What does it take to keep the sick and elderly from spinning through the revolving doors of the nation’s hospitals? Answer: A village.
Although avoiding unnecessary hospital readmissions is typically framed as an issue for hospitals, it’s more accurately seen as an issue for entire communities. One in five Medicare beneficiaries now end up back in the hospital within 30 days of discharge, at an estimated cost of more than $17 billion annually. It will take local health care communities working together to keep more of those patients at home, or at the very least, in a less acute care site.
A recent report from the Robert Wood Johnson Foundation, The Revolving Door: A Report on US Hospital Readmissions, profiles cases that make the point.
- Eric was discharged from the hospital after being treated for chronic obstructive pulmonary disease, yet he didn’t fully understand how to use his inhaler and continued to smoke. He soon ended up back in the hospital. Whose responsibility was it to make sure that the cycle didn’t repeat itself? As it happened, his health plan eventually flagged him as at risk for readmission and he received regular follow-up care, such as smoking cessation classes, and having to answer five questions a day from his care team so they could monitor his breathing.
- Barbara, who has type 2 diabetes, was hospitalized with her blood sugar out of control, and then discharged without understanding how to administer her insulin properly or maintain an appropriate diet. Like Eric, she was one of the 50 percent of newly discharged Medicare patients who don’t see a primary care clinician or specialist within two weeks of leaving the hospital. Whose job was it to get her that appointment? It took a trip back to the hospital before she met with a dietitian and learned how to administer and adjust her insulin.
To crack down on avoidable readmissions, Medicare began penalizing hospitals last year if patients with three conditions—pneumonia, congestive heart failure, and heart attack—were readmitted within 30 days at rates above certain thresholds. At least two other federally sponsored efforts, the Partnership for Patients and the Community-Based Care Transition Program have also worked over the past several years to reduce avoidable readmission rates. A third, the Beacon Community Cooperative Agreement program, is now shedding a bright light on how communities can best use information technology in the process.
The Beacon program was part of 2009 federal legislation aimed at boosting adoption of electronic health records (EHRs) and other health information technology. Seventeen communities won three-year grants totaling $250 million to use EHRs, and exchange of digital information among health care providers, to improve health and health care. Three of the communities—Cincinnati, Detroit and Western New York—are closely linked to the RWJF’s Aligning Forces for Quality efforts in those same communities.
One tool that Beacon has tested is electronic alerts that originate in a hospital’s information system when patients undergo a change in status—for example, when they are admitted to the hospital, discharged, or transferred to another facility such as a nursing home. If the community has a health information exchange system, the message is processed and turned into an ADT alert, then sent to a primary care doctor or care manager. These professionals can then step in to smooth the transition and make certain that chronically ill patients get the attention they need.
Use of ADT alerts has been shown to deter unnecessary visits to the emergency room and initial as well as repeat hospitalizations. But communities must do a lot of hard work, together, to put them in place. They have to forge agreements with technology vendors, adopt data use agreements among providers, and undertake measures to protect patients’ privacy. What’s more, primary care physicians usually have to adapt the way they practice medicine, becoming far more proactive rather than reactive.
Fortunately, even as the Beacon program draws to a close in September, the 17 communities have banded together as the “Beacon Nation” to share the lessons they’ve learned with others. The group recently released the first of eight learning guides, this one to help communities improve care transitions using the ADT alerts. (Full disclosure: Along with my foundation colleague Michael Painter, I serve as one of 14 unpaid members of an advisory committee to the Beacon Nation group.)
Following the steps in the learning guide isn’t simple, but the take-home message is, says Farzad Mostashari, head of the Office of the National Coordinator of Health Information Technology, which oversees the Beacon program. “What the guide teaches us is that it’s not all about the technology,” he says. “Incorporating the technology with the people [in the community]—that’s the lesson.”
In other words, welcome to today’s high-tech health care villages—where lots of dedicated people and communities are coming together to achieve the Triple Aim.