Why 30-Day Readmissions Are High

"There has to be a point in this whole process where reasonable people sit back and look at how the landscape is truly impacted by this focus on readmissions," he said. "We can’t allow our safety net hospitals to be further disadvantaged."

Dr. Vincent Bufalino, Senior Vice President and Senior Medical Director of Cardiology at Advocate Health Care, a 100-physician cardiology group serving 10 hospitals in the Chicago area, said he thinks the readmission rates are a bit deceptive. While the numbers are high, especially in heart failure, these are also very sick patients, he said. "I’m not so disturbed with the readmission rate, although there are obviously opportunities for us to do better," Dr. Bufalino said.

One of those opportunities is in home health. Many heart failure and acute MI patients who could benefit from home health care after discharge aren’t getting it, he said, and it’s mostly because of a paperwork burden. Physicians aren’t making the referrals for home health because the paperwork required by CMS is so daunting.

While there are plenty of areas where physicians and hospitals can do a better job at care coordination, it’s important not to set unrealistic targets that force patients to be sent home when they should be admitted, Dr. Bufalino said.

"If someone is sick and they need to be readmitted, readmit them," he said.

Lessons Learned in Heart Failure

Physicians looking to make a dent in their readmission rates for heart failure can take some cues from successful programs around the country.

While the implementation varies from place to place, programs that have been able to cut their readmissions stress the need for patients to see a physician or nurse practitioner shortly after discharge. Another essential element for success is improving the communication between providers in the hospital and those who will be caring for patients after discharge.

At the University of Connecticut Heart Failure Center, where the all-cause 30-day readmission rates for heart failure patients dropped from 27% in 2008 to under 19% in 2011, patients don’t leave the hospital without an appointment to see a physician within 7 days of discharge.

The appointment might be with a primary care physician, a cardiologist, or a physician or nurse practitioner at the university’s heart failure clinic.

"If we can’t get them in with someone else, we will always make room for them and see them," said Dr. Jason Ryan, codirector of the Heart Failure Center at the University of Connecticut, Farmington.

While patients are still in the hospital, they also meet with nurses who train them in taking their medications and monitoring for heart failure symptoms. Patients also meet with social workers who ensure they have transportation to their appointments and a way to pick up their medicines. And they spend time with a pharmacist who reviews their medications.

The other element they have employed at the University of Connecticut is community outreach. Before the push to reduce readmissions, physicians at the hospital didn’t know anyone at the nursing homes or visiting nurse organizations. Now they hold a monthly meeting with physicians and other providers who work outside the hospital. They have gone from not knowing each other’s names to exchanging cell phone numbers, Dr. Ryan said.

"So when our patients are out there we can communicate a lot more easily when problems crop up," he said.

At the University of California, San Francisco’s Medical Center, they have used similar strategies to cut their readmission rates.

The UCSF Heart Failure Readmission Reduction Program began in 2008 with a 2-year, $575,000 grant aimed at rapidly bringing down readmissions. Now in its fourth year, the nurse-run program has been a success. The 30-day all-cause readmission rates for heart failure patients age 65 and older was around 24% in 2009 but had dropped to less than 10% at the beginning of this year.

But the program couldn’t run without its two nurse coordinators, said Karen Rago, a nurse and executive director of Service Line Administration at UCSF.

"They own this population," she said. "If you don’t have a single point that owns it, there are so many things that fall through the cracks."

The nurses at the UCSF heart failure program spent the first year working with the Institute for Healthcare Improvement to learn the principles in their readmissions toolkit: teach-back, follow-up phone calls at 7 and 14 days, an appointment with a physician or heart failure nurse practitioner within 7 days, and medication reconciliation.