IVF on discharge day Unaddressed abnormal tests Absence of documentation of discharge

planning

Inappropriate care During Hospitalization

Medication errors Medical errors Early Follow up with PCP Inadequate education of caregivers

Complications Of Sending Patients Back and Forth To Hospital from LTC

Increase risk of delirium Medication errors Falls Infections Death

First Conditions For Initial Penalties

Pneumonia Heart Failure Myocardial infarction

Transition Programs Post Hospitalization

Physician Nurse Practitioner Care Manager Social worker Nurses Pharmacist Nutritionist

Strategies to Reduce Re-hospitalizations

Service delivery reform Financing reform Medicare and Medicaid integrated service

and financing reform

Service Delivery Reform

Care coordination between hospital and post hospital settings and providers

Education patient, family, and caregivers Patient monitoring post discharge Some studies showed 39% lower total costs

of care

Service Delivery Reform

Some programs begin from day of admission Arrange follow up appointments with

physicians Arrange follow up tests Teach patient to identify and deal with

emergency situations Expedite transfer of discharge summaries to

outpatient physicians

Service Delivery Reform

Arrange post discharge services Post discharge phone calls Reconcile discharge plans with national

standard guidelines Information technology availability Create interventions that address cause of

readmission

Service Delivery Reform

Establish Home Based Primary Care Medical Home Models Hospice and Palliative Care Use home telehealth Incentive to improve patient compliance

Financing Reforms

Going away from fee for service model Paying providers on good and poor behavior Episode of care starts on day of admission

and ending when patient is not in hospital or SNFs for 60 days

Under new payment method, the difference between Medicare payments and provider are retained by hospital and post acute providers

Integrated Financing and Delivery Models

The Program of All Inclusive Care for the Elderly (PACE)

Medicare Special Needs Plans

Reason For Readmission from Nursing Homes

NH ill equipped to deliver the appropriate care

LTC providers lack sufficient information about beneficiary’s care needs

LOS in Hospital is too short Clinical competence of nursing staff

Measures to Reduce Re-hospitalization from LTC

Educating CNAs about disease symptoms Provide periodic clinical courses to nurses to

recognize signs and symptoms disease processesObtaining adequate records from the Hospital

Do in house labs Ensure drawn lab results are reported timely

Measures to Reduce Re-hospitalization From LTC

Consider having EKG machine More rounding visits by the SNF providers Nurses to round with providers to understand

patient needs more Staff visiting patient homes to evaluate risks

of possible readmissions Pharmacist to review any new medications

for interactions

Measures to Reduce Re-hospitalization from LTC

Understand disease process and aggravating factors

Adequate nutritional support Adequate pain control Monitor for Depressions