Health AGEnda

The Hospital Readmissions Debate: A Primer

TS_200314219-001_Hospital300In recent months, the debate over how best to reduce avoidable hospital readmissions has become a hot topic in the national media. While many are just now joining the fray, the John A. Hartford Foundation has been working on this issue for years.

Hartford grantees have developed evidence-based models that are now in the forefront of the national debate, including Eric Coleman’s Care Transitions Intervention, Mary Naylor’s Transitional Care Model, and the Society of Hospital Medicine’s Project BOOST.

It also has been a topic we have written about extensively on our Health AGEnda blog as we seek to help shape the public debate about an issue that is at the very core of real and sustainable health care reform and of critical importance to older adults.

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Attack on Medicare’s Hospital Readmissions Penalty Program Is Off-Base

There is a yawning chasm between the health care system we want and what we have. Crossing that gorge will be a messy and inconvenient process—but necessary.

There is a yawning chasm between the health care system we want and what we have. Crossing that gorge will be a messy and inconvenient process—but necessary.

While many of us in the geriatrics community were wending our ways home from the 2013 American Geriatrics Society conference in Dallas with dreams of improved care for older adults dancing in our heads, respected health services researchers Stephen Soumerai and Ross Koppel published a Wall Street Journal opinion piece with a stinging attack on Medicare’s new hospital readmissions penalty program.

We’ve talked about the need for healthy policy debates on readmissions policies before, and as a funder of the work of Eric Coleman, Mary Naylor, and the Society of Hospital Medicine’s Project BOOST to reduce hospital readmissions for older adults, I’d like to continue the discourse by responding to the major points made by Drs. Soumerai and Koppel.

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Putting the IT in Care TransITions

© Istockphoto.com/onurdongel

As we age we hope to remain at home and independent for as long as possible.  Most people see the health care system as an important contributor to their ability to maintain this independence. Unfortunately, as we get older we become more susceptible to harm from a lack of coordination and communication between our health care team members.  Different health care settings do not have access to the same information. This can lead to expensive duplication of services, or worse, to actual harm when one clinician doesn’t know a patient’s medical history or his or her current medications.  In short, transitions of care between health care providers and settings are fraught with risk, particularly to the health and safety of older adults.

We at the John A. Hartford Foundation have supported the development, testing, and dissemination of evidence-based approaches that improve transitions of care.  For over a decade we have invested more than $26.4 million in innovators such as Eric Coleman, Mary Naylor, Mark Williams, June Simmons and others.

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A Disastrous Discharge

An article in the October 30, 2010, New York Times, “Money Woes Can Be Early Clue to Alzheimer’s,” reminded me of how important it is for everyone working with older people to have knowledge of aging, including the signs and symptoms of dementia.  While it may not be so obvious that lawyers and financial planners should have training in dealing with older people with diminished capacity, it should be particularly obvious that social workers should.  Unfortunately, recently a social worker lacking such knowledge created a bad situation for me and my uncle.

John Jetton, 2009

I took over the care of my Uncle John five years ago when my Aunt Mary died at age 68 of colon cancer.  Aunt Mary, a licensed practical nurse, had been caring for her husband for at least five years prior.  He had suffered two strokes, one of which was brought on when he was severely beaten with a metal pipe; he suffered some brain damage at that time as well.  Despite these setbacks, Aunt Mary and John loved each other and had lived a very happy, if isolated, life together in a trailer home in the Poconos.  On her deathbed, Aunt Mary asked me to take care of John; they didn’t have children.  She also tried to tell me what I already knew–that John was not 100%, or as they say, he wasn’t dealing with a full deck. 

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A Boost to Better Care

The hope of health reform is to increase access to care, while simultaneously paying for those newly covered people by squeezing waste and inefficiency out of the system. This is easy to say but hard to do, particularly without raising fears of further reducing the rather mediocre quality of care we currently provide.

