Hospital Readmissions: Challenges in Pulmonary Medicine Practice - Part 2

The panel at the American Thoracic Society 2013 International Conference continued discussions that suggested high rates of hospital readmissions may be an indicator of poor initial treatment, or failure to coordinate care. Further, these rates, which varied dramatically from hospital to hospital, were often excessively expensive. Dr Colin Cooke, MD, MSc, in his presentation, “Will the Affordable Care Act Alter the Readmission Landscape?” says that the Affordable Care Act (ACA) will provide various means for improving readmission rates. In fact, Dr Cooke says the ACA offers “a unique opportunity to improve the quality of inpatient care and simultaneously reduce costs.”

Bundled payments are one path towards readmission reduction, according to Dr Cooke. Unlike the traditional fee-for-service model, bundled payments focus on the overall care for a specific condition. In fact, the Bundled Payment for Care Improvement Initiative (BPCI) reimburses healthcare providers (from hospitals, to outpatient care providers) based on the projected costs for episodes of care. Currently there at 48 clinical diagnoses eligible for bundling including COPD, asthma, and pneumonia. Dr Cooke notes that hospitals are able to share in savings if episode-costs below targets, and are penalized if they are above targets. In addition to bundled payments, Accountable Care Organizations (ACOs) will equally focus on incentivized payment models. In general, it appears that healthcare reform efforts are likely to reduce readmissions.

As bundled payments drive providers to work together, so may other collaborative efforts. Dr David Weidig, MD, said there are key interventions that can work together to successfully decrease hospital readmissions. For instance, BOOST (Better Outcomes by Optimizing Safe Transitions) at Society of Hospital Medicine is just one example of an intervention intended to reduce 30-day rehospitalization risk. BOOST includes several tools for addressing readmission risk including the “8Ps Assessment:” problem medications, psychological, principal diagnosis, polypharmacy, poor health literacy, patient support, prior non-elective hospitalization in the last 6 months, and palliative care. There is also a General Assessment of Preparedness (GAP), which evaluates patients’ status upon admission, and prior to discharge.

According to Dr Weidig, “incorporating assessment, intervention, and education into daily workflow” of a healthcare team is crucial to reducing rehospitalization risk. There should also be patient satisfaction training for physicians, including education about Teachback in patient understanding of transition care. Teachback ensures efficient physician-patient communication, because it requires the patient to explain what has been said to them. Additionally, even something as simple as a 48-hour post-discharge call from the physician has shown to contribute to reducing readmission rates.

Gulshan Sharma, MD, MPH says that the hospitalist role will also have an impact on post-discharge outcomes. Dr Sharma noted that hospitalists are defined as “a new breed of physicians…specialists in inpatient medicine—who will be responsible for managing the care of hospitalized patients in the same way that primary care physicians are responsible for managing the care of outpatients.” Services they provide include care of critical patients and development of hospital practice guidelines. Dr Sharma suggests that hospitalists will play an increasingly important role in value-based purchasing, as well as providing support for innovative care models in patient transition.

Improved engagement of patients in their care plans will ensure better outcomes in reducing rehospitalization. Engagement requires involvement from all players on a healthcare delivery team, and a focus on reducing readmission risk must be built into the daily work processes.
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