Continuum-Wide Data Visibility Helps Reduce Costly Readmissions
By Kent Locklear, chief medical officer, Lightbeam Health Solutions
Reducing hospital readmissions continues to challenge hospitals nationwide. This year, 2,592 hospitals — more than half of hospitals nationwide — were penalized by the Centers for Medicare and Medicaid Services (CMS) a total of $420 million for readmitting too many patients with certain conditions in fewer than 30 days.
Perhaps the most concerning statistic associated with the recent list of penalized hospitals in the four-year-old CMS Hospital Readmissions Reduction Program is that all but 209 of the organizations were also fined in 2014. With that much overlap, it seems evident that whatever adjustments these hospitals put in place to curb readmissions were either ineffective or too slow.
Readmission reduction is feasible through informed and empowered care management during and after transitions of care from the hospital to a post-acute facility or back to the patient’s home. Care managers need to have access to data from across the care continuum and be able to easily share information and communicate with providers at the patient’s next care venue, and/or with the patient by phone, mobile device or home computer.
With continuum-wide data visibility and tools to help them easily identify high-risk patients in greatest need of a clinical intervention, care managers can help prevent readmissions to improve their organization’s financial performance, but more importantly, their patients’ outcomes.
Care Transitions Critical
Despite excellent care during a hospital stay, patients may still be readmitted if proper care protocols are not followed at a post-acute care facility or at home. Ensuring high-quality care after discharge requires ample education with patients and/or their family members and detailed reporting to providers at the next care venue or in the community. Likewise, hospital care managers need to be updated by other providers during the crucial weeks after discharge to ensure patients’ recoveries are meeting expectations.
This data exchange is where many healthcare organizations seem to be most challenged.
The CMS commissioned a study of leaders in accountable care organizations (ACOs) participating in the CMS Medicare Shared Savings Program and found care transitions were most important in helping them control the spending that can have a direct impact on ACOs’ reimbursement in the program. According to the study, successfully managing care transitions was affected largely by the availability of timely admissions data and other forms of clinical data to inform outreach and decision making.
The CMS ACO study points out that more experienced organizations had mature information technology systems that were better able to share data. Also delivering an advantage to these ACOs was the ability to analyze claims and clinical data to assist with care management. However, many population health management (PHM) information technology platforms only utilize claims data, which can be up to 120 days old. While claims data are vital, other sources, such as timely clinical data from providers, pharmacy and lab are crucial for accurate risk stratification and timely interventions.
Engaging The Patient
Continuum-wide data visibility is a major factor in ensuring smooth care transitions and preventing readmissions. Also crucial, however, is engaging the patient in their recovery and/or post-discharge treatment plan. After discharge, despite the education and handouts provided by the hospital, many patients and families still need continued support to understand and follow their providers’ recommendations.
Advanced PHM tools can help care managers identify recently discharged patients who may be straying from their care plans. Multiple data sources are analyzed within the PHM tool using advanced algorithms to stratify risk groups by greatest need of clinical intervention, likelihood of improvement, or other relevant information the care manager or provider wants to view. Through easily interpreted charts and graphs, providers and care managers can visualize risk severity, and also determine where the organization is missing opportunities to improve patients’ outcomes.
Once identified, the subsequent patient outreach can be automated via text, phone, or secured email, which reduces the amount of time care managers spend on the phone, increases fee-for-service revenue, and helps satisfy quality measures for value-based payment contracts. At home, patients’ mobile devices can be leveraged as engagement tools. The hospital can push important content to a patient’s device such as reminders to take medications; prescription refill notifications; care-plan instructions; and diet and exercise reminders. If transportation to their primary care physician is a challenge, advanced PHM tools can facilitate post-discharge telemedicine visits with their providers.
Reducing readmissions is an important patient care quality and cost issue, contributing to more than $4.3 billion a year in Medicare spending alone. Hospitals now have tools and workflows to help them identify potential complications in patients post discharge course that can lead to a readmission. With timely care-manager outreach and continuum-wide data capture and analysis, providers can help patients experience a better recovery at home instead of a return to the hospital.