Reduction Of Hospital Readmissions Hany Salama, MD Diplomat ABIM IM Hospice and Palliative Care Sleep Medicine

FACTS FROM NATIONAL HEALTH INTVIEW SURVEY Million persons were limited in their usual activities due to one or more chronic health conditions Prevalence of activity limitations due to one or more chronic conditions increases with age (7% under age 12, 17% age and 43% of people age 75% or older)

One in five discharged patients will be re-hospitalized within 30 days 50% will not have interaction with a clinician prior to readmission* *Jencks S., et al. “ re-hospitalizations among patients in Medicare fee for service Program” New England Journal of medicine 2009

Geriatric population has the highest readmission rate The critically ill constitute 35% of readmission in one month. CHF and COPD exacerbations are the leading causes of readmissions by diagnosis Patients discharged to nursing home are less likely to be readmitted in one month compared to those who go home

Inappropriate Care During Hospitalization Resolution of main problem Increase temperature IVF on discharge day Unaddressed abnormal tests Absence of documentation of discharge planning

Inappropriate care During Hospitalization Medication errors Medical errors Early Follow up with PCP Inadequate education of caregivers

Complications Of Sending Patients Back and Forth To Hospital from LTC Increase risk of delirium Medication errors Falls Infections Death

First Conditions For Initial Penalties Pneumonia Heart Failure Myocardial infarction

Transition Programs Post Hospitalization Physician Nurse Practitioner Care Manager Social worker Nurses Pharmacist Nutritionist

Strategies to Reduce Re-hospitalizations Service delivery reform Financing reform Medicare and Medicaid integrated service and financing reform

Service Delivery Reform Care coordination between hospital and post hospital settings and providers Education patient, family, and caregivers Patient monitoring post discharge Some studies showed 39% lower total costs of care

Service Delivery Reform Some programs begin from day of admission Arrange follow up appointments with physicians Arrange follow up tests Teach patient to identify and deal with emergency situations Expedite transfer of discharge summaries to outpatient physicians

Service Delivery Reform Arrange post discharge services Post discharge phone calls Reconcile discharge plans with national standard guidelines Information technology availability Create interventions that address cause of readmission

Service Delivery Reform Establish Home Based Primary Care Medical Home Models Hospice and Palliative Care Use home telehealth Incentive to improve patient compliance

Financing Reforms Going away from fee for service model Paying providers on good and poor behavior Episode of care starts on day of admission and ending when patient is not in hospital or SNFs for 60 days Under new payment method, the difference between Medicare payments and provider are retained by hospital and post acute providers

Integrated Financing and Delivery Models The Program of All Inclusive Care for the Elderly (PACE) Medicare Special Needs Plans

Reason For Readmission from Nursing Homes NH ill equipped to deliver the appropriate care LTC providers lack sufficient information about beneficiary’s care needs LOS in Hospital is too short Clinical competence of nursing staff

Measures to Reduce Re-hospitalization from LTC Educating CNAs about disease symptoms Provide periodic clinical courses to nurses to recognize signs and symptoms disease processes Obtaining adequate records from the Hospital Do in house labs Ensure drawn lab results are reported timely

Measures to Reduce Re-hospitalization From LTC Consider having EKG machine More rounding visits by the SNF providers Nurses to round with providers to understand patient needs more Staff visiting patient homes to evaluate risks of possible readmissions Pharmacist to review any new medications for interactions

Measures to Reduce Re-hospitalization from LTC Understand disease process and aggravating factors Adequate nutritional support Adequate pain control Monitor for Depressions