Seeking A Root Cause For Readmissions
Hospital executives often minutely study the clinical causes behind readmissions of inpatients within 30 days of discharge, but it may often be as simple as poor communications.
That's the conclusion of researchers at UC San Francisco, which with a group of East Coast hospitals studied more than 1,000 readmissions. Among those cases, some 27% likely could be avoided, while 15% could definitively be avoided. In many instances, the readmissions could have been avoided by making some relatively minor changes to the way patients interact with doctors, nurses and other staff. Critical gaps were found in areas such as the inability of patients to keep follow-up appointments, lack of awareness of whom to contact if problems arose after discharge, discharging patients too soon and insufficient monitoring post-discharge.
The study was supported by funding from the American Association of Medical Colleges and grants from the National Institutes of Health, and published in the most recent issue of the JAMA Internal Medicine.
Among the discoveries: 31% of patients that were readmitted may have avoided that fate if the emergency departments where they initially sought care had not admitted them as inpatients. Another 14% of readmissions of patients with some form of end-stage disease could have been avoided if there had been a documented “goals-of-care” discussion and continued to be cared for at home.
“What we have learned is that the sicker and more complicated the patient, the faster we as providers want them to be seen in follow-up. But the sicker and more complicated the patient, the more they don’t feel up to keeping those appointments,” said tsudy senior author Jeffrey Schnipper, M.D., of the division of general medicine at Brigham and Women’s Hospital, and Harvard Medical School. “So before scheduling that appointment with the primary care physician three days after discharge, we need to have an honest conversation with the patient: Are you willing and able to keep that appointment? If the answer is no, maybe we can arrange the logistics so that they can keep it or find some other way to keep them safe at home until a later appointment.”
The study comes at a critical time for hospitals in California and elsewhere, as the Centers for Medicare & Medicaid Services has begun clawing small but nevertheless substantial portions of revenue from hospitals if their 30-day readmissions for certain patients do not fall below a certain threshold. The penalty began at 1% of Medicare revenue when the readmissions prevention program began in 2012, but has since reached 3% of Medicare revenues. A total of 235 California hospitals received penalties due to excessive readmissions last year. The penalties ranged from 0.01% to 3%, although only one facility – Sutter Surgical Hospital actually received that maximum levy. Most fines were well below 1.5% of Medicare revenue.
“Only about a quarter of readmissions are preventable, and about half of preventable readmissions are due to factors that occur after discharge. It’s easy to complain about this, with the penalties only going to hospitals, but we also can be pragmatic,” Schnipper said. Hospitals need to work with outpatient providers to improve communications and jointly come up with comprehensive programs to keep patients safe after discharge. This requires investment, but it’s a better alternative than paying penalties.”
