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Bellevue’s tools for reducing readmissions


The original Bellevue  Hospital psychiatric facility.
Herewith Modern Healthcare’s look at how Bellevue Hospital, in New York City, a safety-net hospital, has succeeded in reducing readmissions despite the big difficulties in doing so at such hospitals, which  have disproportionate numbers of patients who are homeless, uninsured or simply sicker because they can’t afford regular medical care. Bellevue is nationally well known for the large number of its psychiatric patients, too.

This is part of a debate,  tied to government reimbursements and quality metrics for hospitals, over whether these institutions should be held responsible if their patients cycle frequently in and out of the hospital.

Advocates for safety-net hospitals say  that CMS penalties meant to reduce readmissions unfairly punish them. The CMS has agreed to  consider their complaints.

In any event, Bellevue has had some success in reducing readmissions. Among its strategies.

It  has implemented such readmissions-prevention initiatives as  as Project RED (for Re-Engineered Discharge), developed at Boston University in 2009. This requires care managers to track patients for 90 days after discharge to ensure that they obtain prescriptions or see primary-care doctors.

Bellevue uses a tidy, color-coded intake spreadsheet in its emergency department that lets the department’s chief of service  track  arriving patients. Besides such obvious details  as the patient’s name, vital signs and medications, it alerts doctors and nurses if the patient has been admitted within the past 30 days.

Bellevue also has  robust cooperation between its inpatient and outpatient care departments to help reduce readmissions. Indeed, as part of this effort, it built an outpatient clinic physically attached to the hospital.

To read the Modern Healthcare article on this, including data on its readmissions reductions, please hit this link.


Study: 30% of pediatric readmissions might be preventable


Boston Children’s Hospital.


For Kaiser Health News

One of the key indicators of the quality of a hospital’s care is how frequently its patients are readmitted within a month after being discharged. A study this month examined readmission rates for pediatric patients and found that nearly 30 percent of them may have been preventable.

The study, published online by the journal Pediatrics, reviewed the medical records and conducted interviews with clinicians and parents of 305 children who were readmitted within 30 days to Boston Children’s Hospital between December 2012 and February 2013. It excluded planned readmissions such as those for chemotherapy.

Overall, 6.5 percent of patients were readmitted during the study period.

The study found that 29.5 percent of the pediatric readmissions were potentially preventable. In more than three-quarters of those cases, researchers determined that hospital-related factors played a role. A significantly smaller proportion were related to the patient (39.2 percent), often because of issues that arose after discharge, or the primary care physician (14.5 percent). (Multiple factors played a role in some patients’ readmissions, so the total exceeds 100 percent.)

The most common hospital-related reasons had to do with how patients are assessed, postoperative complications or hospital-acquired conditions.

“One of the things we need to improve upon is engaging families at the time of discharge around how we’re feeling and how they’re feeling about the status of the child at that point in time,” said Sara Toomey,  M.D.,  the study’s lead author, who is the medical director of patient experience at Boston Children’s Hospital and an assistant professor at Harvard Medical School.

Sometimes clinicians and family members may be overly optimistic about a child’s readiness to go home,  Dr. Toomey said.

When policymakers discuss the importance of reducing hospital readmissions, they typically focus on older patients, who make up a much larger proportion of hospital patients than do pediatric patients. The Medicare program, which provides health benefits for Americans age 65 and older, imposes financial penalties on hospitals whose readmission rates are too high.

The federal Centers for Medicare & Medicaid Services doesn’t penalize hospitals for pediatric readmissions, but a growing number of states are doing so, the study found.

Readmissions will never be completely avoidable, Dr. Toomey said. Still, “when you have a child coming home from the hospital, there are things you need to know, and the more active people are in creating a plan and making sure they understand it, the better that will help their children.”

To read the article in Pediatrics, please hit this link



Cutting readmissions through bundled-payment systems

revolving door

Here’s an overview of how bundled payments are helping to drive down  hospital readmissions by encouraging  the creation of seamless continuums of care through much stronger care coordination,  the creation of community partnerships and educating patients to take a far more active role in setting and achieving their medical goals.

To read the Health Leaders Media article on this, please hit this link.


Study says many readmissions not due to poor care


A study in JAMA surgery says that a high percentage of readmissions to hospitals within 30 days of release are not caused by poor care but rather by mental-health issues, substance abuse or (in what is often related to those problems) homelessness.

Becker’s Hospital Review says that “Researchers in Seattle examined one year’s worth of readmissions data from a Level I trauma center and safety-net hospital. Among 2,100 discharges, 173 patients were readmitted to the hospital.

“Almost one-third of those readmissions fell into two groups: injection drug users who were readmitted for infections at new sites (29 patients, or 17 percent of readmissions) and people with lack of adequate social support, leading to issues around discharge and follow-up process (25 patients, or 14.5 percent of readmissions).

“Other causes of readmission were:

  • “Infections not detectable during index readmission (23 patients, 13 percent).
  • “Illness related to injury or condition (16 patients, 9 percent).
  • “Preventable complication of care (16 patients, 9 percent).
  • “Deterioration of medical conditions (two patients, 1 percent).”



Study: Medicare readmissions-cut goal looks too optimistic

A study in JAMA Internal Medicine says that Medicare’s goal of reducing all hospitals readmissions by 20 percent “may be overambitious.”

Yale researchers developed a readmission-reduction program and tested it on 10,000 older patients with Medicare fee-for-service insurance and recently discharged from an urban hospital but with a high-risk for readmission. The program  included such interventions as personalized transition support, education, follow-up telephone calls and connections to community resources such as social workers.

