When most patients leave the hospital, they expect to move forward with their healing, not face a rebound hospital visit right away.
Many risk factors associated with recent hospitalization can make a return visit within 30 days more likely, but physical therapists (PTs) and occupational therapists (OTs) can empower patients to reduce those odds. By providing support before and during the transition to post-acute care, therapists can ensure that patients progress after they are discharged to skilled nursing facilities, rehabilitation units, or their homes.
Hospitals and skilled nursing facilities have financial incentives to reduce unnecessary 30-day readmissions after hospital discharge, and PTs and OTs play a crucial role in reducing readmissions.
Measures CMS Monitors
The rate of 30-day readmissions for Medicare eligible patients reached 17.1% in 2016, according to the Agency for Healthcare Research and Quality. To reduce avoidable rebound hospitalizations, the Centers for Medicare and Medicaid Services (CMS) tracks 30-day readmission measures and applies payment penalties when it deems a hospital’s rates excessive compared with similar patient populations. CMS’ stated goal is to link payments to the quality of hospital care.
CMS monitors risk-standardized unplanned readmission measures related to the following six conditions and procedures:
- Acute myocardial infarction
- Chronic obstructive pulmonary disease
- Heart failure
- Coronary artery bypass graft surgery
- Elective primary total hip arthroplasty and/or total knee arthroplasty
In terms of quality reporting, CMS adds stroke to this list of conditions and tracks readmissions for patients with all seven conditions.
Particular risks accompany each of these conditions. For example, total knee replacement procedures make falls more likely, which can precipitate readmission. Care coordinators should therefore plan for those patients to have therapy services to address safety, mobility, and independence in the home, as well as strength and range of motion, after discharge.
Efforts to reduce the rate of readmissions tend to focus on care transitions, including improvements in communication between hospital clinicians and those in the next care setting, whether home or long-term care; better coordination of care before and after hospital discharge; and patient education on managing their conditions.
Improvements in these areas go hand in hand with providing holistic, patient-centered care. Let’s explore some specific ways OTs and PTs can strategically intervene to reduce hospital readmissions.
Investment in Therapy
Researchers studying Medicare claims and cost data found that hospital spending on occupational therapy had a statistically significant association with lower readmission rates for patients with the following conditions:
- Heart failure
- Acute myocardial infarction
Studying 19 spending categories, the researchers found that an investment in OT services had the potential to boost care quality without significant increases in hospital spending overall. They noted that OTs focus on patients’ social and functional needs, making sure patients can be safely discharged to the post-acute environment. They also investigate whether patients have adequate support networks and work to minimize physical barriers to healing.
In another study analyzing Medicare claims, researchers found that patients who received outpatient physical or occupational therapy after being discharged home after a stroke were less likely to be readmitted to the hospital within 30 days of discharge than those who did not receive therapy. According to the researchers, the results suggested a lower risk of rebound hospitalization when therapy visits started sooner and the number of visits was higher.
Focus on Physical Function
Looking for ways to improve the situation, clinicians have noted that care transition models often do not adequately consider patients’ functional deficits. In a Relias course titled “The Role of the PT and OT Provider in Preventing Rehospitalization,” presenter Andrea Salzman, MS, PT, notes that impaired physical function is “a huge predictor of rehospitalization,” and yet many times, “the physical realm doesn’t even get discussed when talking about rebound hospitalization.”
Functional deficits before hospitalization can make readmission more likely. For example, falls before hospitalization increase the risk of post-discharge falls.
The care team can address those challenges by scheduling PT and OT visits before and after discharge to optimize physical function during the 30-day transition period. “Transitions are where a lot of the problems happen,” Salzman notes.
To reduce these types of problems, researchers have encouraged PTs to take the following steps:
- Standardize communication about functional deficits with multidisciplinary care team members in acute and post-acute settings.
- Research and assess the effects of different approaches to PT services on readmission rates.
- Make efforts to educate other care team members on the role PTs can play in improving patient functioning during the transition from hospital to post-acute care.
Besides risk factors that accompany specific conditions or procedures, these broader challenges related to PT and OT services can affect readmission rates:
- Other health care team members override PT or OT recommendations for care during transition.
- Skilled nursing facilities reduce OT and PT staffing levels and the amount of therapy provided.
- Care coordinators miscommunicate during the transition or fail to follow through on referrals.
On the plus side, during regular therapy visits, PTs and OTs tend to build relationships with patients. Those interactions give therapists opportunities to understand the individual’s motivations, challenges, and fears, and to foster that person’s balance, strengthening, mobility, and other health goals.
Further, through these regular visits, therapists may be the first to notice subtle changes that could be the sign of a medical decline or additional healthcare needs. For example, they may notice elevated blood pressure, mild cognitive changes that could indicate a urinary tract infection or sepsis, and signs of wound infections.
If PTs and OTs share patient-specific insights with the entire care team, they can serve as advocates for their patients’ maintenance of physical function and rehabilitation. Those are vital elements in avoiding unnecessary hospital readmissions.
Areas of Influence
All members of the multidisciplinary care team can positively influence hospital readmission rates by keeping the following opportunities in mind:
- PTs and OTs in acute care and inpatient rehab can assess post-discharge therapy needs before the patient is released.
- Therapists can build relationships with patients, elicit information about their experiences before hospitalization and concerns about the post-discharge environment, and share those with the care planning team.
- PTs and OTs can assess whether patients can live independently or need assistive devices to safely perform activities of daily living.
- OTs and PTs in the hospital can advocate for patients during discharge planning to ensure that adequate attention is paid to improving physical functioning.
- Hospital care team members can ensure that they communicate all notes to the skilled nursing care team or home health PT.
- Therapists can investigate home safety situations before patients are released from the hospital and discharged home.
- Care teams can honor OTs’ and PTs’ recommendations for therapy during the patient’s 30-day transition from a hospital to a skilled nursing facility or a patient’s home.
- Therapists in all settings can work to educate patients, caregivers, and other family members on the efforts they can contribute to prevent hospital readmission, including safety precautions.
- Home health PTs and OTs can recognize signs and symptoms of worsening cardiac conditions, wound infections, depression, respiratory disorders, medication errors, or other factors that pose risks for readmissions and alert the care team.
- Therapists can actively communicate with leadership to share issues they experience and clarify expectations.
Beyond therapists taking initiative to avoid rebound hospitalizations, administrators and leaders can stay alert to the following top-level opportunities to minimize 30-day readmissions:
- Look for trends in your organization’s readmission reporting.
- Meet with care teams, including PTs and OTs, to turn negative trends around.
- Actively promote policies and procedures that support optimum healing.
- When a readmission happens, help the care team assess why and what can prevent such a situation in the future.