Question

Given the significant challenges with patient readmissions within 30 days of discharge, there is a need for additional local analysis by nurses providing patient care.

Question 1: As an experienced nurse, identify and describe (in detail) the specific opportunities at the institutional, organizational, public, social, and health policy levels to decrease and improve patient readmission rates with 30-days. Which key stakeholders need to be involved in addressing this issue.

Question 2: How will you evaluate progress at each policy level when changes are made?

Answer 1

Discharging patients from the hospital is a complex process that is fraught with challenges and involves over 35 million hospital discharges annually in the United States. The cost of unplanned readmissions is 15 to 20 billion dollars annually. Preventing avoidable readmissions has the potential to profoundly improve both the quality of life for patients and the financial wellbeing of health care systems.

Hospital readmissions are increasingly a public policy concern due to the cost and quality burdens and public reporting is a key component of a growing number of state transparency and health care reform initiatives.

States, federal agencies, and private payers are searching for ways to reduce or contain cost and improve quality of care. Payment changes in Medicare are fast-tracking the measurement and scrutiny of hospital readmissions, though the issue is an all-payer one, not just Medicare. States have been at the forefront of public reporting on health care access, cost, and quality information generated from their statewide hospital discharge data reporting systems.

The role that the various stakeholders—health plans, hospitals, suppliers, employers, and patients play in the success of these programs. This work, which included a review of existing models, points to an approach that focuses on fostering a mutually accountable environment where multiple quality and cost issues are addressed in a collaborative way, instead of simply penalizing health systems for any readmission.

All key stakeholders are included throughout the reporting cycle and rely on expert advisory committees.

Legislators: Enact the laws, fund the initiative. Ideally, they should stay engaged through the entire process

Policy makers: Leadership and vision for a transparent, high-performing health system are essential to override initial opposition to reporting. Use of the information about the costs and variation related to readmissions as evidence to justify sustaining/expanding transparency initiatives.

Providers: As the source of the data and the subject of the reports, providers need a say in the reporting process and content. Providers may not know their readmissions rates at the hospital or department levels and benefit from aggregated, cross-system information. An open, transparent process with validation and pre-review is important.

Physicians: The concerns are more clinical than statistical, overall or broad measures may not meet their information needs. Like providers, physicians likely do not know their own or department’s readmission rates and benefit from aggregated, cross-system information to inform their practices

Health Plans: Health plans now report readmissions at the plan levels, but aggregating this information across payer systems for a system-wide view is a challenge for them. Understanding readmission rates by the payer and payer type will also help inform community collaboratives.

Consumers: While we must be mindful of consumer-oriented products and information, the hospital readmissions reporting agenda should not be dependent on consumers to solve and improve systems. In many states, advocacy groups serve as ‘proxy’ representatives of the public/consumer and are excellent allies.

Purchasers: Purchasers are seeking information that is system-wide and independently validated comparing the performance of providers and are an important ally for any statewide reporting initiative, including readmissions.

Health plans and health systems typically pursue independent and unaligned readmission reduction activities, including independent data analysis and unilateral patient outreach and support.

Question 2

Reducing unnecessary hospital readmissions seems to be an attractive means to that end, as fewer readmissions can potentially both reduce costs and improve the quality of care.

Analysis of the identified policies led to the identification of two main dimensions of readmission policies:

(1) readmission measurement

(2) readmission management

Policies can focus either on the readmission of individual patients or on readmission rates. The aim of the policy and the intended audience determine the specific characteristics of how readmissions are measured and how this information is used for readmission management.

Readmission policies can focus on measuring and managing readmissions of individual patients or they can focus on readmission rates. If the focus is on readmission rates, a denominator and numerator must be defined, and the level at which rates are calculated must be chosen. Depending on the aim and audience, this level could be the nation, the region, the hospital or the hospital department.

A policy focussing on the readmission of individual patients has the advantage that it directs the attention to the question of how to avoid specific readmission of an individual patient or a specific group of patients. A focus on readmission rates has the advantage that it enables benchmarking of readmission rates across the chosen aggregate units.

Public reporting: to improve health care quality, population health, to reduce the costs of health care, and to allow hospitals, policymakers, and other stakeholders to evaluate the quality of care and to seek improvements that will impact patient well-being
Financial incentives: to transform Medicare from a passive payer to one that pays not just for the quantity of services but for quality as well.

All hospitals have an interest in reducing readmissions – not only those with readmission rates above a certain threshold. However, this approach can unintendedly penalize hospitals serving local communities where factors out of the hospitals control lead to above average readmission rates. To avoid such penalties, payment rates should ideally be determined based on historical local cost data and include an adjustment for the average cost of and the probability of readmissions net a monetary reduction to provide incentives for reducing readmissions