It is possible, however, and the Foundation is very proud to have facilitated the identification of some of that inefficiency where costs can be lowered and quality of care can also be improved. A few years ago, Foundation grantees Eric Coleman and Mark Williams met at a Foundation meeting on dissemination of innovation. They found they shared an interest in the hospital readmission data that retired CMS staffer Steve Jencks had been sharing at meetings. Jencks, Coleman, and Williams teamed up, publishing their analysis of Medicare hospital readmissions data in the April 2, 2009 issue of the New England Journal of Medicine.

The paper garnered extensive media coverage and made policymakers aware of readmissions among Medicare patients.  The main finding was that 19.6% of Medicare beneficiaries are rehospitalized within 30 days of a hospital discharge.

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All the Health and Aging News That’s Fit to Print

In the last few weeks I’ve been telling people that I feel more confident of eventually improving care for older adults than at any time in my 13 years in philanthropy. Part of that confidence stems from the inevitable effects of demographic change itself.  As the share of the U.S. population 65+ ticks up from 12 to 13 to 14 percent and the leading edge of the baby boom cohort turns 65 next year, awareness of aging in society, including special needs in health care, should become commonplace.

To make that happen, we need to keep putting the message out there that care should—and CAN—be improved. So it is very reassuring when what seems like a long, long media drought is broken by a flood of coverage in our hometown paper of record, the New York Times. (Disclosure – my wife works there, albeit in a different section with no connection to health care issues.)  It began a couple of weeks ago with a piece on hospitalists working to improve the discharge process and reduce readmissions through our project BOOST (May 26, 2010 – New Breed of Specialist Steps In for Family Doctor by Jane Gross) and continued this Saturday with a sort of follow-up piece (June  19, Patient Money, Aftercare Tips for Patients Checking Out of the Hospital by Lesley Alderman). This second article not only included the names of the projects and leaders (The Care Transitions Intervention and Eric Coleman, BOOST and Mark Williams), but also mentioned the Foundation as a funder of this work.

Testimonial on Care Transitions Intervention

Then for Father’s Day this past Sunday there was a major New York Times Magazine piece, What Broke My Father’s Heart by Katy Butler. Butler showed the need for more appropriate, sensitive care for older adults at the end of life by sharing the story of her father’s last years.  (Aside–as of Tuesday morning, this story had generated 422 comments and was closed to further posts!)  The Times followed this on Monday with a front-page story on delirium among hospitalized older patients that mentioned leaders in geriatrics like Sharon Inouye, MD, and Beeson Scholar Malaz Boustani, MD, as well as the American Geriatrics Society itself.  Oddly, the delirium story did not actually mention the name of Dr. Inouye’s intervention program HELP (Hospital Elder Life Program) in the print version. Then, Tuesday’s business section presented Geisinger’s version of nurse-enhanced primary care for the chronically ill. The Foundation is disseminating this type of care through the Guided Care program.

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Fumbling the Handoff?

A few weeks ago the New York Times published an interesting piece on hospitalists caring for patients and particularly what hospitalists are doing to improve the discharge planning process to improve care and reduce rehospitalizations.  (See “New Breed of Specialist Steps in for Family Doctor.”) While the separation between physicians practicing specialty or primary care medicine in outpatient settings from those providing care in hospitals is not new (the Times ran a story on it in 1998: “A New Breed In Medicine: ‘Hospitalist'”), it remains somewhat controversial.

Without citing it as such, the story talks about the Foundation-sponsored project BOOST (Better Outcomes for Older Adults through Safe Transitions) at the Society of Hospital Medicine (SHM). Under this $1.4 million award, built upon smaller, earlier grants, SHM has prepared a tool kit, curriculum, and roll-out process to improve the discharge process for older adult patients. BOOST helps hospitalists successfully “hand off” the patient from the hospital to the next step in care, be that home with a primary care physician, home health services, or a rehabilitation site.

The most striking thing about this story is the audience response.  On the New York Times blog related to the story, the comments are something like 77 to 1 against hospitalist care.  Now, I don’t believe that community-based docs trying to round on their patients early in the morning and interact with the hospital-based medical team between cases in the office–essentially practicing hospital medicine on a part-time basis–actually do better than hospitalists. Yet these patients seem to think so.  The blog’s comments express concerns about hospitalists knowing nothing of the patient as a person or of treatment history, and also highlight a profound lack of coordination.

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