The  researchers compared their  readmission rate to the same hospital within 30 days to a that of control group of adults older than 54 but who didn’t have Medicare fee-for-service insurance and who were  seen as having a lower risk of readmissions.

The new intervention program  only cut  readmissions by 9 percent. “Our analysis revealed a fairly consistent and sustained but small, beneficial effect of the intervention on the target population as a whole,” the researchers wrote.

The study came after research  last month in JAMA Internal Medicine that found hospitals could have prevented more than a quarter of readmissions of discharged Medicare patients within 30 days.

So at least part of the jury is out on how successful readmissions-reduction programs can be.




Behind the foot-dragging on population health


Barry Ronan,  president and CEO of Western Maryland Health System, in Cumberland, Md., asks whether his colleagues are dragging their feet on moving to population health.

Last year he “defined population health as transitioning care delivery to a model that is valued-based that includes focusing on better case management of those patients with multiple co-morbidities, partnering in care delivery with other providers including previous competitors, better managing overall utilization and caring for patients in the most appropriate setting, not necessarily acute care.”

Mr. Ronan says: “Now with that said, the simple answer to the question in the title is: You bet they are dragging their feet! Neither payment systems nor incentives are aligned in 49 states, and many of the payers have little to no interest in cooperating with providers on population health initiatives.”


“The reason why my colleagues haven’t necessarily gotten on board is very simply that they are still being paid under fee for service. I just read recently about a number of initiatives that are being pursued by CMS related to value-based care delivery, but they are not in place as of yet. In addition, there appears to be little to no support for such initiatives from many of the payers. You shouldn’t expect health systems to change their care delivery model 180 degrees without some form of financial assistance to support infrastructure changes. There is a great deal of upfront cost when such a transition begins.”

“Population health is an all-out change in how care is delivered, and it can be very costly at its inception. Over time, we have saved significant dollars in reduced admissions, readmissions, emergency department visits, observation unit stays and ancillary utilization, but such a change doesn’t occur overnight.”


3 happy stories of population-health management


Healthcare IT News looks at how three organizations  are successfully managing population health in part by investing in technologies to ease the transition to value-based care.

The first is Orlando Health, a private, not-for profit  system that has created a clinically integrated network  platform through technology. Orlando Health uses the platform as a single reference source for patient data, which  are used to  target those who meet certain criteria. Those patients are  automatically contacted  via phone, email and text and informed of care gaps. Further, the platform is used to contact their primary-care physicians for appointments, automatic electronic reminders of which are  sent to patients.

Then there’s Northeast Georgia Diagnostic Clinic, a multi-specialty practice that  uses a platform to build registries of chronically ill patients  to identify care caps and do outreach, especially regarding patients discharged from hospitals or ERs who needed follow-up care to prevent readmissions.

Finally, there’s Charleston (W.Va.) Internal Medicine, a small independent practice. It uses population-health management technology to expand the number of patients in its “medical neighborhood” concept via automated daily e-mail campaigns to remind patients about wellness visits and lab tests.

Readmissions and ‘observation’: Hospitals’ relabeling trick?


This piece in HealthAffairs looks at the phenomenon of falling Medicare patient readmissions coupled, apparently, with higher rates of  patients being put under “observation” — even at hospitals outside the Medicare readmissions program.

The authors conclude:

“Our findings suggest that at least some hospitals are substituting observation status for inpatient readmissions, both for Medicare and privately insured patients. These trends raise a number of questions. For instance, do observation patients get the same quality of care as inpatients? Further, do drops in readmission rates truly mean that hospitals are providing better quality care? Or, as David Himmelstein and Steffie Woolhandler suggested in a recent Health Affairs blog, is it merely that some hospitals are avoiding penalties by relabeling patients they previously would have readmitted as observation patients?

“In fact, declining readmission rates may be a misleading measure of hospitals’ success in reducing medical complications or in coordinating patients’ care with other clinicians. By the same token, tying hospital payments to readmission rates may well be equivalent to allowing some hospitals to avoid financial penalties by simply relabeling patients rather than by improving patient care.”

Hospital readmissions: Location, location, location


Even as hospitals  try to reduce readmissions to follow value-based payment models, many of the factors that cause higher readmission rates are location-related and therefore out of hospitals’ control.

A study in the Health Services Research journal  attributed 58 percent of the  variation in hospital 30-day readmission rates to the  demographics of the county where the hospital was located.

The biggest factors in identifying areas with higher readmission rates:  larger percentages of the population eligible for Medicare, higher numbers who had never married and “low employment designation.”

And FierceHealthcare, in its analysis of the research, noted:”One of the most crucial health-system variables that determines the rate of readmissions is the number of general practitioners in the community, primarily because patients in areas with fewer general practitioners have few options but to return to the hospital when they experience complications….”



Works in progress in ACA innovation lab


Illustration by Theodor von Holst from the frontispiece of the 1831 edition of Mary Shelley’s 1818 novel, Frankenstein; or The Modern Prometheus.

Federal officials  have  submitted to Congress a progress report on the work of the  laboratory created by the Affordable Care Act to help transform how medicine is delivered and financed. There are a few successes but the lab mostly reports  that its projects are works in progress.

And “some 2.5 million patients and more than 60,000 hospitals, clinics and doctors will soon be participating in models run by {the lab called} HHS’s Center for Medicare and Medicaid Innovation, the center estimated in its biennial report,” reported Kaiser Health News.

Programs include Accountable Care Organizati0ns, efforts to end preterm births and to lower hospital readmissions for nursing-home patients, and big grants to states to improve care  (and  better control costs) for all  payers and patients, including those with private insurance.




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