Hospitals are under the gun, and insurers can help them — and themselves as well. Beginning in October 2012, hospitals will lose money for readmissions of Medicare beneficiaries within 30 days for a problem that was supposed to have been fixed at discharge. Initially, pneumonia, acute myocardial infarction, and congestive heart failure will be the focus, but policymakers expect to add other conditions, such as COPD and stroke, to the list by 2015.
The hospital readmission problem, huge as it is, is part of an even bigger health care problem: poor transitions of care. “Insurers are well aware that they are throwing huge payments at patients that didn’t get a medication list, at primary care physicians who didn’t know their patient was discharged, at skilled nursing facilities that didn’t know a diagnosis, and at families that are clueless,” says the consultant Jaan Sidorov, MD, a member of MANAGED CARE’s editorial board. “From a risk-bearing perspective, mishaps in the transitions — from ER, to inpatient, to ICU, back to inpatient, to skilled-nursing facility, to home, and all the permutations — are where poor communication and coordination result in huge amounts of unnecessary spending and patient harm.”
That the 30-day mark is so much the focus is no accident. “If you look at the literature and you look at trends with readmissions, there is a bell curve for the first 30 days,” says Janet Tomcavage, RN, MSN, the vice president for health services at Geisinger Health Plan. “It starts to go up on day three or four, peaks from day 15 to day 16, and then comes back down. But there’s still this elevated risk of readmissions for that first 30 days post-discharge.” (For more on how Geisinger handles transitions, see “Geisinger’s Embedded Nurses Improve Transitions,”.)
The best part about smoothing transitions of care is that it is a problem that can be solved right away. “You are not going to have to throw tons of dollars to do this,” says Cheri Lattimer, the executive director of the National Transition of Care Coalition. “And you’re not waiting for new technology or new medication. You’re trying to figure out, How do I communicate better.”
Medical directors at health plans, says Lattimer, should ask themselves how transitions of care take place among providers in their networks. “We’re talking about every time the patient and his family and caregiver move from one level of care, one practitioner to the next,” says Lattimer.
Plans should review how transfers from the PCP to the specialist are handled. “Are there any type of measurements that the health plan is actually looking at? Is that information sent to that appointment prior to that patient showing up? When they see the specialist, are the patients prepared to share information? Is there any type of report that goes back to the PCP? In other words, are they communicating to each other? In those two visits, from primary to specialty, there is a chance that there is a medication change, there is a treatment change, or that there are other services to be provided with other specialists.”
Chad Boult, MD, MPH, MBA, a professor in the department of health policy and management at Johns Hopkins Bloomberg School of Public Health, led a randomized controlled trial of a program called Guided Care, in which smoothing transitions played a prominent role.
“Transitions are very important, as evidenced by the priorities the nurses were given,” says Boult. “They were told that when their patients were in the hospital, that was their top priority. They would visit them in the hospital, but most important, they would make a home visit the day of, or the day after, the person went home from the hospital.” (The nurses in Guided Care coordinate the treatment for multimorbid older people.)
The nurses made sure that everyone understood what medications to take and what food to eat. “They also got them back to see their primary doctor within days so that the doctor who knew them could pick up the reins again.”
Nutrition plays a vital role in readmissions, says Joel V. Brill, MD, the chief medical officer of Predictive Health, a population health management company. Brill cites a 2009 study in the New England Journal of Medicine. “That analysis shows a number of conditions where nutrition-related or metabolic issues contribute to readmissions,” says Brill. “There are a significant number of seniors who have limited resources.”
Boult adds that “It is important to focus on the right patients. In other words, not every patient who goes home from the hospital needs one of these nurse coaches. The ones who need help are the ones receiving complex care, the ones that are at greatest risk for post-discharge chaos and early readmission because they’re confused about what to do. It’s targeting — key word there — identifying the right patients while they’re in the hospital and investing transitional resources in them. Then you get cost savings. If you were to assign transition coaches to everybody in the hospital, there would be no cost savings.”
While keeping up with what’s going on with every member of a plan is an admirable goal, insurers must also be aware of how such an effort might affect premiums, says David Clark, RPh, MBA, vice president for pharmacy benefit management at the Regence Group, a Blues plan that covers two million people in Oregon, Washington, Idaho, and Utah.
Many health plans have discharge planners, Clark notes. “That’s fairly common,” he says. “Whether we’re hitting all of the right ones yet, or not, I don’t know. All plans try to use their data to try and figure out which patients have the highest probability [of readmission]. Our systems use models to identify which patients have the highest risk and we do focus on those. As we work with hospitals, we need to share our models and methodology.”
“The at-risk person might need a home visit in three days, while the person who isn’t at risk might not need a visit for 30 or 60 days, or at all,” says Brill.
Health plan medical directors in particular must also be aware that in this litigious society, providers may hesitate to pinpoint the person responsible for a poor transition of care. “Short of malpractice reform, this type of concern will never go away,” says Brill.
Glen R. Stream, MD, MBI, president-elect of the American Academy of Family Physicians and a practicing family physician, says health plans can help by ensuring that information keeps one step ahead, that the patient’s next physician will have everything he needs to continue treatment.
