Each year, approximately 16 percent of patients in United States hospitals are readmitted within 30 days of discharge. Readmissions and the additional treatments they entail are costly to both patients and insurers. Increasingly, they are costly to hospitals as well.
A portion of readmissions are considered unavoidable, such as a planned readmission for chemotherapy, or an unexpected adverse event unrelated to the original diagnosis. However, many other readmissions are considered preventable through high quality clinical care and effective patient education and discharge procedures.
In an effort to reduce hospital readmission rates nationwide, the Centers for Medicare and Medicaid Services (CMS) has begun financially penalizing hospitals with higher than expected readmission rates. The cost of those penalties across United States hospitals has increased significantly from a total of $290 million in fiscal year (FY) 2013 to a total of $528 million in FY 2017.
More than half of the nation’s hospitals were affected by CMS penalties in FY 2017, and the average total penalty per hospital increased by about 20 percent from the previous year.
CMS’s steep penalties are motivated by a desire to provide better patient care and, in doing so, to reduce healthcare costs. One of the best ways hospitals can prevent unnecessary readmissions is by calling patients after their discharge to check in on symptoms, review medications and treatment plans, and offer patients an opportunity to ask questions about their recovery.
The Financial Impact of Hospital Readmissions
CMS’s Hospital Readmissions Reduction Program (HRRP) began in 2012. In the first year, 65.6 percent of eligible hospitals incurred readmissions penalties totaling $280 million.
(Not all hospitals are eligible for HRRP. Exempt hospitals include all hospitals in Maryland, critical access and longterm care hospitals, and hospitals that treat veterans, children, cancer patients, and psychiatric patients.)
Failure to reduce readmissions has become more expensive over the program’s lifetime. In the first year of the HRRP, the maximum penalty was one percent of Medicare reimbursements withheld. By design, that maximum penalty has since increased to three percent.
National hospital readmission rates have dropped since the program launched, but not enough to decrease penalties. In 2016, CMS announced that it would withhold an all-time high of $528 million from 2,597 hospitals across the United States. Overall, four out of five eligible hospitals were penalized.
The increases are due in part to additional health conditions included in the program. In the program’s first year, CMS evaluated the readmission rates of patients with heart attacks, heart failure, and pneumonia to determine whether a hospital faced penalties. Today, CMS also measures readmission rates of patients with COPD, hip and knee replacement, and bypass surgery.
Additionally, the program is set up such that CMS evaluates each hospital’s readmission rates relative to the national average for each condition. Even as readmission rates drop overall, there will always be hospitals that have more readmissions than the national average.
A 2016 study on hospital profitability published in the journal Health Affairs found that most hospitals in the United States are not profitable, and the median acute care hospital is losing $82 per discharge. Given those numbers, it’s imperative for hospitals to reduce readmission rates and reduce the amount of Medicare reimbursements left on the table.
Readmission Rates and Causes in the United States
According to readmissions data published by CMS on their Hospital Compare site, 15.6 percent of all patients were readmitted within 30 days of discharge from the hospital during the period of July 2014 through June 2015. The overall 30-day readmission rate varied by hospital from 10.8 percent to 19.9 percent. That variation is significant: Patients treated at some hospitals are twice as likely to be readmitted within 30 days of discharge compared to patients treated at other hospitals.
Some number of patients will always be readmitted after discharge. However, the wide range of readmission rates across hospitals suggests that there are addressable factors behind readmissions. In some cases, a readmission may be related to what happened during the original hospitalization. In many cases, however, patient readmission is tied to what happens after the patient is discharged from the hospital.
A study on preventability and causes of readmissions published in JAMA Internal Medicine in 2016 reviewed the cases of 1000 general medicine patients readmitted within 30 days of discharge across twelve United States hospitals from April 1, 2012 to March 31, 2013. Of those 1000 readmissions, 26.9 percent were considered to be potentially preventable.
According to the study, common factors in potentially preventable readmissions were largely related to what happened at the time of discharge and after the patient went home. The authors cited emergency depar tment decision making at the time of readmission, patient failure to keep important follow-up appointments, premature discharge, and lack of patient awareness about who to contact after discharge as the most common factors.
The study’s authors concluded that: “High-priority areas for improvement efforts include improved communication among health care teams and between healthcare professionals and patients, greater attention to patients’ readiness for discharge, enhanced disease monitoring, and better support for patient self-management.”
