BUILDING A TRANSITION HOME MODEL TO REDUCE PREVENTABLE HOSPITAL MEDICARE READMISSIONS

By: Dennis L. Kodner and Arthur Y. Webb November 2011

SUMMARY This paper presents an analysis of the preventable readmission dilemma, its impact on patients, hospitals and the health system, as well as what we have learned from the research literature and several innovative transitional care programs with encouraging results. There is no one size fits all approach to this complex challenge. Based on our understanding of the growing evidence base, therefore, we are proposing another promising model called the Transition Home. The idealized framework for this new approach is sketched briefly. We believe that the Transition Home can be implemented using best practices in care management. INTRODUCTION AND BACKGROUND This paper presents an idealized model of a comprehensive transitional care program for Medicare patients1 to strengthen the discharge planning process and reduce preventable, or avoidable or unnecessary, readmissions to the hospital. The model, which we refer to as a transition home,2 is envisioned as a partnership between a multi-hospital consortium and a care management company. Before sketching our idealized model, we briefly examine the revolving door of hospital admissions. The following discussion focuses on the very significant implications of preventable admissions for patients, hospitals, and the overall health system, as well as its many underlying causes. It also summarizes what a combination and research and successful initiatives tells us work best in reducing preventable readmissions, including the potential impact on hospital utilization and costs.

1 While our emphasis is on Medicare patients, there is no reason why the proposed model program could not be modified and expanded to target patients with Medicaid and private insurance. 2 The term home in transition home is used in the same way it is in the medical home and health home models, i.e., as a reference to a specialized approach and center of activity.

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LOOKING AT PREVENTABLE REHOSPITALIZATIONS3 Hospitalizations are one of the most expensive types of care in the U.S. health system; they account for 31% of total health care expenditures.4 According to the American Hospital Association (AHA), about one-third of the total $2 trillion spent on health care is the result of hospital care.5 Despite this enormous outlay, a substantial portion of all hospitalizations are for patients who return relatively soon after discharge, often within 30-days.6 These readmissions are potentially harmful, costly, and frequently avoidable.7 According to MedPAC, about 18% of all Medicare hospitalizations are 30-day readmissions accounting for $15 billion in spending.8 Others believe that as many as 20% of all live Medicare fee-for-service discharges are rehospitalized within 30-days.9 (Rehospitalizations within one year of discharge are even higher.) Not all of these rehospitalizations are avoidable, but as many as 75% are potentially preventable.10 Heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), and acute myocardial infarction (MI) are the lead medical conditions; coronary artery bypass (CABG), percutaneous transluminal coronary angioplasty (PTCA) and other vascular procedures lead the surgical conditions.11 In addition to these specific discharge diagnoses and procedures, studies show that having a disability and living in poverty are also associated with readmissions.12 Finally, relatively high readmission rates are experienced by Medicare beneficiaries with multiple chronic conditions. In a major study, the mean readmission rate for this cohort was 34%.13 Dual eligiblesMedicare beneficiaries who are enrolled in state Medicaid programsalso account for a sizeable share of preventable hospitalizations; the rate of stay for rehospitalized dual eligibles age 65 to 74 is nearly 2 to 4 times the rate for non-dual eligibles, except for injurious falls.14 Parenthetically, Medicaid patients who are disabled and/or chronically ill experience rates of avoidable rehospitalization that are similar to the above Medicare experience. The likelihood of readmission for this Medicaid group is 16%, but increases to 53% within one year. 15

