As we enter a new era of health-care and payment reform, we are all keenly aware of the need to limit unnecessary readmissions. We have been given tools and tips on how to most efficiently and effectively transition patients from the hospital setting to the outpatient world in order to limit the chances that they will “bounce back” to us, resulting in penalties to our hospital or health-care system. Tools such as Project BOOST and others help us to educate patients, transfer information effectively, follow up on patients post-discharge, and reconcile medications safely across the continuum of care. But without a competent and committed provider of care to “catch” the patient on the other side, we might just be dropping the ball yet again.
It is imperative as we look to safely transition patients into the next level of care that we, as hospitalists, get outside the box and begin to engage the community of care providers outside our walls, and yes, even outside of our control. We have been down this road before with other quality initiatives, which at first glance appeared to be outside our sphere of influence—such projects as post-operative antibiotic use and hospitalwide DVT prophylaxis. Given the right hospitalist leader, with the right set of leadership tools, these quality-improvement (QI) projects have been widely successful in many environments.
I would suggest that the issue of safe transitions for our patients is no different, and maybe more important, to the health and safety of our patients.
Solving the readmission problem on a local level requires an analytical approach, much like a “root-cause analysis.” We need to begin to examine the sources of our readmitted patients, as well as the routes of our discharged patients, and we need to ask ourselves if we are continuing to feed patients into the vicious circle that results in readmissions. Are there post-acute-care facilities in your area that are responsible for more than their fair share of patients returning to your service? If so, why do we continue to discharge patients to their care? Is it because we are pressured to lower length of stay, and any bed at the next level of care is better than another day in the acute-care hospital? At some point, this reasoning fails, and given the penalties coming soon, it may be better to begin to more discriminately discharge patients to facilities that provide higher-quality care and assist us in our goals to reduce unnecessary readmissions. Leading the charge in this endeavor also necessitates that we begin to engage those providers on the other side, making them aware of the quality data related to their facility and providing education and resources to assist them in improving their performance.
Realities of the Care Continuum
Several options pertaining to hospitalist groups are available. The first, already a large movement in our current marketplace, is to extend the current hospitalist group across the chasm and begin to deliver care in those post-acute facilities. Long-term acute care (LTAC) and skilled nursing facilities (SNF) are prime examples of this movement; the obvious advantage lies in the effective control of quality and efficient transfer of information that a single group can achieve when it extends to these facilities. Obviously, manpower issues and financial support are drawbacks in a model such as this.
More realistically, a group might consider taking a less aggressive approach to this problem. Educating care providers and assisting these facilities with QI projects would require fewer resources and might provide a higher return on investment (ROI) for your group and hospital. Engaging these physicians, nonphysician providers, and facility administrators is key to our ability to impact this problem. Demanding quality care for our discharged patients in terms of timeliness of follow-up, adherence to care paths, and responsiveness to changes in condition should be non-negotiable and factored into our development of referral patterns.
As our population of patients continues to be more acutely ill, and the level of care provided at post-acute care facilities continues to rise, our current reality is that a majority of these patients, at any given time, meet hospital admissions criteria. Preventing readmissions requires that post-acute care providers have mechanisms in place to stop the “knee-jerk” transfer to the emergency department, rather than attempt to evaluate and treat the patient in the facility. Interact II (http://interact2.net/index.aspx) is a resource that provides tools for post-acute-care facilities to use in monitoring their own internal data around acute-care transfers. It also provides tracking tools, communication strategies, advanced-care-planning tools, and clinical pathways for limiting the number of acute-care transfers. The reality is, once these patients end up in the emergency department, they are likely to be referred to us for consideration of readmission. The best way to stop this is to stop the transfer before it happens.
We, as hospitalists, need to begin to leverage our own “buying power” as it relates to the care of our patients post-discharge. We can start by educating and assisting care providers on a local level to improve compliance with well-known standards of care that prevent unnecessary readmissions. We need to be prepared to wield our collective weight as a specialty to demand from our post-acute care colleagues what has been demanded of us over the last several years: quality and value. Make no mistake—hospitalists have to get outside the box.
Dr. Harrington is an SHM board member and chief medical officer of Locum Leaders in Alpharetta, Ga.