Post-Discharge Patient Education
Often, a patient is readmitted because they didn’t follow the correct medication regimen, lacked understanding of the treatment plan, or failed to follow up with their primary care physician after discharge.
Ideally, patients receive thorough education about medication regimens and treatment plans throughout their stay and at the time of discharge. However, literacy and comprehension rates vary across patient populations, and patients don’t always understand written or verbal discharge instructions.
Additionally, at the time of discharge, patients are often preoccupied with the logistics and excitement of going home. Attempts at patient education might not be well received, no matter how well delivered. Once patients have arrived at home, the complexity of managing their new medications and daily routines on their own becomes much more apparent.
Several studies have found that other factors, including the patient’s social support network, marital status, gender, and income can affect a patient’s ability to follow discharge instructions and manage their care at home.
Whether it’s addressing a lack of comprehension regarding a patient’s treatment plan or addressing a lack of support in enacting that treatment plan, a post-discharge phone call can provide a way for hospitals to help patients stay well at home.
Using Calls to Reduce Readmissions
Hospitals have many opportunities throughout a patient’s healthcare journey to reduce the chance of readmission. One commonly cited way to reduce readmissions is by improving patient education around managing their care after discharge.
Specifically, implementing a post-discharge phone call to review medication regimens and treatment plans, discuss symptoms and other concerns, and check in on home health services and follow-up appointments has been shown to help reduce readmission rates.
A paper published in the American Journal of Medicine in 2001 found that when pharmacists called patients two days after discharge to review whether they had obtained and understood how to take their medications, patients were much less likely to visit the emergency department within 30 days of discharge. Ten percent of those who received a phone call from a pharmacist went to the ED, compared to 24 percent of patients who did not receive a call.
In another program, IPC The Hospitalist Company tested the effect of post-discharge call center outreach on readmission rates. Nurses at the IPC call center called 350,000 discharged patients from October 2010 through September 2011. During the calls, nurses talked through each patient’s symptoms, medications, home health services, and follow-up appointments. The nurses answered patient questions about discharge instructions and, if the patient had a serious medical need, contacted the patient’s hospitalist or primary care physician.
Nurses successfully reached 30 percent of patients, and it was estimated that the program prevented 1,782 avoidable readmissions over the course of a year.
Setting up a Post-Discharge Call Program
Research suggests that the best time for a post-discharge call is within the first two to three days after a patient arrives home. At this point, the patient has had the opportunity to settle in, fill medications, make follow-up appointments, and it is still early enough for a nurse call to make an impact. It’s likely many patients won’t answer on the first try, so nurses should plan to call more than once in this timeframe for most patients.
One way to improve the success of a call center program is to ensure that call center staff have the best number to reach each patient. Sometimes, that is not the same number as the patient’s home phone or cell phone number. IPC found that by asking patients for the best number to reach them or their caretaker, they were able to increase their successful call rate from 30 percent to more than 40 percent of discharged patients.
Customized Care Call Scripts
Providing nurses with diagnosisspecific scripts can help make care calls more efficient and effective, as many conditions have standard red flags nurses should check in on, such as weight gain after discharge for heart failure. Virtually any type of script can be easily created, including some common scripts for postsurgery, diabetic, and pediatric postdischarge calls. Setting up a unique script with detailed questions for each helps ensure patients understand discharge instructions, address any medication questions, and help ensure the patients are not experiencing symptoms that would cause them to be readmitted.
Nurses should also have access to physicians’ discharge notes to review patient-specific follow-ups. Physician discharge notes will need to be completed in a timely manner to give nurses the information they need for the calls.
To supplement the post-discharge nurse phone call, organizations can also use HL7 integration to receive discharge notifications and set up automated appointment reminder calls. This helps increase the likelihood that patients make it to their appointments, and receive the prescribed follow-up care.
Hospital readmissions are costly for both patients and healthcare organizations. In FY 2017, CMS withheld more in Medicare payments than ever before in response to hospital readmission rates. More hospitals were penalized than ever, and a higher average percent of Medicare payments was withheld from each penalized hospital.
To avoid the penalties and help patients to stay healthy at home, hospitals can leverage call centers and post-discharge phone calls with customized scripts to check in on symptoms, review medications and treatment plans, and remind patients of follow-up appointments. Studies suggest that such measures reduce the rate of readmissions. For hospitals, implementing a discharge call center program can help avoid or reduce Medicare readmission rate penalties. For patients, the program can improve their post-discharge care management and health.