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Population Health News

Hospitals partner with long-term care to reduce readmissions

By Jennifer Bresnick

- The 30-day preventable readmissions penalty instituted by CMS in 2012 might not be very popular with hospitals, but it has been effective in ramping up the focus on how to keep patients from coming back to the emergency room after being discharged.  The looming financial repercussions have forced hospitals to look beyond the care their patients receive while admitted, and have fostered more integrated partnerships with long-term care organizations, hospice facilities, and other post-acute care programs to provide more robust patient education, medication adherence, skilled monitoring, and palliative care proven to aid patients after hospitalization without additional inpatient intervention.

When hospital leaders are asked about their top reasons for readmissions, care coordination and a lack of comprehensive follow-up are cited more often than anything else.   Nearly three quarters of executives cited poor post-discharge monitoring as a major cause of readmissions, with a failure to coordinate physician follow-up coming in second with 67% in a recent Health Leaders Media poll.  “In the hospital we can do the 50 things on a patient’s care plan,” explained Amedisys CMO Michael Fleming, MD, FAAFP. “But when they go back into their community, it’s totally different. So the way we care for them really has to be tailored for their community rather than when they’re in our offices or hospitals.”

For some patients, this means paying extra attention to their discharge instructions.  For others, it might involve downloading a smartphone app to help identify and manage multiple medications.  But many patients need much more help than their iPhone can provide, and that’s when hospitals must start to reach out to community-based organizations that provide home healthcare.  Seventy-three percent of hospitals include home healthcare partners in their strategies to reduce preventable readmissions, with 64% adding long-term care and skilled nursing facilities to the mix as well.

However, not all patients discharged from the hospital end up recovering from their illnesses.  In addition to managing diseases to ensure long-term health for part of the population, hospitals must consider how palliative care and hospice care can lower their in-house mortality numbers while providing patients with the most appropriate end-of-life experience available.  For late-stage cancer sufferers, for example, hospitals can work with palliative care organizations to provide adequate pain control, comfortable surroundings, and management of emotional distress for patients and family alike by offering consults to patients before hospice becomes necessary.

In a study sponsored by the American Society of Clinical Oncology, researchers found that using a specific set of criteria resulted in double the number of patients receiving a consult about palliative care, and reduced 30-day hospital readmission rates by 19% as more patients took advantage of hospices instead of expensive and aggressive treatment in the inpatient setting. “By increasing access to palliative care services, we hoped to help patients clarify their own treatment goals and, in turn, align our clinical goals with those of our patients,” said Dr. Kerin Adelson of Mount Sinai Hospital.

“Hospitals are seeing the benefit of collaborating with post-acute care partners in an effort to improve their patients’ health and prevent hospital readmissions because we can deliver such regular oversight, including strategies such as patient education before discharge, medication management and primary care physician follow-up,” Fleming said.  By building a coordinated network of care providers for patients after discharge, hospitals can extend the continuum of necessary services while avoiding steep financial penalties associated with inadequate follow-up for patients with long-term needs.



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