3 Preventable readmissions refer to readmissions that are clinically related to prior admissions. There must be a reasonable expectation that the readmission could have been prevented if there were better quality of care during the prior admission, adequate discharge planning and follow-up, and/or improved coordination between inpatient and outpatient care teams; see Minot, J. Reducing Hospital Readmissions, AcademyHealth, 2008. 4 Ibid. 5 American Hospital Association (AHA). The Economic Contribution of Hospitals, 2010. Online at: http://www.aha.org/ content/00-10/2010econcontrib.pdf 6 See Goldfield, N. et al., Identifying Potentially Preventable Readmissions, Health Care Financing Review, 30 (1), 2008. 7 Bisognano, M. and Boutwell, A., Improving Transitions to Reduce Readmissions, Frontiers of Health Services Managemment, 25(3):3-10, 2008. 8 Medicare Payment Advisory Commission (MedPAC). Payment Policy for Inpatient Readmissions: Promoting Greater Efficiency in Medicare. Report to Congress. Online at: http://www.medpac.gov/documents/Jun07_EntireReport.pdf. 9 For example, see Mulvany, C., Preventable Readmissions: A Prime Target for Reform, HealthCare Financial Management Association, 2009; Goldfield, N. et al., op cit. 10 MedPAC, op cit. 11 Jencks, S. et al., Rehospitalizations among Patients in the Medicare Fee-for-Service Program, New England Journal of Medicine, 360: 1418-28, 2009. 12 Jencks, S. Presentation at National Hospital Payment Reform Summit, Washington, DC, September 17, 2009. 13 Soeken, K. et al., Predictors of Hospital Readmission: A Meta-Analysis, Evaluation & the Health Professions, 14 (3): 262-81, 1991. 14 Agency for Healthcare Research and Quality (AHRQ), Potentially Preventable Hospitalizations among Medicare-Medicaid Dual Eligibles, 2008. Statistical Brief #96, September 2010. 15 Center for Health Care Strategies (CHCS). Hospital Readmissions among Medicaid Beneficiaries with Disabilities: Identifying Targets of Opportunity. Faces of Medicaid Data Brief, December 2010.

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ROOTS OF THE PROBLEM AND RATIONALE FOR ACTION Readmissions occur for various reasons and circumstances. They may be the result of sub-optimal care during the initial hospital stay,16 inadequate rehabilitation, early/premature discharge, poor discharge planning, and lack of follow-up medical attention, medication problems, and inadequate home care arrangements to name the most obvious triggers. However, many other factors and patient characteristics play a role: lower socioeconomic status, low literacy, non-English speaking, living alone, unmarried/ widowed, reduced social network, and poor transportation access.17 Preventable rehospitalizations, in particular, have been found to be related to gaps in transitional care planning, failures in communication (with patient, family care givers, and community physicians and other health care providers), and delays in scheduling post-hospital care. 18 There are five (5) reasons why avoidable rehospitalizations should receive priority attention. First, such readmissions affect patients peace of mind and can be unsafe and unhealthy. Second, they represent enormous waste, especially during these economically challenging times. Third, they point to a serious weakness in our health care system, i.e., poorly managed interfaces between settings, and the persistence of fragmented and disjointed care. Fourth, they represent low-hanging fruit that do not require rocket science to fix.19 And, fifth, a new Medicare policy beginning on October 1, 2012 will assess a payment penalty on hospitals with excessive 30-day readmission rates for three conditionsheart attack, heart failure, and pneumonia; the list of conditions and size of penalties will increase in subsequent years. 20 LESSONS FROM RESEARCH AND BEST PRACTICE A survey of published evidence prepared by the Institute of Healthcare Improvement (IHI) shows that there are many potential strategies to reduce preventable rehospitalizations; they cut across four (4) main categories: 1) enhanced care and support during transitions; 2) improved patient education and self-management support; 3) multidisciplinary team management; and, 4) patient-centered care planning at the end of life.21 Space does not permit a detailed discussion of the various approaches. The most promising approaches include the following: X Close coordination of care in the post-acute period; X Enhanced patient education and self-management training; X Proactive end-of-life counseling; and, X Extending the clinical and management expertise of the team to the patient over time.
16 Although excellent inpatient care may also result in a subsequent rehospitalization. 17 For example, see Greenwald, J. and Jack, B. Preventing the Preventable: Reducing Hospitalizations through Coordinated, Patient-Centered Discharge Processes. Professional Case Management, 2009; Minott, J., op cit; and, Epstein, A., Revisiting Readmissions: Changing the Incentives for Shared Accountability, New England Journal of Medicine, 360(14): 1457-9, 2009. 18 Bisognano, M. and Boutwell, A., op cit. 19 American College of Healthcare Executives (ACHE), Reduced Readmissions: Reforms Low-Haning Fruit, Healthcare Executive, March/April 2011. 20 Ibid. 21 Boutwell, A. and Hwu, S., Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence, IHI, March 2009.

