Several years ago, Bassett Hospital in Cooperstown began discussing how to reduce the number of patients returning to the hospital within 30 days due to complications.
This effort led to new measures designed to identify high-risk patients and provide them with extra education before discharge and extra attention when they leave.
The hospital makes sure that someone is at home when these patients return and that the patient receives a phone call within 24 hours of discharge. A follow-up appointment occurs within five days, and the hospital makes sure that the patient has transportation. If the patient misses the appointment, an effort is made to find out why, said Ronette Wiley, vice president for performance improvement and care coordination at Bassett Medical Center. Patients are given a toll-free number and encouraged to call if they need help. Each month, the number receives 100 calls from patients and caregivers.
The measures have paid off.
Bassett has reduced its readmission rate among high-risk patients by 70 percent, according to Wiley. She said a lower readmission rate is good for patients, because it means their overall quality of care is better, and for hospitals, because return patients often require expensive treatment.
“The return on investment is good,” Wiley said. “When we call patients after they’re discharged, they know we care about them.”
Bassett is one of fewer than 20 hospitals in the state that wasn’t penalized by the federal government for excessive hospital readmissions. In October, the Centers for Medicare & Medicaid Service began penalizing hospitals that readmit too many patients within 30 days of discharge due to complications.
The idea is to improve quality of care while also saving money. Hospitals are being assessed in three areas: heart attack, congestive heart failure and pneumonia.
The heightened attention on hospital readmissions is part of the federal health care reform bill passed under President Barack Obama.
According to the Medicare Payment Advisory Commission, about two-thirds of the hospitals serving Medicare patients — about 2,200 facilities — will be hit with penalties averaging around $125,000 per facility this coming year. Nationwide, hospitals will lose more than $280 million in Medicare funds over the next year. Hospitals that serve low-income patients will be hit especially hard, according to a Kaiser Health News analysis of the records.
Hospitals are not fined, but they get a percentage of their reimbursements withheld. This year the penalty is capped at 1 percent of a hospital’s Medicare payments, though the penalty for most hospitals is much smaller. But the penalties will rise steadily, to up to 2 percent of base Medicare reimbursements in 2013 and up to 3 percent in 2014. New York state has one of the highest readmission rates in the country. In general, hospitals in the Capital Region fare better than in other regions, particularly downstate, where readmission rates tend to be high.
Nationally, the readmission rate for heart attack patients is 19.7 percent. For heart failure patients, it is 24.7 percent, and for pneumonia patients it is 18.5 percent.
“All hospitals are really struggling with this,” said Wiley, who is leading a statewide effort to reduce hospital readmissions as chairwoman of a work group for the New York State Partnership for Patients, a partnership of the Healthcare Association of New York State and the Greater New York Hospital Association. The work group’s goal is to reduce hospital readmissions throughout the state by 20 percent over the next two years.
“We’re worried about quality of care, and we’re also concerned about cost,” Wiley said.
Under the CMS methodology, excess readmissions are measured by a ratio, by dividing a hospital’s number of “predicted” 30-day readmissions for heart attack, heart failure and pneumonia by the number that would be “expected,” based on an average hospital with similar patients. A ratio greater than 1 indicates excess readmissions.
Wiley said that patients at risk of readmission tend to be 65 or older and have a number of other characteristics. They live alone, they lack social supports such as a strong network of friends, they are on more than five medications, they are depressed and they have been hospitalized within the past six months.
According to the CMS, the rate of readmission at most Capital Region hospitals is no different from the national rate.
For the past two years, Ellis Medicine in Schenectady has made a concerted effort to reduce readmissions for congestive heart failure, one of the main categories of illness for which patients are readmitted.
Such patients are identified early in the admissions process and meet with a nursing resource specialist, who assesses their risk of readmittance. If they are considered high risk, an appointment at the hospital’s relatively new Congestive Heart Failure clinic is scheduled for within three days of discharge. These measures have helped Ellis reduce the readmission rate for CHF patients, from 19.8 percent in 2010, to 16.2 percent so far this year, according to David Liebers, vice president of quality and medical affairs at Ellis.
Liebers said that reducing readmissions involves “extending our knowledge and experience through the continuum of care” — ensuring that patients have the resources and help they need after they’re discharged from the hospital. A big piece of this is medication reconciliation — making sure patients know when to take their medication, and do so.
In February, Ellis launched a new case management program, called the health home, in collaboration with the Visiting Nurse Service of Schenectady and Saratoga, Hometown Health and other community partners. The program serves Medicaid patients with chronic conditions, providing them with “navigators” who can help them find the services needed to maintain good health and prevent readmission.
