Personal touches help patients at risk for readmission

Personal touches help patients at risk for readmission:
Just as the government is ramping up efforts to curb readmissions, hospitals are working to keep discharged patients from bouncing back to the hospital.
Marin General and Novato Community hospitals in California, for example, are part of Advanced Care Transitions, one of the 30 Centers for Medicare & Medicaid Services pilots nationwide, aimed at reducing Medicare costs by $8.2 billion by 2019, Marin Independent Journal reported. The two hospitals target about 700 of the highest-risk Medicare patients with heart failure, pneumonia, diabetes and other chronic conditions.

The county plans to hire two new nurses as transitional coaches, who will meet with patients before discharge and post-discharge at home. Not only are the hospitals improving the discharge process, but they also are making sure patients take their medications during the post-discharge home visit and through patient education.
Having someone the hospital can refer patients to for follow-up after they return home "is something we haven't had in the past," Mary Strebig, a spokesman for Novato Community Hospital, said in the article.
Like the Marin hospitals, Glendale, Calif., hospitals are similarly targeting high-risk patients with heart attack, congestive heart failure and pneumonia, as one in five of those high-risk patients readmit to the hospital within 30 days, according to Glendale News-Press.
The Glendale Healthier Community Coalition created a task force to look at the annual 40,000 patients discharged from area hospitals. The task force not only looks at provider reasons to readmissions but also the patient's situation, such as whether the patient is homeless or foreign-born, which might affect their ability to care for themselves.
"Even going 12 to 18 hours without their medication could already put them on a trajectory for readmission," Bruce Nelson, director of community services at Glendale Adventist Medical Center and cochair of the task force, said in the article.
Nelson said case managers at hospitals are helping with tasks, such as transportation to doctors' offices and refilling prescriptions, as well as coordinating care across the continuum, including skilled nursing facilities.

CMS this month launched two programs, the Community-based Care Transitions Program and Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. CMS has dedicated $500 million to Partnership for Patients funding. The Partnership's two goals are reducing hospital readmissions by 20 percent over a three-year period and reducing harm in hospital settings by 40 percent.

For more information:
- read the Marin Independent Journal article
- here's the Glendale News-Press article

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Supreme Court gets to crux of health reform

Supreme Court gets to crux of health reform:
One of the most highly anticipated U.S. Supreme Court cases in recent memory kicked off yesterday. Inside the Court, testimony was often technical and even dense, while, outside the court, the atmosphere was lively with a gathering of protesters, reporters, pundits, politicians and curious spectators. In fact, the fun started on Friday, when folks (including professional line-standers) started lining up outside the court, in hopes of grabbing a coveted seat.
Yesterday's arguments before the Supreme Court centered on whether the Court can rule on the Affordable Care Act and its "individual mandate" provision, which requires all Americans to have health insurance by 2014 to avoid paying a penalty when they file their tax forms in 2015.
The question in yesterday's case: Is the penalty for not having health insurance a fee, or is it a tax?
If it's a tax, the justices could bow out under the 1867 Anti-Injunction Act, which says the court can't hear a case about unconstitutional taxes before plaintiffs actually have paid the tax, which won't happen until 2015.
Both sides agree on this one matter: The case should be litigated now. In fact, the court had to appoint an attorney, Robert Long, to argue the opposite because neither side wanted to do so. Among his arguments: There is no criminal penalty for not paying the fee and, if the court grants exceptions, it will lead to a flood of litigation.
But the litigants will argue that the individual mandate requires people to buy a commercial product and is unconstitutional for that reason.
Justice Ruth Bader Ginsburg said the tax issue is "beside the point" and questioned Long about the "must-buy" aspect of the case. "... All this talk about tax penalty--­it's all beside the point because this suit is not challenging the penalty. This is a suit that is challenging the must-buy provision, and the argument is made that, if, indeed, 'must-buy' is constitutional, then these complainants will not resist the penalty," she said.
"So, what they're seeking is a determination that that the 'must-buy' requirement, stated separately from the penalty, that 'must-buy' is unconstitutional. And, if that's so, that's the end of the case; if it's not so, they're not resisting the penalty."
It is notoriously difficult--if not downright foolish--to try to guess what the Supreme Court will do based on their questions during oral arguments. Even if they often start statements with the phrase, "It seems to me," the justices play the role of devil's advocate frequently and well.
But there's a general consensus that they will rule on the ACA cases scheduled for today and tomorrow. On Monday, justices pointed out that they've put aside or made exceptions to the Act in order to rule on other cases.
"I don't usually make predictions but I thought it was pretty clear that the justices are going to rule on the Affordable Care Act. The only question is what the rationale is going to be," Nina Totenberg, who covers the court for NPR, said in an audio interview yesterday on NPR's Shots blog.
"[Justice Clarence] Thomas was the only justice who didn't ask any questions. He hasn't asked any questions in six years so we don't know what he's thinking," Totenberg said. "But other than that [I saw] a bunch of justices groping for a way to get to the merits of this case and get over this hurdle."
For the gamblers out there, FierceHealthFinance Editor Ron Shinkman is offering 7 to 1 odds on whether Thomas will ask a single question during the three days of arguments. Odds that the Court will strike down the individual mandate are five to six, and it's even money that ACA will prevail in its entirety, he said.
The Supreme Court is set to announce its ruling on the ACA cases later this summer.
In today's case, The Department of Health & Human Services v. Florida, et al, attorneys will get to the real heart of the matter: Can the federal government require U.S. citizens to get health insurance or face paying a penalty?
"[Tuesday] is really the 'main event' from the perspective of many organizations, politicians, businesses and individuals who have been involved with or just have followed the debate over the constitutionality of the new health care law, Marcia Coyle of the National Law Journal told PBS News Hour in a guide to day two of the ACA arguments.
To learn more:
- listen to an audio recording of yesterday's oral arguments or read the transcript (.pdf) of yesterday's session
- see the docket that lists all the ACA cases before the court, including case filings
- read the NPR Shots blog article and listen to Nina Totenberg's recap and analysis of Monday's oral arguments
- see the News Hour roundup of day one and guide to day two of the ACA arguments
- hear from would-be spectators who spent their weekend waiting in line for a seat in the courtroom
- check out the Bettor's guide to health reform at the Supreme Court from FierceHealthFinance

