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Population Health News

Early Follow-Up Cardiac Care Cuts 30-Day Readmissions by 19%

When providers contact heart failure patients within a week of discharge, the chance of a costly 30-day readmission drops significantly.

- Patients who follow up with their care providers within one week of ending a hospital stay for heart failure are 19 percent less likely to experience a 30-day readmission than patients who are left alone for longer periods. 

Population health management and 30-day readmissions

"Heart failure poses a substantial health and economic burden nationally and is expected to grow significantly in the next several decades," said Alan S. Go, MD, Chief of Cardiac and Metabolic Conditions at the Kaiser Permamente Northern California Division of Research.  Go is also the senior author of the study, which was published this week in the journal Medical Care.

In 2013, close to 400,000 patients experienced a hospital stay due to heart failure, according to recent data from CMS.  Heart failure is one of the top ten DRG codes used for Medicare payments, and the chronic condition contributes significantly to the $17 billion CMS spends each year on preventable hospital readmissions.

Preventable readmissions, especially those that occur within 30 days of discharge, aren’t just a drain on the Medicare system.  They can also directly impact the revenue of hospitals themselves thanks to CMS quality programs that include penalties for high rates of multiple admissions. 

In 2014, 2610 hospitals forfeited up to three percent of its Medicare reimbursements due to unacceptable numbers of 30-day readmissions, with the payment reductions totaling close to half a billion dollars across the healthcare system.

Preventing readmissions for heart failure patients hinges on meaningful follow-up and care coordination, the Kaiser Permanente researchers found.

The investigators examined data on nearly 12,000 adults hospitalized for heart failure in 2013 and subsequently discharged to their homes.  Of those patients, 1587 were readmitted to the hospital within 30 days of discharge. 

Approximately 70 percent of patients received either a clinic visit or a phone call with their provider within 30 days of discharge.  Half of those patients spoke to a provider within one week of returning home.  Eighty-four percent of the patients made a trip to the clinic, while the rest received phone calls.

The study found that contact from a healthcare provider within one week of discharge was associated with a 19 percent reduction in the likelihood of a 30-day readmission. 

Forty-five percent of follow-up phone calls were placed by a non-physician care provider, the study notes, such as a care manager, registered nurse, nurse practitioner, or physician assistant. 

These calls can help providers make sure that their patients truly understand their discharge instructions, have access to any prescriptions they might need, and are establishing good medication adherence habits during the early days of developing a healthy new routine.

"Our results imply that clinicians may be able to leverage the increasing integration occurring in health care to improve the effectiveness of transitional care and reduce hospital readmissions in high-risk populations," said Go.

Providers are increasingly leveraging team-based care to complete this type of population health management task, which does not necessarily have to be initiated by the physician.  Some providers are even finding that an automated telephone system that includes prompts for patients to answer queries about their needs is a cost-effective way of conducting follow-up activities while reducing labor costs.

"These data suggest that health systems can implement different methods of systematic, early patient contact to improve transitional care and, ultimately, clinical outcomes," said lead author Keane K. Lee, MD, MS, a cardiologist also affiliated with Kaiser Permanente Northern California.

"Once the patient is back home, a phone call within a few days with either a physician or non-physician care team member may be more practical to implement by many health care delivery systems compared with clinic visits for all patients."

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