The Hospital Readmissions Problem: Benefits of Home Care in Transitional Care

In 2011, the Centers for Medicare and Medicaid Services (CMS) faced a staggering $41.3 billion cost from 3.3 million hospital readmissions. Hospital readmissions are problematic as they are expensive and lead to less-than-favorable patient outcomes. Reducing hospital readmissions has been a major focus for CMS, hospitals and health plans, but an overlooked solution for systematically reducing hospital readmissions among the elderly is home care.

Hospital Readmissions and Transitional Care Interventions

Prior to 2012, nearly 20 percent of all Medicare discharges saw a readmission within 30 days. At the time, hospitals were reimbursed by Medicare through the inpatient prospective payment system (IPPS). These payments covered inpatient stays, outpatient diagnostics and outpatient non-diagnostic services that were admissions related.

Payments did not include post-release care or any interventions that might reduce readmissions. Naturally, hospitals found little incentive to discourage readmissions. CMS administrators, however, believed a 20 percent readmission rate was unreasonably high and that at least 12 percent of readmissions were potentially avoidable. They predicted that getting hospital readmission rates down to 10 percent could save Medicare $1 billion annually.  

In 2012, the ACA established the Hospital Readmissions Reduction Program (HRRP) to reduce risk-standardized 30-day readmission rates for a variety of conditions. Initially, the HRRP focused on three conditions: acute myocardial infarction, heart failure and pneumonia. The program has since expanded to include chronic obstructive pulmonary disease, elective total hip arthroplasty and total knee arthroplasty, and coronary artery bypass grafts.  

After the ACA’s HRRP passed on October 1, 2012, the program instituted strategies to reduce hospital admissions via financial incentives and penalties. The penalty payment structure aimed to eliminate avoidable readmissions and reduce costs for hospitals with high return rates. If a hospital’s readmission rate was higher than the national average, CMS penalized the hospital three percent of total Medicare payments.  

Some hospital administrators complained of inequities in penalties. Hospitals serving more low-income patients believed they were unfairly penalized. They found relief in the 21st Century Cures Act, passed in December 2016, which divided hospitals into five peer groups that better reflected the patient demographics of individual hospitals.  

Some hospital administrators took steps of their own to avoid penalties and improve patient care. With newfound interest in understanding the predictors and causes of readmissions, many hospitals worked to implement a variety of general transitional care interventions.

Outcomes: Readmissions Reductions

HRRP has had some success in its mission of reducing hospital readmissions: from 20 percent in 2012 to 17.5 percent in 2013. At hospitals subject to the HRRP, readmissions for the special medical conditions targeted by the HRRP declined “significantly faster,” according to an Obama administration study.  

Here are a few of the intervention programs that have resulted in better patient care and outcomes.