Hospital checklists cut readmissions, Medicare costs

Hospital checklists cut readmissions, Medicare costs:
In another win for in-hospital checklists, new research finds that a simple, one-page checklist can keep heart patients out of the hospital, as well as save Medicare billions of dollars, according to a presentation Saturday at the American College of Cardiology's (ACC) annual scientific session.
After using the 27-question checklist before discharge, 30-day readmissions significantly dropped from 20 percent to 2 percent. The checklist focuses on medications and dosage modification, counseling and monitoring intervention, and follow-up instructions, according to information from the ACC.
"In addition to lowering 30-day and six-month readmissions and the associated costs, we also showed that more patients in the checklist group were likely to be on correct medications and had appropriate drug doses than patients in the control group," study lead investigator Abhijeet Basoor of St. Joseph Mercy Oakland Hospital in Pontiac, Mich., said in a statement.
According to the researchers, the checklist takes only a few minutes to administer and has no costs or side effects, reported USA Today.

Meanwhile, another ACC study of public hospitals in Brazil found that checklists and color-coded signals significantly boosted physician adherence to evidence-based treatment for patients with acute coronary syndrome, MedPage Today reported.
"[I]f patient care can be improved when adoption rates are more in the 'middle range,' then our results are relevant to rest of world and to the U.S. for diseases other than ACS, for which evidence-based medicine uptake is much less common," study authors wrote in the Journal of the American Medical Association.
To learn more:
- read the ACC press release
- here's the USA Today article
- read the MedPageToday article

CMS ramps up efforts to keep patients out of hospital

CMS ramps up efforts to keep patients out of hospital:
The Centers for Medicare & Medicaid Services made two announcements this week with the explicit goal of keeping patients out of the hospital.
One of the programs looks to keep patients from bouncing back after hospitalization. On Wednesday, CMS added 23 sites to its Community-based Care Transitions Program, aimed at preventing high-risk Medicare patients from being readmitted. Community-based organizations work with other providers to transition patients from the hospital to their homes, nursing homes or other facilities. As part of the two-year agreement, each participating organization will get a flat fee for coordinating care.

With this round of agreements, CMS has allocated half of the $500 million of the anticipated program spending over five years to the Community-based Care Transitions Program.
The newly added sites bring the total number of participants to 30 providers, including the seven announced in November. The program will support more than 126 local hospitals and help more than 223,000 Medicare beneficiaries in 19 states, according to CMS.

"I've seen the very real difference that support from organizations like our partners in the Community-based Care Transitions Program can make to people's post-hospital care and their health," CMS Acting Administrator Marilyn Tavenner in the Wednesday announcement.
The other program that CMS touted this week similarly looks at coordinated care. CMS yesterday announced the $128 million Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents.
CMS will partner with independent organizations to improve care for long-stay nursing facility residents on Medicare and Medicaid, facilitating transitions to and from inpatient hospitals and nursing homes. Each organization proposes evidence-based intervention and an improvement strategy, targeted at preventive services and improved communication between providers.
"Being readmitted to a hospital is very difficult for low-income seniors, people with disabilities and their families," Tavenner said in yesterday's statement. "Through this initiative, we will work with nursing facilities and hospitals to provide better, person-centered care. By catching and resolving issues early, we can help people avoid costly and stressful hospitalizations."
About 45 percent of hospital admissions of patients who receive Medicare skilled nursing facility or Medicaid nursing facility services could have been avoided, CMS said. That accounted for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005.