Ellis’ readmission penalty was low — 0.11 percent, according to an analysis by Kaiser Health News. The CMS flagged the hospital’s rate of pneumonia readmissions as a problem.
Liebers said Ellis knows it has to address pneumonia readmissions. “Pneumonia is in our sights,” he said.
Some hospitals have complained about the Centers for Medicare & Medicaid Service’s methodology.
Because hospitals are held accountable for readmissions regardless of why they occur, they are penalized even if the patient checks into the hospital for a completely unrelated condition. Many executives consider this unfair, saying it punishes them for events they have no control over.
“We consider 30-day readmissions a terrible way of looking at the problem,” said Frederick Goldberg, vice president of medical affairs at Nathan Littauer Hospital. “It’s a crazy methodology and it includes readmissions for unrelated causes. We should be looking at preventable admissions. If a heart attack patient is discharged and hit by a bus, that’s not something we can prevent. The government is penalizing us for things that are not under our control, that happened long ago.” He pointed out that the CMS methodology uses readmission data for the three-year period that runs from July 2008 to June 2011.
Nathan Littauer was penalized for its readmission rate. The CMS flagged the hospital for excessive readmissions among heart attack and pneumonia patients.
Goldberg said that the hospital is using a different methodology to calculate its readmission rate, one that examines only “potentially preventable readmissions,” and relies on more recent data. Using this methodology, Nathan Littauer’s readmission rate improves quite a bit, he said.
Nathan Littauer’s readmission penalty was .5 percent, according to Kaiser Health News.
Like the other hospitals in the area, Nathan Littauer assesses patients at the time of admission to determine whether their risk of readmission is high; if it is, a nurse is assigned to serve as their coach and educate them about what they need to do to manage their recovery and disease. This program is new; Goldberg said it began during the summer. Hospital staff are also being trained to use a tool called teach-back, which involves making sure the patient understands instructions from nurses and doctors.
Albany Medical Center also had a low readmission penalty — .05 percent. Albany Med was flagged for pneumonia readmissions.
“Our rate is substantially lower than everyone else in the region,” said Louis Filhour, the senior vice president for clinical quality at Albany Medical Center. He said the hospital is pleased with this, because it generally serves a high-risk, lower-income population. “We are a hospital of last resort,” he said. “We often get patients at the end of their rope.”
Much of Albany Medical Center’s effort to keep readmissions low involves communicating with a patient’s primary health care providers, as many of the hospital’s patients are treated for serious and life-threatening conditions and then return home. Filhour said that adoption of electronic medical records, a nationwide initiative, has helped immensely.
For more than a year, Albany Medical Center has also been involved in a pilot project that provides high-risk patients with “transition of care nurses,” who visit these patients in their home and make sure they are doing what they need to do to recover.
Saratoga Hospital’s effort to reduce hospital readmissions involves working with primary care physicians, visiting nurse agencies and others to provide extra education and assistance to high-risk patients. Using a federal grant, the hospital has teamed up with the Saratoga County Office of the Aging to create the Northeastern New York Community-based Care Transitions Program, which provides Medicare patients with a health coach who visits patients in the hospital and after they are discharged.
The hospital also makes sure patients with chronic conditions see their primary care doctor within seven days of discharge, and that they understand how and when to take their medication, and what medications they should be taking.
“Some patients haven’t seen their primary care doctor for years,” said Cindy Lisuzzo, director of care management at Saratoga Hospital.
Like Ellis, the hospital has developed an action plan for reducing readmission rates among patients with congestive heart failure; these patients receive a special toolkit full of information on how to take care of themselves and recognize that they should call a doctor. Because weight gain is a sign that heart failure is getting worse, patients who don’t have a scale are given one.
Because Saratoga Hospital is pretty much at the national average for hospital readmissions, “we feel we’re doing well,” Lisuzzo said.
Overall, “We have seen a decline in readmissions and an increase in patient satisfaction,” Lisuzzo said. “Patients like the callbacks and the communication with doctors.”
Saratoga’s readmission penalty was .67 percent. The CMS flagged the hospital for excessive readmissions among heart attack and heart failure patients.
Bassett’s program to reduce hospital readmissions is modeled on Project BOOST, a national initiative, led by the Society of Hospital Medicine, to improve the care of patients as they transition from hospital to home.
“We’re committed to it because it’s the right thing to do,” Wiley said.