The Commonwealth Fund webinar, "Reducing Rehospitalizations: A National Priority," held April 2, addressed the new Commonwealth Fund-supported New England Journal of Medicine article on the frequency and costs of readmissions. The panelists also outlined effective national, state, and facility-level strategies to redesign care delivery and payment methods to foster reduction in rehospitalization rates. The presentations are available for downloading from this page. You can also listen to the archived webinar.
Because the panelists did not have time to answer all questions during the event, presenters Steve Jencks, M.D, M.P.H., and Mark V. Williams, M.D., F.A.C.P., have provided answers to several questions below.
The webinar included the following presentations: "Rehospitalization Among Patients Receiving Fee-for-Service Medicare." Steve Jencks, M.D., M.P.H., Consultant in Health Care Safety and Quality; "Joint Commission Requirements for Discharge Planning." Paul M. Schyve, M.D., Senior Vice President, The Joint Commission; "Washington State Hospital Association: Rehospitalization." Carol Wagner, R.N., M.B.A., Vice President, Patient Safety, Washington State Hospital Association; "Readmissions: MedPAC's Recommendations for Medicare Policy." and Anne Mutti, M.P.A., Senior Analyst, Medicare Payment Advisory Commission. Commentary was provided by Eric A. Coleman, M.D., M.P.H., Director, Care Transitions Program; Professor of Medicine, Division of Health Care Policy and Research, University of Colorado at Denver, Mark V. Williams, M.D., F.A.C.P., Professor and Chief, Division of Hospital Medicine, Northwestern University; and Amy Boutwell, M.D., M.P.P., Content Director, Institute for Healthcare Improvement and Principal Investigator of the Fund-supported IHI state initiative to reduce readmissions. Anne-Marie Audet, M.D., M.Sc., S.M., Vice President, Quality Improvement and Efficiency, The Commonwealth Fund provided opening and closing remarks.
Follow-Up Q&A
Concept Validity
Q: When should we consider a "rehospitalization" a result of inadequate care coordination and health care provision versus having anything to do with the index (first) hospital admission?
Stephen F. Jencks, M.D., M.P.H: In general, the question is not either-or but both-and. Patients need carefully planned and executed transitions in order to be safe and stay in the next place of care. Those needs are greater if the patient is sicker.
Q: Does the readmission methodology take into account whether the readmission is clinically related to the initial admission? Also, does it take into account whether it was preventable?
Stephen F. Jencks, M.D., M.P.H: The methodology estimated that 90 percent of readmission was unplanned and related. We avoided any effort to label rehospitalizations as preventable or unpreventable because we thought it would be speculative and difficult to defend.
Q: At what point is the hospital no longer responsible for the patient? Shouldn't patients take responsibility for their care?
Stephen F. Jencks, M.D., M.P.H.: We believe the hospital is responsible for making safe arrangements for transition to the next source of care.
Q: How do we account for patient accountability and compliance?
Stephen F. Jencks, M.D., M.P.H.: By educating patients and family and checking our education with teach-back. Only after a patient and family has that knowledge and skill should we even begin to talk about non-compliance.
Data Issues
Q: What is the average national rehospitalization rate? Is there data by state?
Stephen F. Jencks, M.D., M.P.H.: There is no national information. Medicare data is pretty complete for those over 65 but comparable data for persons under 65 does not exist.
Q: How do facilities get their rehospitalization rate?
Stephen F. Jencks, M.D., M.P.H.: Comprehensive (all payer, all discharge, all rehospitalization) rates are available only in Florida and in certain large systems.
Q: Our organization has recently implemented a project to reduce rehospitalizations for heart failure. We are having difficulty finding data we can use for benchmarking purposes. Where is the data on rehospitalizations located?
Stephen F. Jencks, M.D., M.P.H.: Perhaps the best source is the published literature on improvement, which gives a sense of what is achievable. We cite three examples in our paper and Dr. Epstein cited a fourth in his editorial.
Q: What do you say to hospital executives who say they can't afford to make any large investments right now, even into programs that have been proven to reduce readmissions?
Stephen F. Jencks, M.D., M.P.H.: This is really a matter of making discharge safe. Initial efforts to reduce rehospitalizations should not require a large investment. If a hospital has substantial success with initial efforts and feels that it cannot afford to extend safe care to all patients, the board should review the hospital’s priorities.
Length of Stay
Q: I know the message here is aftercare but I'm still curious about relationship between readmissions and initial length of stay.
Mark V. Williams, M.D.: Studies evaluating hospitalists--that note the decline in length of stay with their implementation--have not found any increases in readmission rates. One study (Diamond, Annals Int Med) documented a decrease in readmission rates when hospitalists cared for patients.
Q: When we discuss readmissions as a quality benchmark, aren't we setting a perverse incentive to prolong hospital length of stay unnecessarily? Should we look at the whole "elephant" in the room instead--some combined measure of readmissions and length of stay?
Stephen F. Jencks, M.D., M.P.H.: The financial incentives to shorten stay are so strong in Medicare that this “perverse” incentive does not look like a high risk, particularly since longer individual stays appear to be associated with a higher risk of rehospitalization.
Mark V. Williams: This may be an appropriate fear and why demonstration projects are needed to evaluate efforts to reduce readmission. The total cost of health care should be assessed.
Other Stakeholders
Q: Where are the patients who are being rehospitalized primarily coming from? Nursing homes, skilled nursing facilities, other residential long-term care facilities?
Stephen F. Jencks, M.D., M.P.H.: The source of admission code is extremely unreliable both because it includes emergency room and because there is no incentive to get it right.
Q: What kinds of motivations do non-hospital providers have to help improve transitional care? This is an extremely complex issue, but it seems that better communication between hospitals and ambulatory physicians could be a win-win if patients arrived with better information and hospitals were more able to get follow-up appointments for patients.
Mark V. Williams, M.D.: This is an important question. The combination of no financial incentive to see a patient soon after hospital discharge (these typically would be complex patients with many issues who would potentially require significant time) and the shortage of primary care physicians (PCPs) may be exacerbating the situation. A special, higher payment code for PCPs to see patients post-hospital discharge might be a solution.
Q: Many of these proposed interventions are aimed at hospitals or states. What role do you see health plans playing in reducing rehospitalizations?
Stephen F. Jencks, M.D., M.P.H.: Health plans that actually negotiate with providers about practices, access, and communication--and communicate with their patients about care--are in a very strong position to reduce rehospitalization. Those that focus mainly on obtaining discounts and finding lower cost providers may not have much success.
Hospital Practices
Q: What is being done to improve communication within the hospital itself?
Mark V. Williams, M.D.: Many hospitalist programs have developed sign-out routines and special forms or IT solutions for this. At Northwestern Memorial Hospital in Chicago, we have an active program to promote teamwork and communication both within the hospital and between the inpatient and outpatient settings.
Q: How do you become a boost mentor site?
Mark V. Williams, M.D.: We’ve enrolled 30 sites. The sites, along with all the Project BOOST Materials, can be found at www.hospitalmedicine.org/BOOST