For more information
- read the CMS announcement and program details on care transitions
- read the statement and program details on nursing homes
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ACOs changing economics

ACOs changing economics:
Could health reform, and more specifically, accountable care organizations be slowing down healthcare spending? That's the hope, and for some, evidenced by recent data, Think Progress noted.
The Congressional Budget Office made a major revision to its 10-year Medicare spending projection by decreasing estimates by $69 billion, Paul Ginsburg and Chapin White at the Center for Studying Health System Change, in Washington, D.C., wrote in the New England of Journal of Medicine last week. "[W]e do not believe that the recent slowdown in Medicare spending growth is a fluke," they wrote. "There has been a long-term trend toward tighter Medicare payment policy, and policy changes that began in the middle of the 2000s have continued that tightening."
Part of the major change under health reform is ACOs, charged with changing the payment models for provider and payer reimbursements, as well as quality care outcomes.

ACOs are a "major game-changer," Karen Davis, president of the Commonwealth Fund, said in The Wall Street Journal.
The New York Times also highlighted the economic shift. However, some critics worry that the ACO change comes with too much risk and administrative burdens.
"The costs are going to accrue to the providers, but the benefits are going to accrue to everyone else," said Joseph Golbus, president of NorthShore University HealthSystem's medical group in Illinois. "What I think killed H.M.O.'s in the '90s was limiting access to patients and telling the doctor he is now worth 17 cents per member, per month. We don't want to see that again."

But ACO advocates insist that accountable care is not a repeat of HMO economics. For instance, ACO members can choose whatever provider they want to receive care from.

"This is not about restricting care, but to proactively coordinate care and to ensure that the patients' needs are met early in the process," Jonathan Blum, deputy administrator at the Centers for Medicare & Medicaid Services, told The Times.
Advocate Health Care, provider of the largest commercial ACO, located in Chicago, said the benefits of ACOs go beyond pure financials. For example, care managers who help patients with appointments, diet, exercise and meals address the ACO's 200,000 members insured by Illinois Blue Cross plans.

"A care manager may care for up to 150 patients, and the savings from keeping these patients healthy, and potentially out of the hospital, pays for their salary several times over," said Lee Sacks, chief medical officer at Advocate, in the article. "But it's more than just the economics. It's the right thing to do."

For more information:
- see the Think Progress blog post
- here's the NEJM article
 - read the NYT article
- here's the WSJ article (subscription required)

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Readmission rates higher with chronic conditions

Readmission rates higher with chronic conditions:
Hospital readmission rates for chronic conditions are substantially higher than rehospitalizations for acute conditions, regardless of payer or age group, the Agency for Healthcare Research and Quality (AHRQ) announced yesterday. For example, conditions such as congestive heart failure or diabetes had higher incidences of patients bouncing back to the hospital than for an acute cases like pneumonia or heart attack.
"Readmission rates were consistently higher for non-surgical hospitalizations," the report states.
In 2008, one in five nonsurgical cases had a 30-day readmission, compared to one in eight surgical cases.
According to AHRQ's latest numbers, readmission rates for nonsurgical hospitalizations for chronic conditions was 23 percent, compared to 19 percent for acute conditions in elderly Medicare patients (over 65). For Medicaid patients age 18 to 44, it was 26 percent for chronic conditions versus 19 percent for acute conditions, that is, about one-third higher. In children under 17, the readmission rate was two-times higher, regardless of whether the initial stay involved surgical treatment, according to the data.
However, in privately-insured adults, ages 45 to 64, the 30-day readmission rate following surgical hospitalizations was similar across chronic and acute conditions.
The numbers which came from inpatient databases for 15 states (Arkansas, California, Florida, Hawaii, Louisiana, Massachusetts, Missouri, Nebraska, New Hampshire, New York, South Carolina, Tennessee, Utah, Virginia, and Washington) represent 42 percent of the U.S. population, according to the report.

Although the report didn't specify why readmission rates were higher for chronic conditions over acute conditions, it did point to associated factors of chronic cases: limitations on self-care, independent living and social interactions, as well as the need for ongoing intervention with medical products, services and special equipment.

As a quality measure with reimbursements on the line, hospitals are certainly keeping a watchful eye on their readmission rates.
For more information:
- read the AHRQ press release
- check out the data

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Patient-centered care 'flawed' with consumer focus

Patient-centered care 'flawed' with consumer focus:
Despite the trend in the catchphrase, "patient-centered care" is a flawed way of putting it, wrote Charles L. Bardes of New York's Weill Cornell Medical College in a New England Journal of Medicine (NEJM) article, published Thursday.

