Written by Kim Krisberg
In Seguin, the 125-bed Guadalupe Regional Medical Center first began targeted efforts to reduce readmissions in 2012, and, as with many Texas hospitals, the results have been positive. From 2015 to July 2017, the hospital went from an overall readmissions rate of 9 percent to just below 6 percent.
Rhonda Unruh, vice president of quality at GRMC, however, said that pushing down the readmissions rate even further will be particularly challenging as providers grapple with forces outside of the hospital’s control that cause patients to return for care.
“Our readmissions focus now is high-risk, complex patients,” Unruh said. “As we deal with a population that is living longer and living with chronic illness, that number of high-risk, complex patients will only continue to grow.”
Incentivized to launch a system-wide evolution to reduce preventable readmissions, hospitals have overhauled provider training, engaged families and community organizations, and redesigned daily operations. Since its passage in 2010, the Affordable Care Act has focused attention on reducing readmissions for Medicare beneficiaries with select conditions. The Medicare Hospital Readmissions Reduction Program seeks to reduce 30-day readmission rates after initial hospitalization for heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, elective hip or knee replacement, and coronary artery bypass graft. Hospitals that exceed national readmission averages face payment reductions on total Medicare discharges of up to 3 percent. Nationwide in fiscal year 2017, hospitals sustained Medicare payment reductions of more than $525 million.
Through an array of strategies — such as enhancing discharge instructions and coordination with primary care providers — hospitals have reduced readmissions. A 2016 New England Journal of Medicine study of nearly 3,400 hospitals nationwide found readmissions for select conditions declined from 21.5 percent in 2007 to 17.8 percent in 2015. However, the study noted that while readmission rates declined quickly during the early years of the ACA, that decline has plateaued in recent years.
For Texas hospitals, overcoming that will require a much deeper dive into the social factors that impact readmission rates.
A Complex Challenge
Today, every patient hospitalized at GRMC is assessed for readmission risk. A screening tool covers a number of indicators, including recent hospitalizations, chronic illness, medication regimens and social supports. If a patient is determined to be high-risk for readmission, he or she is referred to a nurse to discuss enrollment in the hospital’s Transitional Care Program, which follows patients for 30 days post-discharge. Unruh said most patients who get referred decide to enroll, with the program now working with nearly 400 patients a year.
The follow-up — which could extend beyond 30 days if needed — includes one home visit as well as weekly phone calls to reinforce discharge instructions, check on a patient’s health, ensure medications are being taken properly and answer any questions. Many times, Unruh said, the check-ins turn into resource assistance calls, such as helping patients make doctor’s appointments or arranging transportation.
“Many of our readmissions often are the same patients,” she said. “Helping them get to a state of disease management where they can live their lives outside the hospital walls has been the biggest win for us.
“It’s challenged us to think about how we fit into a new health care delivery model —to think about ways to improve the lives of our patients,” Unruh continued. “In the shift to population health, (readmissions reduction) has been one of the important cogs in the wheel.”
But as readmissions rates plateau — which Unruh agreed they have — hospitals may find their capacity to impact readmissions risk factors can only stretch so far. One possible solution includes finding partners already working in the community to help ease the intensive work required within readmissions reduction programs.
Such partnerships have been key at Medina Healthcare System in Hondo, a 25-bed critical access hospital, which began targeting readmissions in 2015 as part of its quality improvement efforts, according to Billie Bell, the hospital’s chief nursing officer. While being a critical access facility exempts the hospital from Medicare readmissions penalties, Bell and the MHS team still set out to reduce readmissions. They gathered baseline data in late 2015. With an overall readmissions rate of 13 percent, they set a goal of reducing 30-day readmissions by 10 percent by September 2016.
“Readmissions aren’t just a hospital issue — they’re a community issue and a social issue,” Bell said. “We knew we couldn’t do this by ourselves.”
The hospital reached out to the Wesley Nurse Program at Methodist Healthcare Ministries of South Texas as well as to their local emergency medical service, Community EMS. The three organizations together devised a plan to help keep patients healthier at home. And the plan, which Bell refers to as a “community approach to care,” is showing signs of success.
Medina patients at high risk for readmissions can work with Wesley nurses to access social supports, such as prescription drug assistance, while Community EMS visits patients in their homes, often providing patients with transportation to a pharmacy or grocery store.
As a result, Medina has reduced its readmission rate to about 5 percent in less than a year.
“It tells me that people in our program are accessing the resources they need and getting the education they need to better manage their conditions,” Bell said. “We thought it would work, but we had no idea it would be this successful.”
Beyond the Hospital Walls
As a nurse, Diana Ruiz spent years caring for patients at the bedside. But she admits she rarely gave much thought to how her patients could stay healthy and out of the hospital.
“To be honest, I didn’t think about what happened beyond the hospital walls,” said Ruiz, director of population and community health at Medical Center Health System in Odessa. “But the shift toward a population health mentality has shown us that we were wrong — that we do have to consider what happens outside the hospital’s walls. We have to own it.
“We’re always fighting the social determinants of health,” Ruiz said.
At Odessa’s Medical Center Health System, which admits 14,000 patients annually, efforts to reduce readmissions began in earnest in 2013 in response to both the Medicare HRRP as well as Texas’ Medicaid 1115 Transformation Waiver, which financially incentivizes health care improvements through its delivery system reform incentive payments program.
At first, Ruiz said, the effort included two distinct teams: one on the inpatient side that assessed nearly every patient hospitalized for readmissions risk, and another on the outpatient side that followed up with patients for 30 days after discharge.
However, taking responsibility for patient outcomes weeks after discharge was a marked difference from previous protocol. Ruiz described it as a difficult shift in thinking for many hospital staff. Initial readmissions reductions came in below expectations.
“The efforts were strong, and we had good intentions, but we didn’t have amazing results,” she said. “We just didn’t have it quite together.”
In March 2015, Ruiz paused the program to determine what was missing. She and her colleagues began reaching out to hospitals where readmissions reductions programs had achieved greater success. Examining operations at hospitals in Dallas, El Paso and Lubbock, the team learned about strategies they could bring back to Odessa. In July 2015, Ruiz re-launched the effort in a high patient turnover area — the hospital’s telemetry cardiac unit — using a “2 Plus 2” model: two care coordinator nurses plus a community nurse navigator and a social worker or care transition coordinator. In other words, the inpatient and outpatient teams responsible for reducing readmissions were completely merged, establishing a continuous collaborative effort aimed at helping patients stay healthy at home.
The process begins with an inpatient assessment that analyzes risk for a readmission. If the patient is at risk, he or she is referred to the outpatient team, which follows the patient for at least 30 days and often, much longer. Patients receive critical follow-up information on how to care for their conditions and prevent further complications, and the community health team helps them find and access the social supports that enable better health, from prescription drug assistance programs to Medicaid enrollment to something as simple as a bus pass for patients without their own transportation.
The revamp was a success: To date, the average length of stay at the Odessa hospital has dropped by a solid day. Readmissions have dropped for patients with acute myocardial infarction, heart failure and joint replacement; the hospital’s readmissions penalties were cut in half between fiscal years 2016 and 2017. Today, four units within the hospital participate in the full 2 Plus 2 model, Ruiz said, with hopes to expand it across the hospital.
“We’ve absolutely transformed health care in this hospital,” she said. “We want to make this program so valuable to the community, our patients and the hospital that we can’t continue to do our work without it.”
Ruiz said continuing to reduce readmissions will certainly get tougher — “but that just means we have to get smarter, quicker and more creative.”