Following is the full conversation of Episode 5 of the Hospital Readmissions Reduction Podcast.
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In this post, you’ll learn:
- How income and zip code can be predictors of potential readmissions.
- Tools a hospital can use upon admission to assess a patient for readmission risk.
- How the day of discharge and discharge disposition affect readmissions.
- How can a hospital identify which facilities are sending patients back more than others and what can they do with that information.
|Michael: Welcome to the Hospital Readmissions Reduction Podcast brought to you by BESLER Consulting. This is the podcast for hospital leaders seeking insights and strategies they need to help reduce readmissions at their organizations. I’m Mike Passanante, your host for this podcast, and I think you’re going to enjoy today’s session. We’re going to be talking about patients and looking at the characteristics that some patients may have that make them potential candidates for readmission to the hospital. Once again, I’m joined today by Dr. Edward Niewiadomski. Dr. Niewiadomski has over three decades of experience in direct patient care and healthcare administration. He’s the former Senior Vice President of Medical Affairs and Chief Medical Officer for a community acute care facility in New Jersey. Dr. Niewiadomski, welcome.|
|Dr. Niewiadomski: Yes, thank you, Michael, and thank you for having me today.|
|Michael: Yes, absolutely. We’re going to dive right in. Can you just tell me, in your experience, what are some of the characteristics associated with patients who are likely to readmit?|
|Dr. Niewiadomski: It’s pretty obvious to talk in terms of the amount of comorbidities or disease burden a patient has. And what I mean by that, if a patient has multiple comorbidities, certainly, the core measures – AMI, heart failure, COPD, pneumonia and total joint hip and knee replacement – if a patient has comorbidities associated with one of those core measures, they have a higher likelihood of an unplanned readmission. In addition, comorbidities and chronic diseases also go hand in hand with the amount of number of medications a patient is required to take on a daily basis, so the number of medications a patient takes is associated with a higher risk of readmission. Additionally, other things such as the number of emergency room visits in the last six months of the index admission clearly shows a patient with a deteriorating disease process, or perhaps even a pattern of non-compliance with either diet, exercise, or medication patterns. Other things, such as socioeconomic issues, socio-demographic issues, all play a role in a patient’s likelihood of readmission.|
|Michael: In some of the literature, gender is indicated as perhaps one factor associated with readmissions. How does that play in?|
|Dr. Niewiadomski: I’ve seen that myself recently in the literature, and CMS does define gender as a risk for readmission. However, if you look at the total line up of risk factors, gender being on the list is more towards the bottom of the list. And I think what the literature is trying to point out is that if you look at the differences between men and women – male-female patients – female patients have a tendency to be more compliant. They are more compliant with their medications, they tend to be more compliant with diet restrictions – for example, for heart failure patients, sodium intake, fluid intake, those type of things – and they are more surveillant and more aware of what’s happening on a day-to-day basis of their health. If they notice a weight gain or fluid retention, those types of things, they’re more likely to report that to their physician and seek care and intervention on those issues. Where us guys, we tend to be a little more complacent in areas, may not be as compliant with medications, we may miss a dose of medication – not think anything of it – may liberalize fluid and liberalize salt and sodium intake, and as a result, we get ourselves into problems much more often and more frequently than our female counterparts.|
|Michael: Two things that haven’t come up so far in our conversation that are characteristics, but maybe not characteristics per se are income and zip code. Those are two things that you can measure about the patients that you see. How do you get that information, number one, to analyze that, and really, how do you use it to shape your readmission reduction strategies?|
|Dr. Niewiadomski: Again, the literature surrounding readmission reduction and readmission risk stratification clearly point to socioeconomic and socio-demographic issues. A couple of issues kind of come to mind when we look at this data. One is clearly an access to health care. Patients on the lower end of the socioeconomic scale have more difficult times in accessing medical care. Transportation issues come into play, access to public transportation may be a problem or limited, so that’s one thing. Also access to medications – once discharged from the hospital, some patients may find it difficult to make their way to the pharmacy to get prescriptions filled. Getting there is a challenge at times, and actually paying for these medications is a challenge so the organization that– the hospitals need to be aware of these issues and need to start some planning during the discharge-planning process of helping patients access not only their physician and clinics, but also accessing their medications and finding ways to assure that patients have their medications available to them upon discharge.|
|Michael: You just talked about discharge. What are some of the tools that a hospital can use when a patient comes to the hospital, when they’re admitted, to stratify them and help understand whether or not they’re a candidate for potential readmission?|
|Dr. Niewiadomski: We have talked about risk stratification tools several times in our education processes around the readmission reduction programs. Risk reduction tools and risk reduction stratification tools are readily available. One of the tools, the LACE Score, L-A-C-E, is very widely discussed in the readmission literature. And what LACE stands for is, the L stands for length of stay of the index admission, the A stands for the acuity of the admission – whether the patient came into the emergency room or was a planned admission on the index admission – the C stands for comorbidities – and that utilizes the Charlson Comorbidity Index, which speaks to the presence or absence of other comorbidities, to the reason why the patient in the hospital – diabetes, hypertension, hypercholesterolemia, those type of things, or underlying malignancies. And the E stands for the number of ED visits the patient has had within six months of the index admission.|
