Treat and Release: Transitions of Care Planning Should Include Medical Decision-making

Shorter ALOS was associated with increased readmissions.

Recently a fellow RAC Relief community member wrote that while 30-day inpatient readmissions had deceased under the HRRP (Hospital Readmission Reduction Program), the number of total hospital encounters, which include ED and observation revisits, have increased. Providers seek to treat and release patients from observation units or the ED for the targeted conditions. The community member referenced a study found online here: https://www.bmj.com/content/366/bmj.l4563.

He further wrote, in summary of the article, that “although reductions in readmissions have been attributed to improvements in discharge planning and transitional care, as intended by the HRRP, these declines instead appear to be due to intensified efforts to manage patients who return within 30 days of discharge in emergency departments and observation units.”

Frankly, I never bought into the concept that improvements in transitions of care planning were going to be any savior. My departments have been performing aggressive anticipatory case management for years. Handoffs to primary care providers are strong. Post-acute providers have their own readmission issues; primary care providers (PCPs) can handle patients only so early in the recovery curve.

Until a year ago, our readmission numbers looked good, and then they wandered into penalty territory.

In in an effort to find anything actionable, I looked at the role of medical decision-making, specifically the average length of stay (ALOS), for the index hospitalization. Both inpatient and observation encounters were included in the data, without differentiation as to status at index discharge or upon return. Also considered were days between index and return. A look back at the previous six months of hospital encounters was also accounted for. I was searching for anything that would inform how to view and attack the issue. The days between hospitalizations was further broken down to increments of three, seven, and 14 days, figuring these would be more revealing. They were.

What I found was that shorter ALOS was associated with increased readmissions. The margin was not wide. A decrease in ALOS of 0.5 days resulted in a disproportionate increase in readmission rate, and vice versa.

Interestingly, the ALOS of the return hospitalization was comparable to the index. A second 30-day readmission was rare. Targeted conditions were nearly matched by another: severe sepsis.

The utilization management (UM) committee, in an effort to derive actionable items, made the following informed assumption: returns within three days were completely avoidable. Since around 25 percent of readmissions occur within three days, we decided to look no further than this narrow time frame.

Drilling down on the data pointed in the direction of too much being asked of post-acute providers, expecting too much from the primary care provider (and their ability to fit hospital follow-ups into an already overburdened schedule), or the result of incomplete medical care before index discharge.

Because the return encounter ALOS is comparable to the index and subsequent 30-day hospitalization is rare, the idea that a patient can be discharged too early in their recovery curve was reinforced.

Success with HRRP is a success with individual patients, driven by adequate preparedness for discharge: this means good, early, and comprehensive transitions of care planning, which includes medical decision-making.