Reducing hospital readmission rates and improving care transitions

Caring for communities

According to federal data analyzed by Kaiser Health News , in 2022 more than 2,500 hospitals will be penalized by the Centers for Medicare & Medicaid Services (CMS) for having too many Medicare patients readmitted within 30 days.

When Kaiser looked only at critical access hospitals and others exempted by Congress, the number of facilities to be fined rose to 83%. In light of these alarming numbers, it’s not surprising to learn that one in four Medicare patients with a chronic disease is readmitted within 30 days of discharge. And although the readmission rate is lower for other patients, hospital readmissions cost Medicare an estimated $17.4 billion every year.

These statistics paint a disturbing picture for companies in the health care industry, who are already struggling with COVID-related financial issues and would prefer not to be burdened with their share of the estimated $521 million in penalties that will be imposed by CMS in 2022.

That is why Enhabit Home Health & Hospice provides comprehensive oversight and compassionate care during transitions from one care setting to another. In doing so, Enhabit helps reduce readmissions, increase patient satisfaction and improve health outcomes.

Factors driving high hospital readmission rates

According to a study published by the New England Journal of Medicine, 67% of Medicare readmissions are due to medication noncompliance. But that is just one factor among many.

In a white paper, Jason Falvey, PT, DPT, GCS, Ph.D. reports that poor physical function at the time of discharge is also near the top of the list of contributing factors for readmission.

In fact, failure to improve physical function — including the ability to handle activities of daily living — within 30 days of discharge is associated with a 250% increase in the risk of readmission or death. Yet, despite these numbers, information about physical function is included in physician discharge summaries only 26% of the time.

Other key risk factors include underdeveloped discharge plans, complex discharge instructions and inadequate communication with physicians. According to a study by JAMA, 50% of Medicare patients who are readmitted have had no interaction with a physician between discharge and readmission. Further, due to lack of collaboration between hospitals and providers, many primary care physicians (PCP) don’t even have access to their patients’ discharge summaries.

There are other factors leading to high readmission rates, especially among patients nearing end of life. Most of these problems are due to long-standing gaps in the home-to-hospital transition process. And most of these gaps are, in large part, due to a lack of coordination and communication between the providers involved.

Closing the gaps in the hospital-to-home transition

Kristi Wimberly, vice president of care transitions at Enhabit, credits overcoming readmissions to a strong sense of collaboration.

“By taking a coordinated team approach to care, we give patients a safe and effective transition from the inpatient setting to the home,” Wimberly said. “Working with the patient’s entire team of experts helps us provide a post-acute solution for our hospital partners and also helps to get the patient the right service, at the right time.”

Although studies have shown a lack of coordination and communication between care settings, there are strategies being employed by leading health care organizations and institutions to help close the gaps in the hospital-to-home transition and, thereafter, to enhance care in the home.

Improve communication and collaboration

“Efforts to reduce hospital readmissions must begin before discharge,” Wimberly said. “Inpatient facilities must ensure that essential information, including functional status and patient-specific risk factors, is available to everyone on the care and discharge teams, and that there is close collaboration between them.”

Enhabit’s Care Transitions Program has a team of coordinators and navigators who help ensure the transition from hospital to home is successful. These clinicians focus on things like pre-admission drug regimen reviews, risk stratification of patients and on-site case conferencing.

Additionally, Enhabit focuses on collaborating and helping to fill the gaps between settings by partnering with discharge planners, providing fully integrated transitional services, coordinating follow-up appointments with PCPs and supporting patient adherence with post discharge regimens.

Expand the role of rehabilitation professionals

Often, hospital discharge proceeds without the input of rehabilitation professionals, who specialize in post-discharge care. While they may be involved in recommending an acute or post-acute setting, they may not be involved in other critical conversations. Increasing their role in the process can help ensure that patients are not only discharged to the best possible location, but that they receive the best possible care once there

“Our care transitions coordinators and transition navigators collaborate with the interdisciplinary care team to understand functional status, potential barriers to a safe transition and anticipated needs in the home setting,” Wimberly said. “Engaging in these conversations improves the continuity of care as our CTCs and TNs pass this information on to their clinical partners who will be providing care in the home.”

Our CTCs and TNs collaborate with the interdisciplinary care team including the therapists to understand functional status, potential barriers to a safe transition and anticipated needs in the home setting. Engaging in these conversations improves the continuity of care as our CTCs and TNs pass this information on to their clinical partners who will be providing care in the home.

Increase focus on physical function

When functional information is ignored during the hospital-to-home transition, patients are often discharged to face a range of unmet care needs. These needs can range from the lack of durable medical equipment (such as a tub bench) to the lack of a caregiver to help with activities of daily living.

“To minimize readmissions, discharge planning must include a heightened focus on this key determinant of successful or unsuccessful recovery and rehabilitation,” Wimberly said. “Our program focuses not only on the patient but the caregivers as well, prioritizing their understanding of how to care for the patient to achieve the best possible outcome.”

Leverage the power of home health

When properly integrated into the continuum of care, home health becomes a critical part of ensuring that patients discharged from hospitals or other inpatient settings don’t suffer relapses that require readmission. Recent data from health insurance company Paramount shows that patients who utilize home health services within 14 days of discharge from an acute care facility are more likely to avoid a readmission in the 30 days after discharge.

At Enhabit, we believe that collaboration, predictive analytics and patient-centered care are the keys to helping every patient meet their goals at every step of the health care journey. In addition to cutting costs, maintaining this approach to home-based health care helps to facilitate smoother transitions, reduced readmissions and better outcomes for our patients and their loved ones.

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