“The patient might not have an appointment to see me for a week, but the day after his discharge, he has a question or an issue,” says Stream. “If I don’t have the information in the moment, I’m impaired in my ability to give the best care.” (For more on the AAFP’s reaction, see “Long Way to Go?” below.)
Sam Ho, MD, executive vice president and chief medical officer for UnitedHealthcare, says that his plan takes predictive modeling to the patient level, looking at a patient’s hospitalization and claims history.
“There is also a component related to risk scoring and stratification of patients who are already in the hospital who are most at risk for hospital readmissions, and we use both of those data sets to produce more intensive and comprehensive discharge planning while patients are still in the hospital,” says Ho. “This is all part of a readmission reduction program that we started in February 2008. We intensified it in early summer about a year ago to 2010.”
To determine who may be at most risk for readmissions, the plan has devised a scale that’s based on the top 10 diagnoses that point toward readmission. Both the predictive modeling and the risk scoring work well, says Ho, especially for Medicare patients.
Brill says, “What the plan brings to the table is the ability to use data to stratify the patients, identify who’s at the greatest risk, and work collaboratively with the providers to focus their collective efforts on those who are the greatest risk for readmission. That helps you to utilize your resources most effectively.”
Every regional medical director knows who his best physicians and hospitals are, says Brill. “You know which are innovative and which are responsive to new thoughts and new ideas — such as having a care coordinator in the physician’s office who does patient outreach. You know which provide linguistically and culturally specific educational programs, or provide medication therapy management, or maintain hours at nights or on weekends to accommodate working people,” says Brill.
“You know which of them are working with you to help their patients throughout the transitions of care.
“Focus on those systems, those hospitals, those physician groups that are most receptive and work with them to create your pilots and demos so you will have your success stories to share with others.”
Commit to those partners who seem to get it, in other words. “Start small and launch a pilot,” he says.
Blue Cross Blue Shield of Michigan, along with the Society of Hospital Medicine and the University of Michigan, created the project BOOST (Better Outcomes for Older Adults through Safer Transitions) model. It seeks to cut back on hospital readmissions, but lately the mission has expanded, according to Tom Leyden, director of the value partnerships program at Blue Cross Blue Shield of Michigan.
“In the past, the BOOST program was primarily looking at the hospital setting with the hospital looking at its own discharge policy,” says Leyden. “What we’ve done in Michigan was expanded that to include the primary care physician setting.”
Review claims, Lattimer suggests. Talk to the heads of various departments, whether it’s customer service, case management, quality management, or utilization management. What do they see as the big gap in variance during a transition? “There are in every health plan folks who know the biggest gaps and barriers that they’re struggling with,” says Lattimer.
Clinical administrators at health plans can take an incremental approach to addressing the transitions of care.
“Everything starts small, and there are things that you can do now,” says Brill. “There are going to be forward-thinking doctors and facilities in your provider networks that clearly understand the opportunity. Reach out now to them and work with them. At the end of the day, building relationships, building trust, and building a culture that can really improve things for all the stakeholders — then we all can do well by doing good.”
Patients in a transition-of-care program at Geisinger Health Plan will get a call from a nurse manager within 24 hours. The nurse will go over four or five points, of which one is definitely the most important, says Janet Tomcavage, RN, MSN, the plan’s vice president for health services.
“One of the biggest opportunities that we’ve uncovered in transitions of care has been several challenges around medications. Sometimes important medications that the patient should be taking are omitted.”
At other times, brand drugs are substituted for the patient’s usual generic medication and the patient goes home and takes double the dose, thinking they are different drugs.
“Or sometimes patients won’t take new medications until their primary care physician blesses the new medications,” says Tomcavage. “Our nurse sits in the primary care office, working with primary care and the patients to make sure we get them on the right series of medications in that transition.”
Teri Treiger, RN, president of the Case Management Society of America, recalls that until the recent emphasis on reducing needless hospital readmissions, there was practically no oversight of what medications patients were taking at home.
The pharmacy staff can help with the duplication problem. “They can perform a medication review,” says Treiger. “Looking at both underutilization and overutilization is a fairly standard strategy for pharmacy benefits nowadays. Also, looking at individuals who are prescribed five or more different medications.”
Often it’s a pharmacist at the health plan or a pharmacy who is in a position to alert the primary care physician or prescribing physician to the situation.
“The first step is direct contact with the providers,” says Treiger. “However, it is important to keep in mind that providers are contacted by multiple sources — payers, hospitals, specialists, vendors, among others. Each one of these contacts requires some kind of follow-up and managing this volume of interaction is challenging, and near impossible.”
David Clark, RPh, MBA, is vice president for pharmacy benefit management at the Regence Group, a 2-million- member Blues plan that covers people in Oregon, Washington, Idaho, and Utah.
Right now, the health plan is able to track patients who, for example, have a heart condition, and those with other complexities. “Then we try to use some kind of coordination between medical and pharmacy to make sure the medications are taken care of as well,” says Clark.