First coined in 1969 by British psychoanalyst Enid Balint, the term implied taking into account a patient's social context to deal with illness. Patient-centered care, however, in today's environment focuses too much on the consumer, Bardes said. The purpose of the patient shifted from obeying to purchasing, now with a strong emphasis on marketing and branding, he explained.

"If the patient is reconceived as a consumer, new priorities take center stage: customer satisfaction, comparison shopping, broad ranges of alternatives, choice, and unimpeded access to goods and services," he wrote.
Bardes's position is much like an earlier NEJM article by two Beth Israel Deaconess Medical Center physicians who voiced concerns about industrialized patient care. Pamela Hartzband, assistant professor of medicine at Harvard Medical School, and Jerome Groopman, chair of medicine at Harvard Medical School and chief of experimental medicine at the Beth Israel, described hospitals like "factories" and patient encounters like "economic transactions," further explaining that the "consumer" term was inappropriate.

However, others see the trend of patients as the focus as undeniable. Patient-centered care could mean simply looking at the individual, perhaps more appropriately (or inappropriately) named "personalized medicine."

Kent Bottles, senior fellow at the Thomas Jefferson University School of Population Health, said personalized medicine is a trend that healthcare executives can't ignore, in today's Hospital Impact blog post. The important trend is personalized medicine that concentrates on the individual not the population, Bottles said. For example, cancer screening by mammography after age 40 in women and colonoscopy after age 50 in men and women does not take into account the different genetic predispositions for breast cancer and colon cancer in individual patients.

As the debate rages on about patient- versus physician-centered care, Bardes suggested a better term that combines the shared investment in care.

"The flaw in the metaphor is that the patient and the doctor must coexist in a therapeutic, social, and economic relation of mutual and highly interwoven prerogatives. Neither is the king, and neither is the sun," Bardes said. He continued, "Patient and physician must therefore meet as equals, bringing different knowledge, needs, concerns, and gravitational pull but neither claiming a position of centrality."

For more information:
- read the NEJM article

Geisinger plan reduces readmissions 44% with telemonitoring

Geisinger plan reduces readmissions 44% with telemonitoring:

Geisinger Health Plan, based in Danville, Pa., reports that its use of a home telemonitoring program for patients with congestive heart failure reduced their readmission rate by 44 percent, compared to a control group. The success of the telehealth program, which incorporated technology from AMC Health, has prompted Geisinger to expand it to include patients with hypertension and diabetes.

The core of the heart failure program is an interactive voice response (IVR) system that asks discharged patients a series of questions about their symptoms after they have submitted their weight.

In the two-year study, Geisinger compared the 30-day readmission rates of patients who received only case management with those who both had a case manager and used the telemonitoring system. Eighty-five percent of the patients in the study used this system regularly.

Today, about 1,000 patients with congestive heart failure are utilizing the telemonitoring system at any given time. According to Geisinger, the technology has allowed the case management program to accommodate more patients than it previously could.

A survey of Geisinger case managers found that most believed the telehealth program helped keep their patients out of the hospital. Nearly all of them found that the system enabled them to monitor the patients more efficiently.

A large-scale 2008 study by the Veterans Health Administration (VHA) of several telehealth technologies found that they reduced the number of hospital bed days by 25 percent and hospital admissions by 19 percent. A recent report prepared for the U.K. National Health Service said the U.K. should follow the VHA's example.

To learn more:
- read the Geisinger announcement
- see the VHA study

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Transitional care life coaches, clinics save hospitals thousands

Transitional care life coaches, clinics save hospitals thousands:
Hospitals in Virgina are trying to keep patients from returning to the hospital by bolstering the shift to outpatient care, reported The Virginian-Pilot. For instance, Bon Secours Hampton Roads Health System in Norfolk, Va., has found that using hospital "life coaches" reduces preventable readmissions and saves money.
The life coaches--or medical life coach navigators--connect low-income and uninsured patients with free or reduced-price care at nearby clinics. Of the 1,000 patients seen by the hospital's two life coaches in 2010, only two came back to the emergency room for the same complaint that year. Meanwhile, 90 percent followed through with the coaches' plans for ongoing care.
The life coaches, both licensed practical nurses, also saved the hospital about $150,000 in 2010, according to Catholic Health World.
As the life coach program expands, Bon Secours Hampton Roads is examining whether coaches paid by the hospital or an external agency are more successful, hospital spokeswoman Lynne Zultanky told Catholic Health World.
With similar goals in mind, Chesapeake (Va.) Regional Medical Center has launched a transitional care clinic, which costs about $102,000 to run, noted the Virginian-Pilot.
Providers examine uninsured chronically ill patients within two weeks of their hospital stays. And within two months, they arrange ongoing primary care, usually at a free clinic. Despite the operational costs, the transitional clinic could save Chesapeake Regional about $400,000 a year, according to an analysis of the first seven months.
For more information:
- read the Virginian-Pilot article
- check out the Catholic Health World piece
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