|So we need to calculate this, and we can do this upfront on day one of the admission. And actually, when you speak to the discharge planning process overall, discharge planning actually starts day one of the admission. So we need to be looking at what is going to be available to the patient upon discharge, and all the parameters of a good discharge plan need to be in place from day one. But calculating the LACE stratification score and putting that on the medical record, so that the entire clinical team will have that available to them during the course of the episode of care, we’ll then look to whether or not a patient needs to have additional resources available to that patient upon discharge.|
|The LACE Score came out of the Canadian Medical Association in their publications out of Ottawa. They demonstrated that for a score of ten or greater a patient is in a high-risk category for readmission. And an interesting point came out of that study – I think the study was over around 48,000 patients – that for every one point of the LACE score that results in an 18% higher likelihood of an unplanned admission within 30 days of the discharge, so clearly a well-studied risk stratification tool for readmissions and one that we have seen many organizations utilize in their readmission reduction strategies.|
|Let me pivot for just a second. One of the things that we’ve noticed, I think here at Besler and the data that we’ve analyzed for many hospitals and also out there really in the literature, is the day of discharge. And sometimes the day of discharge seems to be at least a potential indicator for potential readmission. Why is that and what is a hospital supposed to do with that information? How do they use that?|
|We have identified certain days of the week that, for some reason, are yielding in higher readmission rates. And if you look at the discharge process, those patients that are discharged towards the end of the week – meaning Thursdays and Fridays, especially Fridays – have a higher readmission rate than those discharged in the beginning of the week. And if you look at what happens in the hospital, if a patient is discharged at 4:00 on a Friday, most of the time the doctors are making rounds and planning discharges for Thursday and Friday to avoid having a huge census going into the weekend – especially if they’re looking towards using physicians to cover their services for vacations, or holidays, or weekends, those type of things, that they don’t want to burden the covering physician with additional patients to monitor in their absence.
So a discharge may be done prematurely or may be done hastily towards the end of the week, and that will yield a higher readmission rate early on either within the beginning of the subsequent week on that index admission. If you look at the staff that’s available during the latter part of the week, we’ve found that the discharge process that occurs on a Friday afternoon may be not as complete or thorough, which then yields to problems in the post-discharge period. One last thing, if a patient is discharged on a Thursday or Friday, there’s no way they’re going to go see their attending physician in his or her office within two or three days of discharge, so now the patient is left at home during a longer period of time and that yields the higher potential for the patient to run afoul of their regimen and their management recommendations at home.
|Michael: Certainly, heading into the weekend that makes sense. There could be some potential issues that occur that are just unavoidable because of the time of the week, but that’s not always true. There could be other instances where there’s a different day of the week that there’s a strange trend or something that’s there. That could be a breakdown in a protocol or some other issue that you could potentially identify, correct?|
|Dr. Niewiadomski: Yes, and actually when speaking to the discharge process, one of the most important aspects of the discharge plan is the medication reconciliation – making sure the patient has a clear understanding of the medications that they’re taking at home – what each medication is, what it looks like, and what it’s meant to treat, the dosage, the amount, and how frequently they’re taken – once a day, twice a day, or three times a day and such. And there’s been studies done, and one of them in particular is out of Yale that appeared in circulation, and that focused essentially on heart failure. They identified six strategies that organizations could implement to reduce readmissions or unplanned readmissions. They found in the study that they had a 2% drop in readmissions, and that doesn’t sound like a lot, but that 2% could really be enough to totally mitigate a hospital’s readmission penalty. But one of the important strategies – one of the six – was found that nurses did the absolute best job of working with patients and going over their medication regimens and the medication strategies. They looked at various providers – physicians, pharmacists, nurses – but they found that nurses had better outcomes. And patients, when they’re queried about their medication regimens, had a better understanding when the nurse went through that with them rather than any of the other providers listed. So rather interesting, so get your nurses to sit down with the patient just before discharge and go over their medications. It’ll prove very beneficial to both the patients and your organizations.|
|Michael: That’s a great thought. I’d like to get your thoughts as well on the concept of discharge disposition. It’s certainly an important concept. In your mind, how does a hospital decide where to send a patient, once they’re done their treatment of care in the hospital?|
