CMS Releases Guide on Reducing Readmissions in Diverse Populations

When patients cannot understand discharge instructions, it's questionable whether it's fair to penalize them when patients return to the hospital.

With CMS calling for 30% of Medicare reimbursement to be tied to alternate payment models this year, the heat is on to find new ways to solve old problems. Reducing hospital readmissions, among minority and socioeconomically disadvantaged patients, is known to be a tough problem that hits hardest on hospitals that can least afford to lose federal dollars.

With that in mind, CMS has released its Guide to Preventing Readmissions Among Racially and Ethnically Diverse Beneficiaries, a 29-page document which summarizes strategies that hospitals can use to help reduce unnecessary readmissions. A 2004 study that helped propel the push to reduce readmissions found that 20% of fee-for-service Medicare patients were readmitted within 30 days, costing taxpayers $17.4 billion a year.

That study led to the creation of the Hospital Readmission Reduction Program and initiatives within accountable care organizations to zero in on transitions from the hospital, and care coordination once patients are home. Among minority populations with limited English proficiency, issues like not understanding discharge instructions, and generally poor literacy are huge barriers to preventing readmission for patients with congestive heart failure, raising questions whether it is fair to penalize these hospitals.

The report released yesterday covers a lot of ground, starting with 7 high-level recommendations:

· Have a strong radar. Knowing who is being readmitted and why, as well as the cost, is the first step to reducing readmissions. Demographics, education levels, language, and other factors must be known.

· Identify the target. Once the target population is found, the barriers to preventing readmission must be identified. Is there mistrust with the hospital?

· “Start from the start.” Preventing readmission must begin when the patient arrives at the hospital—not at discharge.

· Deploy a team. Keeping patients from coming back to the hospital involves more than doctors and nurses. CMS’ report said going beyond “the usual suspects” to reach nutritionists, pharmacists, substance abuse treatment providers or others is essential.

· Social support. Creating culturally appropriate systems that give the patient what he or she needs is essential—and easier said than done.

· Communication in high-risk scenarios. This involves the things that can go wrong—such as medication reconciliation, making sure the patient understands discharge instructions, etc. Cultural competency is essential.

· Community, coordination, continuity. Hospitals need partners in the community to meet behavioral and social needs. Is transportation available? Can the patient get to primary care doctor? Are groceries available? The report says, “Coordinating all these efforts will separate success from failure.”

“CMS has an important opportunity and a critical role in preventing hospital readmissions while promoting health equity among diverse Medicare beneficiaries,” said Cara James, director of the agency’s Office of Minority Health. The guide, she said, encourages hospitals to be proactive in preventing readmissions among those patients who present the greatest challenges.

The report was prepared with Massachusetts General Hospital’s Disparities Solution Center and the National Opinion Research Center at the University of Chicago.

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