Any business operation that has 20 percent of its goods or services returned should be in the market for serious reevaluation of its current products and production methods.

 

Numbers show that almost one in five, or 19.6 percent, of the more than 11 million Medicare beneficiaries who had been discharged from a hospital, were re-hospitalized within 30 days during 2003-2004; 34 percent were re-hospitalized within 90 days; and half of those of those who had been discharged after surgical procedures were re-hospitalized or died within 30 days after a medical discharge back into the community.

 

It has been estimated the cost to Medicare of unplanned re-hospitalizations in 2004 was $17.4 billion.

 

The 19.6 percent rate of re-hospitalization within 30 days of discharge for Medicare beneficiaries is consistent with the rate in the Medicare Payment Advisory Commission's 2008 report of 2005 data (17.6 percent at 30 days).

 

The need to reduce the re-hospitalization rate demands the attention of policymakers seeking a way to improve quality of care and reduce costs in the Medicare system, according to Eric A. Coleman, MD, MPH, a Johnson Clinical Scholar, director of the Care Transition Program at the University of Colorado Denver, and author of a landmark paper in the New England Journal of Medicine on re-hospitalizations among patients in the fee-for-service Medicare program. Coleman helped write the portion of healthcare reform related to care transitions.

 

Coleman recently spoke about the Medicare financial picture at several seminars in Nashville hosted by HealthSpring, Inc. The lectures, designed to show a "roadmap" to use in identifying high risk patients, enhancing the role of patients and caregivers, measuring the quality and safety of care transitions, and using HIT to promote safe care transitions, were givenat the Frist Lecture Hall in Belmont University's Inman Health Sciences Building on July 24.

 

In 2007, MedPAC designed a Hospital Reduction Program aimed at reducing preventable admissions, which goes into effect on Oct. 1, 2012. The program will require hospitals to make public disclosure of their 30-day, risk-adjusted readmission rate, adjust payment based on performance, and bundle payments across hospitals and physicians.

 

The plan calls for reducing payment for readmissions of Medicare patients within 30 days by 1 percent in the first year, 2 percent in the second year, and so forth. The program is slated to begin with selected applicable conditions and then expand to cover more conditions. Hospitals stand to be penalized if the patient is readmitted in 30 days no matter what the reason.

 

The program, according to Coleman, is "all sticks and no carrots." He added that anytime a national health program has promised reduction of costs, there is "a perfect record of raising costs" once the program is implemented.

 

Coleman observed, "Although the care that prevents re-hospitalizations occurs largely outside hospitals, it starts in hospitals." He continued, "When the typical patient has almost two chances in three of being re-hospitalized or of dying within a year after discharge, it is probably wiser to consider all Medicare patients as having a high risk of re-hospitalization."

 

As an example, he said, "Ensuring that a follow-up appointment with a physician is scheduled for every patient before he or she leaves the hospital probably is more efficient than trying to identify high risk patients and arranging follow-up care just for them. Re-hospitalization is a frequent, costly and sometimes life-threatening event that is associated with gaps in follow-up care."

 

He continued, "We are beginning to understand that the rate of re-hospitalization can be reduced with the implementation of more reliable systems, but it would be premature to predict how much reduction can be achieved.

 

"From a system perspective, a safe transition from a hospital to the community or a nursing home requires care that centers on the patient and transcends organization boundaries," Coleman added.

 

The American Geriatric Society defines transitional care as "as set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations. Transitional care encompasses both the sending and the receiving aspects of the transfer."

 

Coleman pointed out that there are "so many facets to improving care, many of which start with enhancing the role of patients and families."

 

Patients and their families have a "gold mine of information and insights on risks." For instance, Coleman said, the patient should be asked to describe in her/his own words the factors that led to his re-admissions.

 

He cited examples of innovative programs — such as a pilot bundling program for integrated care during an episode of care around a hospitalization for three days prior to admitting and 30 days post discharge — that includes acute inpatient services, physicians, Emergency Department services, and post acute service. This discourages unnecessary care, encourages coordination across providers and potentially improves quality.

 

Coleman said it has been estimated that national health spending could be reduced by 5.4 percent between 2010 and 2019 with this kind of approach.

 

He encouraged physicians and staff to "listen to your patient — they are telling you how to improve quality by solving the same four obstacles every time by saying that they are: inadequately prepared for next setting; getting conflicting advice about managing their illness; inhibited by an inability to reach the right practitioner; and repeatedly dealing with tasks left undone."

 

Coleman cited the four pillars that provide a core set of medical directions that the patient should have: medication self management, follow-up appointment with the primary care physician or specialist, a knowledge of "red flag" or warning signs of symptoms and how to respond to them, and a personal health record that is a portable core set of medical directions including a medication list and allergies, an advance directive, treatment preference, and room for patient questions and concerns.

 

He suggested that a care transitions coach could help the patient by modeling behavior to resolve discrepancies, respond to red flags and obtain a timely follow-up appointment. The coach should help the patient practice for his next encounter with his provider and identify two or three questions to discuss.

 

The coach, Coleman said, should ask the patient to "show me what medications you take and how you take them." He noted, "If they don't feel prepared to take care of themselves they are going to come back."

 

Studies show that care transitions intervention coaching results in a significant reduction in 30-day hospital readmits, as well as a significant reduction in 90-day and 180-day readmits, and a net cost savings of $300,000 for 350 patients per 12 months per coach.

 

Coleman suggested the first step in breaking the cycle of readmissions should be to do away with the term "discharge" — "It has no positive connotation. There is no 'quick fix,' but we have a real opportunity to think about rebuilding care," he concluded.