The Annals of Internal Medicine (December 2016) provides an analysis of early readmission rates (Readmission Rates After Passage of the Hospital Readmission Reduction Program: A Pre-Post Analysis – http://annals.org/aim/article/2594952/readmission-rates-after-passage-hospital-readmissions-reduction-program-pre-post). Medicare imposes a 3% penalty and extracts approximately $425 million in fines from hospitals. It has been estimated that this penalty amounts to only $250 per re-admission.
This is a decrease in revenue that has made it difficult for hospitals to engage readmission reduction programs. The nationally acclaimed transitions programs have price tag’s significantly exceeding the $250 per admission penalty they were designed to avoid (Note. Guided Care program ~$1700 per patient per year, Geriatric Resources for Assessment and Care of Elders (GRACE) program ~ $1,432, Transition Care Model8 (Naylor Model) ~ $982.). The most popular care transitions program – Care Transitions Intervention (Coleman Model) – has been reported to cost ~$196. However, a number of transitions care providers have had difficulty producing Coleman Model programs at this price point.
In an effort to understand if this penalty has had any effect on 30 day readmission rates Wasfy et. al. evaluated readmissions at 2868 hospitals. The study evaluated admissions for myocardial infarction, heart failure and pneumonia. The authors concluded that readmissions for these admissions decreased after the penalty was enforce, however the largest progress occurred at hospitals where 30 day readmissions were lowest prior to the imposition of the early readmission penalty. In addition, the authors noted that the reduction in early readmissions could not be associated with the early readmission penalty.
Medicare (and likely soon other payers) will move to reimburse hospitals on a “bundled payment” basis. Hospital based ACO’s will likely be charged with identifying meaningful risk reduction strategies. For many early readmissions sub-optimal medication use is a significant factor driving the readmission. As many ACOs have been developing medication management programs, a cost-effective approach to is to incorporate readmission reduction into the medication management service.
While readmission reduction programs need to be priced at a “market” price point, they must include some key features
- The Hand Off. How will hospital staff identify and notify the program of patients who are getting ready to be discharged and eligible for the program. Most hospitals produce an ADT (Admissions, Discharge, Transfer) file. This file is produced at least daily and indicates who is ready to be discharged. In my experience, it is always better if a new program doesn’t produce extra work for the hospital staff. To minimize extra work, your program might include monitoring the ADT file. The medication management staff monitor the ADT files and recommend patients for inclusion in the readmission reduction program.
- The Criteria. What are the criteria that will make patients eligible for your program? Initially it is probably best not to “boil the ocean”. Select age ranges, disease states, types or number of medications that will provide a tractable number of patients until you refine your program process. You can always expand the inclusion criteria.
- The Process. What is your transition care process? Medication management programs focused on readmission reduction must achieve patient contact in daily cycles. In addition the patient interaction must be focused on aspects of care which prevent admissions. Here you probably don’t need to re-invent the wheel, abstract from the evidence based processes that have been developed by other successful programs. Components that are critical to a care transitions program might include:
- Medication Reconciliation. Understanding the discharge medications, previous medications and coming up with a consensus list for the patient, primary, pharmacy and specialists.
- Primary Care Visit. One of the key features of transitions programs that reduce re-admissions is a primary care visit within a week of discharge.
- Medication Synchronization and Compliance Packaging. Getting the patient’s medication in a form that the patient can easily adhere to their regimen in a consistent and reliable manner.
- Documentation and Reporting. You will need to have a system for documentation and reporting. For the most part, EHRs are not good, for this type of documentation – they are designed primary to facilitate face-to-face visits and they do not collect patient information in a format (structured data) that will allow you to demonstrate your program’s value.
I am a big fan of the minimally viable product – deliver a product that provides only the essential components required to produce the promised result. At some point you may want to consider adding additional services to your program offering. These can be a part of the core program or add-ons that a client could elect. Some examples of additional services are:
- Transportation coordination. Many patients will be re-admitted because they have no body to take them to their medical, physical therapy, etc. visits.
- Meals. Poor nutrition has been sited as a key factor in increasing early readmissions. Coordinating with meals-on-wheels and other nutritional services may be a low capital add on service.
- Home Safety Inspection. Falls are also a large factor in early readmission. Home safety inspections identify loose carpets, bath safety issues, etc. which might promulgate a fall. While a home safety inspection is generally conducted by an Occupational Therapist and outside the scope of medication management services it is a service that can be coordinated by the medication management pharmacist.
James Notaro, RPh, PhD