A recent study by Brigham & Women’s Hospital published in the British Medical Journal looked at patients readmitted within 30 days for possibly avoidable causes. The researchers found that infection and heart failure accounted for 21 to 34 percent of the total readmissions. They concluded that care after hospital discharge should focus not only on the primary diagnosis, but also on related complications.

What are some of the ways we can save Connecticut’s healthcare delivery system money, and improve outcomes, by preventing patients from being re-admitted to the hospital after their surgery or treatment? How does home health care enter into the equation?

For answers, we turned to Barbara Katz, Director of Clinical Program Development at VNA Community Healthcare, which serves 34 Connecticut cities and towns from offices in Hamden and Guilford. As recipient of the Connecticut Association for Healthcare at Home’s 2013 Judith A. Hriceniak Award for Excellence in Nursing Leadership, Barbara leverages her nursing background and strong business acumen to support clinicians and home health care professionals as they improve hospital-to-home care transitions.

Q: Why is reducing hospital readmissions critical to improving the quality of care and outcomes for patients?

A: Readmissions are quite expensive and are contributing to growing and unsustainable medical costs. Cardiologist Harlan M. Krumholz, MD, director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE) and director of the Robert Wood Johnson Clinical Scholars Program at Yale has researched the after-effects of people’s admission to hospitals.

While Dr. Krumholz studied first-time admissions, we also know that re-admissions expose people to the same stressors: Patients can become physically deconditioned, losing the strength they need to perform daily activities. Elderly patients can become delirious. Medications can get changed or mixed up.

 

Q: What does the Affordable Care Act (ACA) ask hospitals and home health agencies to do to avoid readmissions?

A: First and foremost, the ACA imposes severe financial penalties on hospitals for readmissions. This is the driver of much of the readmission reduction work being done. In each state, Medicare Quality Improvement Organizations have been set up to reduce readmissions. Here in Connecticut, Qualidigm is working collaboratively with hospitals and post-acute healthcare providers to reduce readmissions. A number of Medicare innovation grants are focused on preventing readmissions. Yale New Haven hospital has a grant for a care transitions program called Co-Starr that was funded in this way.

The ACA is also providing funds to test new models of financing such as post-acute bundling of payments. This is based on the theory that giving post-acute health care providers and hospitals one payment will induce them to work together more effectively, which will lower costs. If Medicare forces everyone to adopt value-based purchasing and pay-for-performance models, that will also help reduce re-admissions.

 

Q: How have home health agencies always sought to reduce hospital readmissions?

A: Home health care nurses have always taught patients self-care skills. We recommend home modifications to reduce falls and injuries that reduce hospitalization. We act as the patient’s advocate with the medical care system.

We help patients with Chronic Obstructive Pulmonary Disorder (COPD) learn how to breathe better. We teach heart patients how to monitor and check their weight. These measures are just two examples of how we help keep our patients from being re-admitted to the hospital.

Physical and occupational therapy provided in the home, including customized exercise programs to help patients function at their optimal level, reduces falls and helps reduce unnecessary hospital re-admissions. Occupational therapy, which is often overlooked, has played a vital role in helping patients improve their movement to more safely perform daily living activities.

 

Q: What are hospitals doing now to reduce readmissions?

A: Interdisciplinary teamwork is becoming an integral part of the hospital-to-home care continuum. We’re beginning to remove the silos through frequent communication.

Our agency belongs to a multi-disciplinary care transitions group at Yale New Haven Hospital. We discuss how to communicate across settings and what each entity in the continuum needs to know to avoid future readmissions. We also work together to put in place best practices and offer education to our patients.

There’s now a lot better transfer of information between hospitals and home health care entities. For example, Yale New Haven Hospital’s EPIC data capture system provides data to patients, their families and home care providers during the first 48 hours after the patient’s discharge. Patients can also get access to the system to monitor their admissions, which also serves as a readmission reduction tool.

Hospitals are measuring readmissions and feeding back the data to the home care agencies they refer to. At some point in the future, referrals may be dependent on results, i.e. lower readmissions.

Q: How are home health care agencies using clinical best practices to reduce readmissions?

A: Home health care best practices include things like front-loading home visits, ensuring that patients see their physician within a week of discharge to adjust medications and modify the treatment plan if that’s needed, medication reconciliation. We use telemonitoring to help patients learn self-management. Telemedicine also provides an early warning system that helps us identify patients who are physically decompensating due to their heart condition.

Some agencies, such as ours, are training staff in patient engagement, health literacy and motivational interviewing to deal with patients’ adherence to their care plan, which is a major problem in readmissions.

Home health care agencies are also breaking down communications barriers with other post-acute providers with strategies such as pre-discharge liaison visits, regular readmission case reviews and nursing home diversion strategies. Some agencies are using APRNs to see the sickest and most high-risk patients after their discharge from the hospital.

 

Q: What still needs to be done to reduce hospital readmissions?

A: Primary care doctors — the one key stakeholder group that is not yet active in hospital readmission collaboratives, but can make all the difference in avoiding readmissions —need to become much more engaged.

Meanwhile, home health care agencies need to better understand the factors that are driving readmissions and the ways to address them. Home health care agencies must become much more sophisticated in the use of data, the tools and the techniques of process improvement. This usually means changing traditional work processes, and, in some cases, work structures, such as changing from a geographic model to a specialty model of service.

Home health care agencies must strengthen their liaisons with other post-acute healthcare providers, including skilled nursing and assisted living facilities. Our VNA does liaison visits to the skilled clinical facilities in our area. We engage with the social worker in each facility. We help the patient’s family understand what’s realistic, what can be done in the home and what can’t. We do regular re-admission case reviews: what worked, what didn’t what could be done better.

Finally, we health care professionals need to shift our brains to think of ourselves as partners with patients, not directors of their care. We must learn to use health literacy, motivational interviewing, health coaching and other sophisticated techniques to engage patients in their self-care. This interdisciplinary teamwork needs to become an integral part of how we work with patients who have complex needs.