Re-Focusing on Readmissions Through Quality Initiatives

Discharging a patient, particularly one that suffers from heart attack, heart failure or pneumonia, likely leaves healthcare providers on edge these days. Did they understand the discharge instructions? Will they make that follow-up appointment? Will they fill their prescription? Will they take their medication as instructed? How much money will we lose if they come back within 30 days?
These questions are now being asked by healthcare facilities across the nation with greater urgency as a result of a CMS policy instituted last fall that reduces Medicare payment for hospitals with higher-than-expected readmission rates. Hospitals with excess risk-adjusted readmissions for the three conditions mentioned above stand to lose as much as 2 percent of total Medicare diagnosis-related group payments, with an increase to 3 percent in 2014.
Providers, therefore, are becoming increasingly focused on preventing readmissions, and taking a corresponding look at improving quality in turn.
Putting Readmissions Practices into Pilot
“Anytime anything costs a hospital money, it’s instantly very important,” explains Anna Drachenberg, CEO of Excellence in Healthcare (EiH), a healthcare quality assurance consulting firm in Arkansas. “Thirty-day readmissions is likely the first quality metric that has had incentives or fines attached to it with scores.”
Drachenberg and her team are looking to discern the affect specific protocols combined with healthcare technology and home healthcare will have on readmissions as part of a 90-day pilot program. The program involves two hospitals, a combined 15 patients, and four home health and long-term care facilities. Protocols for the two hospitals are being finalized, and Drachenberg expects congestive heart failure patient discharges to start being tracked in March. The first set of measurable results will likely come in April or May.
Goals of the pilot include reducing the number of the previous year’s readmissions in the same category, and better defining patient need for post-discharge follow-up based on several socioeconomic factors. “Follow-up phone calls and home health aide visits make the most sense with an elderly patient on a fixed income who returns to a home with no Internet connection or computer,” Drachenberg explains. “Secure emails might be the best method of communication for an elderly patient who returns to a home with younger caregivers such as children or grandchildren.”

Making the HIT Leap
Healthcare IT certainly has a part to play in readmissions programs, but it is not an easy jump to make for some facilities. “Hospitals, for the most part, have in the past three to five years started to get ahead of the curve on the technology side,” says Matt Drachenberg, EiH’s COO. “Not very far ahead, but head. The culture around nursing homes and to a certain extent home health is very reactive. They’re unlikely to do anything to change until it starts hurting. That’s the difficulty in that part of the chain. You’ve got to really show them a benefit.”
Quality’s Part to Play
While home health and long-term care facilities play catch up, acute-care facilities are beginning to see a positive connection between HIT adoption and improved quality of care, which likely correlates to stagnant or lower readmissions. As noted in a recent BMC Health Services Research study, there is a link between healthcare IT utilization and care quality; more care quality benefits could potentially be achieved by adopting advanced IT systems and demonstrating meaningful use of EMRs.
Contrast this finding with a recent American Hospital Association letter to CMS explaining that today’s EMR systems aren’t capable of meeting requirements of the Hospital Inpatient Quality Reporting program. AHA Senior Vice President of Public Policy and Development Linda Fishman added that “hospitals will not be ready to routinely report clinical quality measures through EMRs until measure developers and vendors build electronic specifications and EMRs that support efficient generation of accurate and reliable quality data.”
And therein lies the rub.
It is a point of contention that Lyda Gardiner, RN, BSN, Practice Director of Quality and Performance Innovation at Jacobus Consulting, knows all too well. “Figuring out how to use EMR technology to drive quality is a struggle for many quality officers and directors right now,” she explains. “People know intellectually how it’s supposed to go together, but that involves a pretty big practice and culture shift, so making it a reality and operationalizing it is a major challenge.
“Legislators want to see quality experts move away from manual data extraction and data intermediaries and start to utilize data right out of the EMR,” she continues, “but quality folks don’t always see that as a main drive. They still do a lot of manual data extraction, so I think there’s a gap there in terms of learning. Making that shift will help drive better healthcare and outcomes through performance improvement programs with interventions put into place, but the challenge is getting those lined up to support the organization’s strategic plan.”
Seeing Quality in the C-Suite
Gardiner does believe quality and readmissions go hand in hand, especially from a change management perspective. “Quality departments should be the owners of change management, overseeing a consistent, organization-wide change-management program they use for everything new,” she says. “This type of program needs to be consistent across discharge, discharge communication and coordination of care. There’s definitely a need to reengineer processes and communication around discharge.”
Hospitals are certainly paying attention; some are even creating Chief Quality Officer positions within their executive teams. And with more than 6,000 quality directors currently working in acute-care settings across the US, their attention spans show no sign of waning.
Gardiner, in fact, foresees the rise of the “quality informaticist” – someone who offers combined skill sets of performance improvement, quality measurement, data management, change management, IT and information services.
If her prediction is correct, quality-focused staff members will in the coming years become integrated throughout a hospital’s various departments, always on the alert for ways in which to reduce the likelihood of readmissions. Perhaps as these personnel changes are made and EMR systems become more mature, providers can rest easy at the time of patient discharge.