|Dr. Niewiadomski: Actually, I just want to make a point of clarification. It’s actually physicians and the caretakers that decide where a patient goes. But the physicians, when they look at disposition for a patient, the most common disposition that we see in the hospital, if you look at the data, is patients get discharged to home. However, there’s another– part B of that is patients can be discharged to home with home care through a home health care agency. And then, certainly, other patients might go for a period of rehab in the post-discharge period. And that rehab, we kind of think rehab for just total joint replacements, those type of things, but patients are very amenable to rehab for other chronic medical conditions. Patients can be admitted to the hospital, say, for heart failure or for having a myocardial infarction, pneumonia, COPD. They can go for rehab for several days or even up to two weeks post-discharge, and that proves to be very beneficial to the patient to actually get them back on their feet and get them to a point where they can actually care for themselves and go through their activities or daily living fairly easily when they find themselves back in their home setting.|
|One thing that we identified using our readmission analytic tool is a fair number of patients that are discharged to home, have orders and are billed to have home healthcare upon home never receive that home healthcare implemented. Now it’s hard to figure out. We only have the data from numbers, but l think if l were a hospital organization, l’d want to know that and figure out what’s going on, why a patient who was ordered to have home healthcare at home did not receive it, and we find that patient – coming back to the hospital – becomes an unplanned readmission, and then becomes of our data and calculate into our readmission penalty. So something that patients at the hospital need to be aware of, that even though we may order something, the patient may not always enjoy the benefit of that order.|
|Michael: Obviously, in addition to home healthcare, you have other options, you’ve got SNIFs, you have other types of facilities that patients can get admitted to. Let’s talk about care coordination plans. What are some best practices that a hospital can implement to ensure that there’s a good transition of care from the acute setting?|
|Dr. Niewiadomski: A lot of work has been done in the discharge planning and the coordination of care between the acute care setting and other – a lot of programs out there identified already, well-studied. There’s the RED Program – the re-engineering of discharge planning – which came out of the Boston University Medical Center – that redesigns that discharge planning and makes sure the patient gets the adequate care in the post-discharge period. They were actually using nurses to call patients for follow-up care. They actually transitioned using nurses to actual virtual nursing, where the patient would get a call, and it was digitally an electronic call. They found that that was just as effective to making sure patients were on their prescribed care plans at home, number one, and actually led to about a $425 savings per patient in overall care of that patient in the long run. Other programs, like the BOOST program that came from the Society of Hospital Medicine – and BOOST, B-O-O-S-T, stands for Better Outcomes through Optimizing Safe Transitions – just as you mentioned, a transition of care from acute care setting to yet another setting, that is shown to have very good results in reducing unplanned readmissions.|
|Dr. Niewiadomski: But I think the commonality and the common elements of a lot of these discharge planning and safe transition programs really require programs and initiatives to be an enterprise initiative. This touches all aspects of the hospital – pharmacy, discharge planning, case management, the physicians, the medical staff – and there needs to be a sense of awareness throughout the entire organization that these readmission reduction initiatives and strategies are really critical to the patients, number one, but also to the financial stability of the hospital. And if you’ll look at what happens in those care plans, a lot of programs and hospitals have initiated committees and have meetings between the staff at the hospital and the staff at some of these destinations – the home health agencies, number one, some of the SNIFs, as you mentioned – so a lot of these are common committees that oversee quality and coordination of care, and they are very effective in reducing unplanned admissions.|
|Michael: It makes sense. Not all facilities are created equal. How is a hospital, number one, supposed to identify which facilities are returning, essentially, patients to the hospital? And then what are they supposed to do with that information? How do you make that relationship better so that you can reduce readmissions?|
|Dr. Niewiadomski: Again, it comes back to having a fluid and manageable database to track these issues because your point is spot on. You need to know where you’re– the origin of those readmissions. If they’re coming from home, that could lead to certain discussions as to why this is happening. But if they’re coming from a skilled facility or a home health agency had not gone out to provide care, we need to know these things. So we need a good database to identify these opportunities for improvement, number one. And once we identify the source or the origin of these readmissions, then we can go back and figure out what happened that led to their readmission. Either it was care not being implemented timely. Orders – if it’s at a SNIF – perhaps orders or medications arriving that are specific for that patient, there may be a delay in initiating care plans. There may be a delay in the physicians’ rounding on those patients back at the skilled facility. From the home health agency, it may be a delay or a timeliness of when that home health agency – say that three times fast – the HHA responds to the patient upon arrival back at the home. So every aspect of care needs to be delineated, and we need to identify where the shortcomings are, so we can then refocus our readmission reductions strategies.|
|Michael: One final question for you, and then we’ll wrap this one up. Just give me a short list. What are the most important things a hospital can do to help a patient from rebounding?|
|Dr. Niewiadomski: Have a solid provision of care during the inpatient stay is number one. Good communication with the patient in that discharge planning upon discharge, making sure the patient has an understanding of the problems or chronic medical conditions that they’re experiencing, the care that was provided during that episode of care, a good understanding of the medications and diet and activity levels the patient should adhere to upon discharge. And most important, making sure they have a sound and definitive follow-up appointment either in the medical clinic at the hospital or with the patient’s primary care physician in a timely fashion – the single most important factor.|