Stephen Jencks, MD, MPH, lead author of the 2009 landmark study of the multibillion-dollar cost of readmissions, says there’s “been a great deal of movement” on readmissions since his work was published in The New England Journal of Medicine, but there’s more that hospitals and communities can do.
Dr. Jencks, an independent consultant in health-care safety and quality, and a senior fellow at the Institute for Healthcare Improvement, shares his insights with Curaspan Connections.
Curaspan: Will there be a follow-up to the NEJM report?
Stephen Jencks: Yes, we’re looking at this with a research team at Johns Hopkins. I don’t think you’re going to see a dramatic change from the original report, but it’s hard to tell. We’re looking at some subtle issues like readmission for surgery that may be elective, as an example, and asking “Should this be considered and counted as a readmission?” And we’re looking at factors affecting hospital readmission rates.
How do hospitals ensure a discharge doesn’t result in an avoidable readmission?
What I think is most important is communication. First, hospital staff need to talk with downstream providers, such as nursing homes and home health; practitioners, such as physicians and community clinics; and caregivers, such as families and concerned neighbors. Second, patients and caregivers need oral and written instruction, confirmed by “teach-back,” on what medications to take, why and how to take them, and how to get them. Third, patients and caregivers need similar instruction on how to recognize signs of trouble and a specific person or number to call. Fourth, every patient should leave with a follow-up appointment and the hospital staff needs to take responsibility for communicating the continuing care plan to the appointment. The hospital’s responsibility does not end until the hospital knows that the downstream provider has taken over.
So building and nurturing a network with a patient-centered approach is key?
We are not going to defragment care with a fragmented community. We recognize the importance of good communication with post-acutes like home-health agencies and skilled nursing facilities, and improved technology certainly will play a role there. But it’s the emphasis on the consumer that is key. Consumers need to be part of the solution. If they are not part of the solution, I don’t think it will work very well. Of even greater importance than readmissions is making sure we’re providing care that is more focused on the patient.
How much weight does patient input have?
What patients say is going to matter. Value-based purchasing for hospitals is going to rest as much on outcomes reported by patients such as the HCAHPS survey. Right now, HCAHPS has limited information on discharge and transition, but there are a number of trends moving toward care-transition measures into the HCAHPS. From a hospital perspective, it’s listening to the patient. The patient is the consumer and has a clearer picture of care quality. The patient and caregiver were there, and they know how transitions went in a way that providers do not see and cannot fully appreciate.
What else can hospitals do?
It’s critical to create awareness of the importance of care after the patient leaves the hospital. The observation of a patient doesn’t end when he’s discharged, but this requires a change in the health-care system. Incentive for follow-up is a key step. We’ve had a system which was very much encouraged to say, “I’ve done my job right,” and the patient goes to someone else. So, with readmissions there can be a lot of finger-pointing. It’s much more productive to say, “What could we have done better?” than to say, “It’s not my fault.” Providers know transitions aren’t going well. They have families of their own. I often ask them to think about the last time a family member or close friend was discharged from the hospital and to give it a grade. There aren’t a lot of A’s.
Have you seen a reduction in readmissions since the original report was published?
We hoped to see an immediate impact on a small scale, and we are seeing that. For example, the QIO program has been fairly successful at a community level. But this is an issue that is not going away. My impression is that the interest to reduce readmissions is widespread. Medicare is putting in a very intense effort and lots of resources.
Is there more awareness now?
Congress raised awareness dramatically by tying Medicare payment to readmissions — we now have incentives and penalties. A second step is lining up payments with the core patterns we want to see. The third approach is taking the analytic performance of the individual hospitals and putting it up on the Web. Medicare and Medicaid are piloting a focus review process to add hospital surveys on issues related to readmission. Hospitals don’t want to be penalized. They want to do the right thing. So, yes, awareness is high.
What’s at stake?
If we aren’t focused on improving patient transition, readmissions and patient safety initiatives — if we can’t make these work — we’re going to see shrinking coverage, shrinking eligibility and decreased payments. I think we’re moving into a period of difficulty for hospitals. I think what’s necessary are substantial changes in how cost reimbursement is managed. This will be essential for many hospitals’ survival.
Is the hospital C-suite paying attention to readmissions?
The short answer is that I’m talking to people who are paying attention to it. Almost everyone has figured out that this is going to affect the bottom line. That gets the attention of people who may not have been following it. I think it would be the exception that there’s someone in the C-suite who does not know that readmissions are becoming a big deal but there’s huge variation in how much more they know.
Stephen Jencks, MD, MPH, is an independent consultant in health-care safety and quality, and a senior fellow at the Institute for Healthcare Improvement. At the Centers for Medicare & Medicare Services he was chief scientist in the Office of Research and later was senior clinical advisor and director of the Quality Improvement Organization program in the Office of Clinical Standards and Quality.