SAN DIEGO – Thinking through how to better prepare patients to go from the hospital to home occupies an increasing amount of time for the typical hospitalist. Aside from the fact that transitions of care are a core competency in the specialty, Medicare is also turning up the heat with its plan to impose financial penalties on hospitals with excessive readmission rates. Those penalties will take effect this October.
At the annual meeting of the Society of Hospital Medicine, Dr. Mark V. Williams, chief of hospital medicine at Northwestern University in Chicago and principal investigator for Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) joined Dr. Eric A. Coleman, professor of medicine and director of the Care Transitions Program at the University of Colorado in Denver, for a freewheeling question-and-answer session.
Dr. Eric A. Coleman
The hourlong exchange covered everything from the state of research in the field to how to avoid Medicare penalties.
One take-home message from the discussion is that reducing preventable readmissions will be a focus for virtually every hospitalist, even though some of the key research questions that could help improve care transitions are still unanswered. For instance, there have been many prediction scales that have looked at risk for readmission. But the scales don’t work very well in practice.
"[The scales] come out to be okay, but not great," said Dr. Coleman, who has tried to develop a more reliable risk prediction tool as part of his own research efforts.
But the real lesson from the lukewarm success of existing risk prediction tools is that researchers and clinicians may be focusing on the wrong variables. "I’m not exactly sure that what we think we’re after is what we’re after," Dr. Coleman said.
Dr. Coleman said when he speaks to patients at the bedside about why they think they have been readmitted to the hospital multiple times, it’s not necessarily about organ systems function. And that supports the findings of some research he was involved in that found that factors such as cognition and literacy were the biggest predictors in whether patients would actually follow through on their discharge instructions. "These are not necessarily things that we routinely collect and screen for," he said.
Dr. Williams agreed that there’s a need to routinely collect more data, beyond whether or not patients have specific comorbidities. Quantitative data on the patient’s socioeconomic status, health literacy level, occupation status, and social support could shed a lot of light on whether they will be capable of following through on their care when they return home. Dr. Williams said one of the hospitalists who has been involved in Project BOOST once told him that when he sees a patient he always asks, "Do you have a daughter?" And if the patient says yes, he can relax because now he knows that there’s great social support at home.
While improving care transitions is good for patient care, it will soon also be good business for hospitals. Under a new readmission program from the Centers for Medicare and Medicaid Services, Medicare officials will cut payments to hospitals whose readmission rates for acute myocardial infarction, congestive heart failure, and pneumonia are considered too high. But what many hospitalists may not appreciate, Dr. Williams said, is that CMS officials will be basing that determination on the hospital’s 3-year average performance from fiscal year 2009 through 2011. The next year, the CMS will use data collected from fiscal years 2010-2012.
While reducing preventable readmissions is now a focus for most hospitals, they really should have started that work years ago, Dr. Williams said.
Dr. Mark V. Williams
"We need to have been working on this for awhile because the clock is ticking; data are being collected," he said. "And very importantly, it will take awhile to improve those numbers unless you’re able to make staggering changes right off the bat because it’s a 3-year rolling average."
Hospitals that have been doing well for the past 3 years are probably in pretty good shape, Dr. Williams said. Those that have been doing poorly will have to play catch up. "I think right now every site ought to be looking at their care transitions process," he said.
Hospitalists can try to partner with physicians and other health care providers in the community, said Dr. Coleman.
"When you look at some of the more successful collaborations going on across the country that have been able to significantly reduce their readmission rates and subsequent admission rate as well, it is because of these developing partnerships and realizing that hospitals can’t do it all on their own," he said.