“The Boomer” is a column written for adults nearing retirement age and those already in their “golden years.” It will also promote reader interaction by posting e-mail responses and answering reader questions. E-mail your questions or topic ideas to firstname.lastname@example.org.
Last month a friend of mine was admitted to the hospital to have a cancerous tumor removed from his back. The operation was successful and he only had to stay in the hospital for four days. But just three days later he landed back in the hospital because he was unable to cope with the complicated wound care regimens advised by care staff at the hospital when he was discharged.
My friend is not alone. Rehospitalization rates have been increasing, taking a heavy toll on the nation’s health-care system. According to a 2009 study published in the New England Journal of Medicine, close to 20% of hospitalized Medicare patients are back within 30 days, costing $17 billion a year. Hospitals across the country are working to reduce readmissions in anticipation of new penalties coming in 2013: hospitals face a penalty equal to 1% of their total Medicare billings if a high number of patients are readmitted. The penalty jumps to 2% in 2014 and 3% in 2015.
The discharge process from a hospital is a critical point in a patient's recovery, especially for older patients with chronic conditions. The process is supposed to be carefully planned and thoroughly reviewed with the patient, but often it is poorly coordinated and rushed, resulting in readmissions to the hospital or emergency room.
In September, Dartmouth University released a study called “After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries” that showed easy follow-up procedures with clinicians fell short throughout the country, and that a “significant proportion of Medicare patients discharged to home did not see a clinician within 14 days of discharge.”
I had an opportunity to discuss this study along with what’s behind this alarming trend and how boomers can avoid becoming part of this group with Dr. David Goodman, director at the Center for Health Policy Research at Dartmouth Atlas of Health Care.
Boomer: How does improving care coordination for patients being discharged from the hospital help with the costs of Medicare?
Goodman: Patients who make the transition from the hospital to a community care setting appropriately have a better outcome--they stay healthier and they are less likely to have acute illness and are less likely to need to be hospsitalized.
Hospitalization is the most expensive activity in health care. If patients can stay well and don't need to be in the hospital it serves both the patient and Medicare.
Boomer: What factors beyond discharge planning and care coordination cause hospital readmissions?
Goodman: The important factor that we found in our report, and was also reported in the New England Journal of Medicine last week, is what we call “local system affects.” We found there are some places in the country where patients are more likely to spend time in the hospital even when we accounted for differences in illness levels. Places that have high general admission rates tend to have high re-admission rates as well, and areas with low admission rates tend to have low re-admission rates. The gap in readmission rates is not because of differences in discharge planning or care coordination. Different practice patterns have evolved generally in relation to the supply of health-care resources. Good discharge planning and care transition can certainly affect readmission rates further.
Boomer: For patients with chronic illnesses, how can early physician follow up after discharge from the hospital help with readmission cost control?
Goodman: Patients with a chronic illness who need to have surgery have a higher risk of having more problems with their chronic illness. Infections and problems that develop while in the hospital will obviously be treated, but hospital stays tend to be pretty short these days, and often problems don’t develop until after the patient leaves. Early follow up care with a physician or nurse practicioner and a good discharge planning that includes the discharge planner making sure that the patient understands and can execute the treatment plan are key to a quick recovery and avoiding readmission.
For patients that are admitted to the hospital because their chronic illness gets worse, the role of the hospital primarily is to stabilize the illness. When this is the case, discharge planning and care transition should act as a bridge to community care that will continue the care that began in the hospital to improve the patients’ health long term.
Chronic illness is just that---chronic and we want care in ambulatory community settings close to patients home and their family to keep them healthier so they don't end up in the emergency room and back in the hospital.
Boomer: What are some of the overall findings in your study and how can we improve both the cost and quality of care?
Goodman: There were three overall important findings: readmission rates are not declining, rates vary across the country and we need to improve patients’ health.
During the time span of the study, readmission rates did not decline, despite the problem being well known and discussed in the health-care world.
There was some progress in some places and there was some increase in readmissions in some places, but most places didn't see much of a change. Second finding is that
Readmission rates vary a lot from place to region—but most of the time patients and even providers are not aware of the differences. We need better public reporting and public information of health care systems to help both patients and providers know and track progress.
We know the discharge planning and care transition process is crucial to lowering readmission rates, but we must also actively work to improve patients’ health and well being.