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A companion IHI study presents a compendium of 15 promising programs to reduce rehospitalization.22 Three (3) reported interventions focused specifically on improving the discharge planning/ coordination process and care transition processes, and are based on very strong trial or evaluation data. These models are: X Project Re-Engineered Discharge (RED), developed by Brian Jack, MD at the Boston University Medical Center. A specially trained nurse called the Discharge Advocate educates the patient about her/his diagnosis throughout the hospital stay; reconciles the discharge plan with standard care and organizes the discharge process; makes appointments for physician follow-up and tests; provides the patient with a written discharge plan and makes sure she/he understands; and, follows-up with the patient several days after discharge to help solve any problems.23 X Transition Care Model, developed by Mary Naylor, PhD, RN at the University of Pennsylvania School of Nursing. Focusing on high-risk elderly patients, a trained nurse called a Transitional Care Nurse acts as the primary coordinator of care. This includes in-hospital assessment and the development of an evidence-based care plan; ongoing post-discharge telephone support and home visits (24-hours/day, 7-days/week) to monitor the care plan for up to 2-months; emphasis on early ID of health care risks and symptoms and avoidance of adverse events; active engagement of patients and families; and, communication with the patient, family caregivers, physicians, and other health care providers. 24 X Care Transitions Program, developed by Eric Coleman, MD, MPH at the University of Colorado Health Services Research Center. This four-week program focuses on community-dwelling patients age 65 and older; it is designed to improve care transitions by fostering improved patient self-management. The program centers on the use of a specially trained nurse or nurse practitioner called the Transition Coach. There are four (4) main program components: 1) medication self-management; 2) patient-centered health record (PHR); 3) physician follow-up; and, 4) patient knowledge of red flags or warning symptoms and how to respond. The Transition Coach speaks with the patient on post-discharge days 2,7, and 14, and also makes home visits. She/he also assists the patient in updating the PHR, and also reconciles any medication discrepancies. Finally, role-playing is used by the Transition Coach to help prepare the patient for follow-up visits and provider interactions.25 In summary, the programs were not only effective in reducing readmissions, but also suggest considerable cost-savings potential.
22 Boutwell, A. et al., Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions, IHI, 2009. 23 Jack, B. et al., A Reengineered Hospital Discharge Program to Decrease Rehospitalization, Annals of Internal Medicine, 150: 178-87, 2009. The program significantly reduced post-discharge ED utilization and rehospitalizations. 24 Naylor, M. et al., Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial, Journal of the Amerucan Geriatrics Society, 52:675-84, 2004; also Naylor, M. et al., Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders: A Randomized Clinical Trial, JAMA, 281:613-20, 1999. These two randomized, controlled trials documented fewer rehospitalizations, improved patient satisfaction, and lower overall health care costs. 25 Coleman, E. et al., Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention, Journal of the American Geriatrics Society, 52(11): 1817-25, 2004; https://www.innovativecaremodels.com/care_models/12; Coleman, E., CMS Learning Session: The Care Transitions Intervention. December 20, 2007. Patients in the program were significantly less likely to be rehospitalized than controls; also the time to rehospitalization was significantly longer than controls. Finally, investigators estimated almost $300,000 in savings for 350 patients over 12-months.