• Patient discharge and self-management coaching
  Patients who leave the hospital may not fully understand the seriousness of their condition or how to self-manage their care. Reviewing patient checklists pre-release and allowing patients to take checklists with them that provide post-care instructions can help reduce readmissions. ‍
• Providing non-native English speakers with access to adequate translation services also can result in better patient care and outcomes.
• Care coordination and care-setting transition planning
  ‍Transitional care nurses (TCNs) and other professionals who facilitate transition to outpatient care can help avoid readmissions. TCNs help patients and family members understand the conditions and aftercare requirements, including scheduling follow-up appointments and transportation to and from medical appointments. ‍
• Medication reconciliation  
  After a hospitalization, medications may change or doctors may introduce new medications. Different medications involve different side effects, and the combination of medications prescribed by different providers can cause problems. These changes place patients at increased risk for an adverse drug event (ADE). An ADE is “an injury to a patient resulting from medication intervention, which can occur in any health care setting,” according to Health Research & Educational Trust (HRET). For example, a patient prescribed an opioid and a medication that acts as a respiratory depressant, such as a muscle relaxer, may be at increased risk of respiratory depression, according to HRET. Evaluating and comparing a patient’s medication regimen when admitted to the hospital, during the patient’s stay and at discharge can help prevent an ADE.
• ‍Social determinants of health interventions
  Probably one of the most overlooked elements of patient care until recently involves a patient’s social determinants of health (SDOH). According to the Henry J. Kaiser Family Foundation (KFF), “social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care."‍
• A multitude of state and federal initiatives focus on addressing social needs, according to KFF.
  One state, Ohio, encourages primary care providers to connect patients with community-based prevention programs and social services that could benefit the patient. Other states have similar programs, according to KFF. Addressing social determinants of health is now an important concern in health care, helping to reduce hospital admissions through screening and support of SDOH factors. ‍
• Building bridges with community partners able to offer social, emotional, financial, logistical and nutritional support can help socially isolated and low-income patients avoid readmission.
• Data mining  
  Hospital administrators understand that to better treat their patients, they need to acquire and parse non-traditional data about their patients. For example, household income can predict which patients will struggle to pay for home care. Address data can provide insight into which patients live in areas without enough community support, such as access to Meals on Wheels or other vital services. A broader understanding of patients can help hospitals discharge patients more successfully. ‍
• Follow-up care and communication
  Many hospitals now use a Care Transitions Program, assigning a transition coach to manage care post-discharge. Usually within 72 hours of discharge, a transition coach visits the home and then calls the patient by phone over the next month. These visits and calls can help preempt emerging medical problems. Increased communication is one key to better transition from hospital to home. One health system in Colorado reduced 30-day hospital readmissions by 30 percent and saw a 17 percent decrease in 180-day readmissions after implementing a Care Transition Program. The average cost-per-patient decreased by almost 20 percent, as well.‍
• Partnering with local hospitals or care facilities  
  Aftercare providers play a critical role in preventing hospital readmissions. Home-care agencies, assisted living centers and other medical providers play a crucial role in the paradigm shift from volume reimbursement to value-based reimbursement models. According to Leading Age Magazine, most of these readmissions, at least in the former decade, were preventable. Forming a post-transition care team that continues to communicate with the hospital physicians can help to prevent hospital readmissions. Targeting transitional care post-hospitalization enables hospitals to avoid CMS penalties and provide a higher level of patient care.

Has the HRRP Helped Lower Readmissions?

As hospitals implemented quality improvement strategies designed to prevent hospital readmission, readmissions have decreased. Both improved patient outcomes and the savings of potentially millions of dollars in penalties are the results of these quality improvements.

However, readmission reductions have begun to level off since 2015, so further improvements may be more difficult to envision and implement. Only a multi-stakeholder approach will help to build a more thorough post-release protocol that will further reduce readmissions.  

Here are some of the improvements allowed by HRRP’s penalty payment structure that have helped hospitals retool and improve:

• Increased emphasis on care coordination across care silos  
  Traditionally, medical practitioners practiced in silos with little communication between providers. Today the focus is on collaborative transitions of care between home and hospital. Clear communication of care plans to medical and home-care providers is now foremost in discharge planning. Collaborative relationships between hospitals and the patient’s community resources are key elements of care coordination and patient recovery.  
• Increased emphasis on patient outcomes rather than care processes Historically, pay-for-performance measures focused on care processes. A patient-centered outcome approach measures factors that matter to patients and their families, not only to medical providers. A one-size-fits all approach in measuring outcomes is too limited for preventing hospital readmissions.  
• Improved total care  
  Many times, hospital readmissions are unrelated to the “index” or primary hospitalization. For example, a cardiac arrest patient may return home, but then face a readmission several days or weeks later, perhaps after a fall in a cluttered home environment. When CMS incentivizes hospitals to focus on all-cause readmissions, the hospital will look beyond the initial diagnosis to help ensure the home or community environment supports the individual’s successful return to his or her household.  
• Fewer premature discharges  
  Managed care, by its nature, pushes shorter hospitalization stays. However, in countries where cardiac patients remain hospitalized longer for heart failure, readmission rates within 30 days occurred at a lower rate than in US hospitals. The HRRP balances a desire to limit long hospitalizations with the need to prevent readmissions.  
• Shift toward value-based care  
  Value-based care is improving outcomes, increasing access to care, and lowering costs. Accountable care organizations (ACOs) are an example of this model, but with limited resources, ACOs will need to prioritize which quality measures are the most important – including interventions that reduce readmissions.  

