Readmission Reduction: Multifactorial in Cause and Solution

Readmission reduction has become something of a Holy Grail: always just beyond reach. 

Elegant solutions risk creating a negative return on investment (ROI) or prove difficult to sustain. The penalties are not yet severe enough in many cases to merit substantial resources. 

But for large institutions and systems, the dollar amounts are nonetheless attention-getting. The notion that hospitals ought to do the heavy lifting is something I have always found ridiculous. In our accreditation survey four years ago, I got into a discussion with a surveyor about how readmission reduction, from a hospital perspective, in isolation, was a business decision. They disagreed, stating that readmission is a failure in discharge planning – a notion based on a non-peer-reviewed assertion from 10 years prior, put forth in an opinion piece in the American Case Management Association’s official publication. 

The industry is finally realizing that readmission is multifactorial in cause and solution. 

Many will point to population management as the solution, or better connectedness to primary care, while still others still focus on discharge planning.  The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) gives the impression that this is still front and center to the feds.

Population health initiatives are costly, and take years to realize meaningful results. Truthfully, this is unproven territory, although intuitively it makes sense. The effort is worthwhile. Private insurers have limited interest, since losses are offset by premiums or rationing of care. Therefore, there will have to be a sea change in healthcare finance, and how government spends healthcare dollars, to achieve real impact on the social determinants of health (SDoH). 

CalAIM has the potential to be a national model for the Medicaid population. Many states, however, will never be willing to spend Medicaid money differently; they are seemingly committed to simply spending less. It’s a long-term investment with an ROI into the next decade, for which many do not have the patience.

Primary care connectedness, yes! This is a proven methodology…as soon as we have enough providers, it will stand a chance. 

For those of us in the hospital, here are a few of solutions to consider:

Medical decision-making: look at readmissions within three to five days of the initial stay for actionable items. Go much further out, and I just don’t see the hospital having a role without complete vertical integration and control of the continuum of care. If a patient returns in three to five days, even to the ED, medical staff must investigate root causes and perhaps individual physician practice patterns.

Payer mix: look at the proportion of Medicare-Medicaid discharges to total discharges. Medicare readmission penalties are driven off the expected readmission rate, which is a weighted figure that essentially allows for higher readmission rates in that population. It’s a given, and there is only so much that can be done with the sickest and most financially challenged among us.

Consider longer lengths of stay (LOS) for some patients with certain conditions. Yes, that’s heresy in some circles. But studies have shown a connection between short LOS and readmission with certain high-risk conditions, most notably congestive heart failure (CHF). Some patients need to be further along the recovery curve before discharge. In five years of tracking, I can attest to the finding’s pertinence.

Finally, consider the intention of the IMPACT Act of 2014. 

Initially, I found the substance of the law, and the resulting changes to the Conditions of Participation (CoP), overly prescriptive. It is actually a well thought-out law. Patients are better prepared for discharge when they are more fully engaged in the discharge planning process. Pioneering studies over a decade ago found that patients under treatment for cancer, when multiple options were available, had improved outcomes when they were put in charge, not the doctors. Patients invested in the treatment plan are more likely to adhere to the medically prescribed regimen. The same will hold true when applied to transitions of care. Patient engagement to gain participation with and ultimately buy-in to a plan is not only a compliance issue, but something proven to work. Patients will follow a medically prescribed regimen, gain the most from post-acute providers, and connect to primary care when they have a sense of ownership in the process. 

There are, of course, access-to-care issues in poorer neighborhoods. People of color may have a well-deserved mistrust of healthcare providers. But access or not, if a patient and their preferences are not at the center of the treatment plan and transition of care, it’s unreasonable to expect blind adherence.

Since the increased LOS idea is sure to generate the most controversy, below are links to studies supporting what I have observed in five years of analysis of readmission causes. 

https://www8.gsb.columbia.edu/articles/ideas-work/do-longer-hospital-stays-lead-better-outcomes

https://www.ahajournals.org/doi/10.1161/circheartfailure.112.000265

However, it is parsed, readmission (and re-presentation to the ED) have many possible solutions. Any of them will require energy to overcome inertia, but not necessarily vast sums of money, which are unlikely to materialize.