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BUILDING A TRANSITION HOMEAN IDEALIZED MODEL The models sketched above are not the end-all or be-all in transitional care management. Based on our understanding of the growing research literature and best practice results, we propose an idealized framework for an alternate model which we refer to as the transition home. The transition home is a comprehensive transitional care program for Medicare patients delivered by a care management company under contract to a group of hospitals.26 We see the transition home being paid two fees: 1) a monthly sum for implementing planned system-wide changes at the hospital level; and, 2) an all-inclusive rate per eligible discharge based on the cost of the care transition services at the patient level. With appropriate data, it is conceivable that the all-inclusive rate could be risk-adjusted to reflect the complex of characteristics, resources and costs involved working with specific patient target groups. TARGETING Targeting is the holy grail of readmissions.27 There are a variety of readmission risk assessment tools that can be used to generally stratify risk, although none are perfect.28 A more direct, personcentered approach would be to identify Medicare patients age 65+ with one or more specific chronic conditions (or procedures) known to be associated with especially high rates of preventable readmissions plus at least one other chronic condition: For example, CHF and/or Diabetes and at least one (1) other chronic condition. Other factors could also be considered, e.g., poor self-health ratings, history of hospitalizations within past 6-months, caregiver assessed as stressed or overburdened, living alone, etc. At the center of the transition home will be a Transition Counselor, a specially-trained nurse who will work with patients fitting the program targeting criteria. The Transition Counselor would be backed up by consultants specializing in social work and care management.29 The Transition Counselor will perform a pre-discharge assessment of the patient; develop a customized, but evidence-based transition plan; ensure that patients and family caregivers understand the post-discharge instructions and are able to meet self-care needs; reconcile medications for discharge; assist the patient/family in filling prescriptions, making follow-up physician appointments, and arranging medical transportation; provide real-time critical information to the next providers (receiving physician, home health agency, etc.); and, generally support the patient/family, including problem-solving and help with community referrals and resources for up to 30-days after discharge. Much of the focus on these activities involves patient and family engagement; this is critical to improving care transitions and curbing avoidable readmissions.

26 Initially, the program could begin at one hospital with a small group of patients. Once the model is tested and refined, it can be expanded to the entire hospital and then to other hospitals taking part in the consortium. 27 Advisory Board International, Preventing Unnecessary Readmissions: Extending Accountability for Positive Patient Outcomes, 2011. 28 For example, the LACE Index, PARR, and Prediction Model of Hospital Readmission in General Medicine Patients. 29 Foreign language capabilities and knowledge of local health care-related resources would be essential.

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INTERACTIONS WITH PATIENT AND FAMILY CAREGIVERS To effectively manage each patients transition, the Transition Counselor will make at least one inhospital visit, one in-home visit, and maintain on-going contact telephone (regularly scheduled and in emergency situations) with the patient and family caregivers. Depending on the level of risk involved, the Transition Counselor could make additional home visits and even visit with the patient for the first post-discharge medical appointment. The first follow-up phone call would be made within 48-hours of discharge. Teach-Back would be used by the Transition Counselor in all interactions with the patient/family. 30 PUBLIC POLICY FACTORS AFFECTING REHOSPITALIZATIONS AND CAVEATS This paper was not prepared with any particular federal or state policy initiatives taking place in a particular state. Also the specific application of this model to any setting or collaborative approach was not taken into account. We also didnt take into account the financial modeling that would be necessary to assess risk and reward or the challenges to implementation of any particular model.

*This paper was authored by Dr. Dennis L. Kodner and prepared with the support of the Author Webb Group, Inc. Dennis Kodner, PhD, FGSA is a global thought leader on health systems/services integration. He is an expert on coordinated care and managed care systems for people with chronic, disabling, medically complex, and high-risk conditions, including the frail elderly and those whose needs cut across the health, long term care, mental health, and social service systems. Arthur Y. Webb Mr. Webb has extensive experience in the policy and practice areas of serving high needs, high cost individuals. See www.arthurwebbgroup.com

30 Teach-Back is an important health literacy tool and communication method to enhance the capacity of patients and family caregivers to make sure they understand what they have been told by the health care provider. In essence, it asks individuals to explain or demonstrate what the provider told and/or taught them.