How Home Care Agencies Can Help Health Plans and Healthcare Systems Reduce Readmissions

Home care agencies offer hospitals, medical providers and healthcare systems distinct advantages in preventing hospital readmissions among the elderly. Non-medical home caregivers assist seniors at home with activities of daily living: making sure post-discharge seniors have the medications they need, nutritious food to eat, an uncluttered environment to prevent falls, transportation to and from doctor’s appointments, adequate exercise and socialization, and more. They serve as eyes, ears and arms in the home to help seniors stay healthy and keep hospital readmissions – and associated high healthcare costs – at bay.  

Just as important, non-clinical caregivers can also address or alert clinical teams to social determinant of health needs that can impede a hospital recovery and lead to a hospital readmission. SDOH that American seniors frequently struggle with include adequate housing and nutritious food. Non-clinical caregivers can assist by contacting clinical teams or community groups who can help or by shopping and preparing nutritious meals in-home.  

Here are a few more ways a strategic home care strategy can assist in reducing hospital readmissions:

• Post discharge doctor visits  
  Hospital discharge processes and instructions can be lengthy and confusing for patients. In one study, 40 percent of patients didn’t understand the reason for their hospitalization and 54 percent could not recall the details of their follow-up appointments. A home caregiver can encourage patients to follow-up with their physicians and can ensure patients have transportation to and from appointments. Additionally, doctors often prescribe medications used post-discharge. Caregivers can pick up the medications at the pharmacy and assist with medication reminders. Caregivers can also watch for any adverse drug reactions.  
• Discharge instructions  
  While discharging nurses are typically thorough in explaining discharge instructions, hospitalization can be an overwhelming experience. Senior patients may need help once home to understand and follow the instructions. Home care practitioners can help patients understand the instructions and ensure that the patient follows them.  
• Care management  
  Caregivers can stabilize patients, helping them to complete their recoveries and avoid setbacks and readmissions. They can act as an extension of the medical care team, communicating what they see in-home to medical providers and alerting them to any deteriorations in the patient’s medical condition.  
• Real-time health data from inside the home  
  Home care staff provide boots-on-the ground data resources. Mobile technology and care plans synced to daily dashboard updates and alert systems can help care management teams catch emerging medical issues as they happen in real time. This data allows for early interventions, stabilizing patients in home before conditions escalate, to prevent readmissions.  
• Patient history  
  High-risk patients who do not fully engage in their own treatment plan can be difficult to help. Home caregivers can help to identify unmet needs that the patient may not want to discuss, such as recognizing that the patient cannot perform certain daily living activities or is having issues with medication management. This “total person” caregiver strategy can pay dividends in knowing what actually needs to be done to preserve health and prevent hospital readmissions.  
• Care communication  
  Home care practitioners address critical social determinants of health, including ascertaining family support, scanning the environment to reduce fall risks, ensuring patients eat and take their medication as well as lessening problems associated with social isolation.  

Case Study: Outcomes of Home Care Agencies in Care Transitions

The burden of reducing readmissions was made easier for Providence Health & Services, an ACO, who partnered with home-care network CareLinx to coordinate and stabilize patient care from hospital through home. In this partnership, CareLinx coordinated post-acute care with Providence to help seniors age in place and transition successfully from hospital through home. The non-medical services included transportation, housekeeping, exercise, bathing, medication reminders, mobility, grocery shopping, companionship and more.  In the Providence-CareLinx partnership, participating patients saw a decrease in hospital readmissions over a 30-day episode post-discharge of roughly 43 percent, although the pilot did not allow for statistical significance. About 16 percent of participants experienced readmissions during the pilot; a similar period in 2017 with a comparable patient mix had a hospital readmissions rate of 23 percent.