Are Collaborative Care Planning Teams and Technology the Key to Reducing Readmissions?

Tick tock goes the clock – in six short months the Centers for Medicare & Medi

Tick tock goes the clock – in six short months the Centers for Medicare & Medicaid Services (CMS) will begin withholding 1% of Medicare inpatient payments for avoidable readmissions within 30 days. Peaking at 3% in 2014, this penalty has the potential to be a major financial hit to some hospitals already facing lower reimbursements. According to PriceWaterhouse Coopers Health Research Institute’s, “The Price of Excess: Identifying Waste in Healthcare”, preventable hospital readmissions are a significant avoidable cost in the U.S. health care system, costing an estimated $25 billion annually. Further noted by authors Stephen Jenks, MD MPH, Mark Williams, MD and Eric Coleman, MD MPH, poor discharge procedures and inadequate follow-up care lead to nearly one in five Medicare discharged patients being readmitted within 30 days. And across all insured patients, the preventable readmission rate is 11 percent, while the rate for Medicare patients is 13.3 percent.

While Jenks et al. noted that the highest rates of preventable readmission diagnoses are heart failure, COPD, psychoses, intestinal problems, and various types of surgery (cardiac, joint replacement, or bariatric procedures), the National Priorities Partnership estimates that total hospital readmissions could be reduced by up to 12% by improving procedures for admitting and discharging patients, providing better follow-up care and utilizing health information technology. With many readmissions costing between $6,000 and $10,000 each, a number of innovative solutions aimed at helping reduce avoidable incidents could be implemented:

During the Inpatient Stay

– Collaborative Care Planning (CCP) – similar to morning management huddles, convene a multi-disciplinary discharge planning team to start working with the patient prior to transition to develop a care plan in laymen’s terms that effectively addresses appropriate care, medication instructions, future physician appointments, transportation and other psychosocial needs.

Include health plan, home health, skilled and long-term providers in discussion via innovative technology or other means
Request primary care physician acknowledgement of care plan before patient transition
- Schedule first follow-up visit to occur within five days
Clinical Pharmacist member of CCP team meets with patient to discuss medication, preventable errors and presents 30 day supply
Require patient to ‘consent’ to care plan and sign-off prior to transition
- Additional literature has highlighted the fact that most patients have one primary care giver – look for ways to integrate this individual into your discussions and follow-up
Similar to the VA’s blue button, integrate the care plan with current EHR technology and make available online, in addition to paper format, via a patient portal

Following Discharge

– CCP team member follows-up with patient within 48 hours

– Schedule follow-up visit by CCP team member for high risk patients to review progress, monitor safety of home and manage medication adherence

Akin to the Health Alliance Plan’s HealthTrack, enroll patient in disease management program
- Assign Care Navigator/Coordinator/Health Coach
Provide patient education materials in paper and online format, including interactive symptom checker driven by evidence based tool that delivers directives based on a decision tree
Implement telehealth, IVR and/or wireless monitoring to remind patients to take meds, follow preventative measures, attend PCP visits and provide early warnings of worsening health conditions
Educate patients regarding early warning signs and appropriate next steps

– Explore means of sharing data with all participating parties in order to avoid duplicative visits, tests and other unnecessary resource consumption

– Standardized discharge summary is sent to primary care physician, payer, clinicians, care givers

– Post-mortem review of readmitted patients

If significant reductions in readmissions are to be achieved, a true system approach must be implemented with appropriate payment reform to bind payers, providers, physicians, pharma and specialty organizations to this important initiative. Reengineering current processes to include collaborative care teams and progressive information technology could be the key for improving transitions, reducing readmissions and delivering safe, quality, patient-centered care.