When the nurse shows up her southeast Atlanta home each month, Sandra Alexander feels some peace of mind.
Without her help, Alexander’s 88-year-old mother who suffers from dementia and has faced multiple bouts of pneumonia would likely end up back in the hospital. Monica Beshara — a nurse practitioner with the nonprofit home health care service Visiting Nurse — gave her mother antibiotics and taught Alexander how to use a nebulizer, a device that delivers medicine in a mist that’s inhaled.
“She’s very patient with my mamma,” said Alexander, 63. “I can depend on her.”
Hospitals across Georgia and the nation are increasingly working with home health care providers, nursing homes and family doctors to better coordinate care beyond their walls to ensure discharged patients don’t end up back through their doors just days or weeks later.
While key to improving the quality of care, failing to reduce readmissions could soon put hospitals at risk of losing millions of federal dollars.
Avoidable readmissions of patients within 30 days cost Medicare more than $17 billion each year — burdening an already taxed health care system. Many readmissions — which can cost between $6,000 and $10,000 each — reflect inadequate discharge planning and poor follow-up care, industry observers say.
Starting next year, Medicare — the federal health program for people 65 and older — plans to stem costs by cutting payments to hospitals with excessively high readmission rates. The result could be a major financial hit to some hospitals, which are already facing lower reimbursements and can’t necessarily shift costs to the privately insured.
“Hospitals haven’t typically seen themselves responsible for what happens after (patients) leave,” said Alan Bier, chief medical officer at Gwinnett Medical Center. “That’s really what is changing.”
Medicare’s focus will initially center on some of the most at-risk patients with heart attacks, heart failure and pneumonia.
For patients, it means more help making sense of often overwhelmingly detailed lists of instructions to follow and medications to take after leaving the hospital. Medical staff also work more closely with social workers to help those who can’t afford medications or have no way of getting to the doctor for follow-up appointments.
“Patients will be supported to a far greater degree,” said Jeff Selberg, chief operating officer of Massachusetts-based nonprofit Institute for Healthcare Improvement.
Nationally in 2009, 16.1 percent of patients were readmitted within 30 days of discharge, according to a study of Medicare patients by The Dartmouth Institute for Health Policy & Clinical Practice. That compares to 16 percent in Atlanta and 15.8 percent in Georgia.
Many metro Atlanta hospitals hover around the national average for heart attack, heart failure and pneumonia readmissions, though some have done better, the government Hospital Compare website shows. Piedmont Hospital’s readmission rate for heart failure is 21.9 percent, compared with 24.8 percent nationally.
Gwinnett Medical and WellStar Health System are two Atlanta providers involved in pilot programs to develop transition coaches who guide patients through the discharge process and follow up with visits and phone calls.
A coach may go with them to the first doctor visit and follow up with phone calls for up to a month, said Robin Wilson, vice president of medical management at WellStar, which will kick its program off in January. Patients will receive their personal health records and be able to call coaches with questions, Wilson said. WellStar’s overall 30-day readmission rate, not just for Medicare patients, was 9.59 percent in fiscal 2011.
“American health care is trying to transition to where the individual patient is being held more accountable for their own health care,” he said.
Lifestyle changes— losing weight, exercising more, quitting smoking — will be major challenges, said Bier with Gwinnett Medical. Transition coaches can offer advice but patients must take personal responsibility, he said. Gwinnett’s Medicare readmission rate for the top three conditions is 18.3 percent with a goal of reducing it to 16.5 percent.
At Atlanta Medical Center, a dozen or so doctors have volunteered to do check-ups with patients within seven days of discharge. Nurses call patients within 3 days. A hospital committee reviews readmissions.
“What may have gone wrong,” said chief medical officer Pano Lamis. “What can we do better?”
Less than a year ago, the hospital began partnering with Walgreens to offer consultations with patients while still at the hospital to make sure new medications don’t conflict with prescriptions at home. And it began building strong connections with other providers, such as Visiting Nurse, to create better communication about patients’ conditions and needs.
Mismanaging medications is a top reason people end up back in the hospital, said Mark Oshnock, CEO of Visiting Nurse.
Patients of the home health service have 15 different medications on average. They have multiple doctors and might remember eight of 10 drugs if asked, Oshnock said. One of the first things nurses do is check medicine cabinets for conflicting drugs.
“It is a mess of a process,” he said.
At the suggestion of one hospital, nurses put magnetic white boards on refrigerators with reminders about medicines and what time of day to take them.
“You’re tired. You’re ready to go home,” said Naphtali Edge, director of transition management at Emory Healthcare. “Then you have someone give you 12 pages of information. It’s hard to remember all that.”
Emory launched a transition management program a little more than a year ago to identify patients at high-risk of being readmitted. Whether they have family support and cognitive limitations are some contributing factors.
Doctors, social workers, nurses and others meet to discuss patients’ needs after discharge. Transition managers call within 24 hours of discharge and then at least weekly, Edge said.
Patients will see everyone is on the same page, he said. “They’re truly getting everything they need to be successful at home.”
Starting in fiscal 2013, hospitals could face a penalty equal to 1 percent of total Medicare funding, followed by 2 percent in 2014 and 3 percent in 2015 if 30-day readmission rates are too high. The change reflects a larger push toward payments based on quality of care, overall outcomes and patient satisfaction.
It’s still unclear what readmission rates hospitals will have to meet to avoid penalties.
“We’ve got to do better, regardless,” said Emory assistant administrator Jennifer Schuck. “Bottom line, we need to do what’s best for the patients.”
Back in 30 days
Avoidable readmissions of patients within 30 days cost Medicare more than $17 billion each year. Each readmission can cost between $6,000 and $10,000. How Georgia hospitals’ readmission rates compare.
Nation 16.1 percent
Georgia 15.8 percent
Metro Atlanta 16 percent
Source: 2009 rate survey from The Dartmouth Institute for Health Policy & Clinical Practice
Learn more
Find out how the quality of care at your hospital matches up against others. Visit www.hospitalcompare.hhs.gov, where you can compare up to three hospitals at a time – checking out how they rank on patient safety and experience, readmissions and other quality measures.
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