By Jane Norman, CQ HealthBeat Associate Editor
June 14, 2011 -- Costly hospital readmissions that pose a huge challenge for the health care system can be reduced among Medicare beneficiaries, preliminary "dramatic" results from a major Medicare study as well as a separate Harvard Medical School report are indicating.
The findings could be significant because an increasing number of Medicare patients are being readmitted to hospitals within 30 days of their discharge. Avoiding readmissions has been become a priority for Centers for Medicare and Medicaid (CMS) officials as the agency is trying to become a major force in the improvement of the nation's health care. Also, under the health overhaul law, beginning in October 2012 Medicare will begin financially penalizing hospitals for certain preventable hospital readmissions.
Paul McGann, deputy chief medical officer at CMS, said at a "Medicare Readmissions Summit" that a three-year pilot program at the agency that involves some 1.12 million Medicare patients is showing "dramatic" preliminary results. The "Care Transitions Project" that aims to reduce unnecessary readmissions is targeted to 14 communities around the nation. Each is led by a state Quality Improvement Organization.
The idea has been to focus on how to make "seamless" transitions can from hospital to home, skilled nursing care or home health care, involving all the providers that a patient sees as well as community, family and care givers. McGann said he believes it's one of the largest studies that's ever been done on readmissions. The results are being analyzed in preparation for a published paper in a peer-reviewed medical journal.
According to a June report from the Agency for Healthcare Research and Quality, there was a 19 percent 30-day readmission rate among Medicare patients age 65 and older in 2008, based on data from 15 states. Among younger Medicare patients – those with disabilities—the rate was about 24 percent. Rehospitalizations in Medicare are estimated to cost $17 billion a year and can be very debilitating for patients.
The CMS study involved 70 hospitals, 227 skilled nursing facilities, 316 home health agencies and 89 other facilities. The health care providers and communities weren't told what to do but rather were encouraged to come up with locally generated plans in their own backyards.
They did get dozens of suggestions, though, such as asking doctors to regularly follow up with phone calls to patients after their discharges, improving patients' understanding of the right medicine to use and when, or using "care transition coaches" to help people make the shift from hospital to home, according to documents on the CMS web site.
More broadly, the U.S. health care system needs to have leaders who will see rehospitalizations as an important issue, said McGann. "There is a significant lack of leadership in this regard, both in the communities and the hospital community and even at CMS" he said. "We are taking steps to correct this at CMS."
What's important is to make the decision to change, he said. "Will is important here and we have to agree to correct this problem," said McGann.
McGann said that the project found that readmission rates "clearly"were reduced and the rate of initial admission were reduced even though that wasn't a goal of the study. Nursing home and home health care services utilization increased slightly. Preliminary cost savings are "very promising" though numbers are not ready for release yet, he said. "These results are going to be dramatic and they are going to be powerful," McGann said.
The 14 communities were divided into three tiers. The bottom tier "struggled mightily" with reducing readmissions rates, said McGann. But the top tier managed to improve by about 15 percent, he said.
Separately, a new study at the Hebrew Rehabilitation Center, which is affiliated with Harvard Medical School, looked at discharges from the center's skilled nursing facility before and after certain interventions were made. The rehospitalization rate fell from 16.5 percent to 13.3 percent. More people were sent home and the number sent to long-term care facilities decreased. The study was published in the Journal of the American Geriatric Society and the lead author was Randi E. Berkowitz, a geriatrician.
Patients admitted to skilled nursing facilities tend to have a high rate of early and unplanned readmissions, said a statement from the center about the study. To reduce readmissions, the center used several approaches. It employed a standardized template for admissions that included guidelines for care for common geriatric problems and questions about what medications patients were taking. Patients with three or more admissions in six months received palliative care—that relieves symptoms of serious illness without resolving the disease—to see if hospital admission was what the patient and family wanted, or if the condition could be better managed at home or in long-term care.
Another CMS initiative cited by McGann is the Partnership for Patients campaign, an ambitious patient safety project announced in April that is designed to decrease preventable hospital-based acquired conditions and lower hospital readmission rates by the end of 2013. It's already come under attack, though, by congressional Republicans who question how much money it will actually save. More than 3,000 organizations have signed up for the partnership, said McGann.
Given the preliminary results of the care transitions project, "with deliberateness and method and purpose, if we continue to pursue this and modify as we go along, it's clear readmissions rates can be reduced" by the magnitude envisioned by the Partnership for Patients campaign, he said.
McGann also offered extensive praise for CMS Administrator Donald M. Berwick. "CMS under Don Berwick's leadership is the most exciting place that I've ever worked in my life," said McGann. "It is just an unbelievable ride."
He said he has been asked by others if he is "masochistic" for working for an administrator who apparently tends to challenge presentations or concepts brought to him.
"The reason is because he's engaged," said McGann. "So often in the past ... we'd be going to an administrator to present the things and a rubber stamp would come out and there was no interplay of ideas or exchange of innovation. Under Don Berwick, you never know what's going to happen next. You can work for three months on something and bring it in and he'll just generate on the spot very new ideas.
"So it's an exciting place and things are just changing at a very rapid pace."