By Asad Zaman, MD, FACP, and Lucy Zielinski, Vice President, Health Directions
We wrote an article last summer about reducing readmissions from long-term care facilities. Several readers commented on the article, providing great ideas on how hospital leaders can work with LTC facilities to lower rehospitalization rates. But one commenter noted that long-term care is just a piece of the readmission puzzle.
In her hospital, she wrote, more readmissions come from discharges to subacute rehabilitation facilities and from patients sent home. The comment is on target, and it raises some important issues. Consider the following scenario:
A patient undergoes emergency bypass surgery. After three nights in the hospital, he is ready for discharge. The medical staff want to send him to a subacute rehabilitation facility for a few days, but the patient wants to go home, and his children are confident they can take care of his needs. In the days that follow, however, the patient develops wound complications. Family members are soon unable to control his pain. Five days later, the patient is back in the hospital.
What does this scenario show? It demonstrates that rehospitalizations are a true communitywide problem that involves providers, patients and family members. Human factors — not just clinical and organizational processes — drive many readmissions. Solving this complex problem requires unconventional thinking. Five planning strategies will help health care leaders to address the human factors that lead to hospital readmissions.
Plan for Success and Failure
Health care today is focused on outcomes. The goal is to design optimal clinical pathways that proceed smoothly from care through recovery. But while it is important to envision success, we are missing an opportunity if we fail to think about minimizing the inevitable failures.
Let's return to the bypass patient. What could have been done to keep this patient in good health? The possibilities include better discharge planning, better use of technology and better use of social services to support home care. Thinking along these lines is important, but we should also plan what happens if patients run into trouble.
One solution is to connect patients proactively with a skilled nursing facility in the hospital network. The hospital forwards the patient's records to the SNF and provides clear instructions to the family about when to turn to the facility for assistance. If the bypass patient's family had been put in touch with this resource, they could have asked SNF staff about wound care and pain control. And if the patient had developed a defined condition (such as shortness of breath), the family could have transported him directly to the facility.
A system that plans for failure will allow many patients to get appropriate care more quickly. It also can prevent a significant portion of hospital readmissions.
Tinker and Troubleshoot
Some ideas for reducing readmissions will fail and should be discarded. Some failures, however, can be turned into successes with just a bit of tinkering.
One reader who commented on our previous article argued for stationing nurse practitioners at LTCs. This is a good idea, but making it work can be a challenge. An LTC in the Chicago area recently experimented with hiring a nurse practitioner. Unfortunately, the NP found it almost impossible to reach physicians to get critical direction. The experiment was both frustrating and ineffective. But should the idea be scrapped? No — better to scrutinize the specific problems and troubleshoot a solution.
One possible modification is simply to rework the chain of command for clinical advice. If an attending physician does not respond to the NP within an appropriate time frame, the NP should page the LTC medical director as the supervising physician. Streamlining the process bypasses communication roadblocks. How will this arrangement be coordinated with primary care providers? One approach is to send physicians a memo clarifying that the LTC medical director will be responsible for all newly admitted and readmitted patients, as well as any patients who need acute attention. This will clarify that patients remain under the care of their primary physician and will avoid HIPAA violations.
Avoid One-Size-Fits-All Solutions
Eliminating variations in care is one key to improving quality and reducing readmissions. At the same time, clinical leaders should not miss opportunities to tailor care paths to different situations.
For example, a hospital's standard protocol when discharging a patient to a subacute rehabilitation facility might include nurse-to-nurse communication. However, this one-size-fits-all protocol might not be optimal for the most complex patients, such as a chronic obstructive pulmonary disease patient with acute pneumonia. For these transfers, consider having the attending physician or hospitalist communicate directly with the subacute rehabilitation facility medical director to discuss patient problems and care needs.
It would be too expensive to apply this process to all handoffs, but it could be appropriate and cost-effective for patients in certain high-risk categories.
Forget about the Small Change
Cost control is a critical part of health care reform, but hospitals should avoid being penny-wise and pound-foolish. Our previous article looked at the problem of missed drug doses following transfer to a long-term care facility. One commenter suggested that hospitals send medications (such as high-end cardiology drugs) to the LTC with the transferred patient and work out reimbursement later.
Why not go one step further? Hospitals should consider sending along an extra day of medications for certain patients, such as those with diabetes or congestive heart failure,and not worry about the reimbursement. You're probably wondering, Won't this add pharmacy costs that are included in the hospital DRG payment? Yes, but focus on the bottom line. If providing transition medications to 100 patients (in certain defined categories) prevents just one readmission, the small investment will be well worth the realized savings. The key here is to look closely at individual situations and identify the true cost/benefit of different approaches.
Create Collaboration within Competition
To secure discharges, LTCs, subacute rehabilitation facilities and other post-acute facilities must now demonstrate that they are able to keep readmissions down. This competition is spurring many providers to elevate their standard of care. However, competition can have negative effects. The least sophisticated facilities (and their patients) may be left behind as the bulk of resources flow to the strongest performers.
This is a problem for hospitals. Even if a hospital cultivates a network of preferred post-acute providers, many patients will "leak out" to other facilities. For instance, many patients will choose to transfer to a non-network LTC if a family member works nearby. From a population health viewpoint, hospitals should foster a collaborative environment that will improve post-acute care in the entire community.
One option is to sponsor regular meetings of the medical and nursing directors of local LTCs and subacute rehabilitation facilities to share information and explore solutions to shared problems. To focus and energize the discussion, the hospital should monitor and share key post-acute metrics such as 30-day readmissions and lab turnaround time. Hospital leaders can encourage cooperation by vocalizing the expectation that all providers will work together to improve performance.
Accentuate the Practical
The common denominator of all these strategies is that they represent a practical approach to a complex problem. Understanding the human factors at play in the post-discharge period will help hospitals and their partners to develop workable systems for preventing unnecessary readmissions.
Asad Zaman, M.D., F.A.C.P., is a member of the board of directors of Advocate South Suburban Physician Partners and the immediate past chair of the department of medicine at Advocate South Suburban Hospital in Hazel Crest, Ill. He is also the medical director of Symphony of Crestwood (Ill.) and ManorCare of Homewood (Ill.). Lucy Zielinski is a vice president at Health Directions LLC in Oakbrook Terrace, Ill.