Readmission to the hospital is costly and sometimes dangerous, especially for seniors. People over the age of 65 are more likely to be readmitted than their younger counterparts, and readmission can have particularly devastating effects for these older patients. Physicians, coverage providers, hospitals and policymakers are now working towards reducing readmission rates among seniors.
Nearly one in five Medicare patients returns to the hospital within a month of discharge, according to Centers for Medicare & Medicaid Services (CMS). Medicare released its first report presenting national estimates on hospitalization, readmission, and death, using NHIS information gathered from Medicare claims and death data in September 2015. That report shows 17.3 percent of non-institutionalized Medicare FFS beneficiaries aged 65 and over was readmitted to the hospital within 30 days after discharge.
Researchers in a study entitled “Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia,” compared Medicare fee-for-service claims data for 30-day readmissions after hospitalization for patients with heart failure, acute myocardial infarction, and pneumonia. They found the 30-day readmission rate of 24.8 percent after heart failure hospitalization, a 19.9 percent readmission rate after acute myocardial infarction, and an 18.3 percent readmission rate after hospitalization for pneumonia.
The average age of readmissions was 80.3 years for heart failure patients, 79.8 years for patients originally hospitalized for acute myocardial infarction, and 80 years for those originally hospitalized for pneumonia.
The researchers found that readmissions generally occurred within 15 days of discharge, with 61 percent of heart failure patients, 62.6 percent of pneumonia readmissions and 67.6 percent of acute myocardial infarction readmissions happened during that time. Only about one-third of readmissions occurred between 16 and 30 days of discharge.
Readmission comes at a tremendous price. Readmitting these 2.6 million seniors costs the nation more than $26 billion annually. Readmission also poses a great inconvenience for patients and increases their risk for hospital-acquired infections and other complications.
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Readmission and Post-acute Care
Post-acute care facilities, such as skilled nursing facilities, are working to reduce climbing readmission rates to improve patient outcome and to secure full CMS payments.
On August 4, 2015, CMS issued its 2016 Medicare skilled nursing facility payment rates rule that includes value-based purchasing provisions for these post-acute care facilities based on a hospital readmission measure. It sets the All-Cause Risk-Standardized Readmission Measure and adopts the measure for its purchasing program. The new rule is part of the Protecting Access to Medicare Act of 2014 (PAMA), which established a 2 percent withhold to skilled nursing facilities Part A payments that can be partially earned back based on a facility’s re-hospitalization rate and level of improvement.
A new study raises questions about the quality of processes for transitional care. The authors note that hospital readmission and mortality rates are increasing rapidly for patients discharged to post-acute care facilities, and wondered if a mismatch exists between patient needs and post-acute care resources.
The study, published in the Journal of Post-Acute and Long-Term Care Medicine, found that almost 23 percent of patients discharged to a post-acute care facility after acute hospitalization were readmitted at least once within 30 days of discharge. Nearly half of the readmissions occurred within 14 days of discharge, according to a press release issued by the University of Colorado School of Medicine.
The most common factors in readmitted patients were the need for an invasive device, such as a urinary catheter or feeding tube, and the need for dialysis, oxygen therapy or other forms of advanced care. Understanding the cause of hospital readmission from these facilities is critical to improving quality of care and reducing payment penalties for readmissions.
“Patients who experienced readmission during their stay in a post-acute care facility were less likely to return to the community,” said lead author Robert Burke, MD.
The authors of the study noted that patients who experienced readmission to a hospital during their stay at a post-acute care facility were less likely to return to the community and had a higher mortality rate.
“Readmitted patients were twice as likely as non-readmitted patients to die in the 30 days following hospital discharge and nearly four times as likely to die in the 100 days post-hospital discharge,” wrote the authors.
The study results also suggest that payment systems affect patient outcomes.
“Under a prospective payment system, hospitals are incentivized to discharge these patients as early as possible, and in contrast to discharges home, hospitals are not currently penalized for readmissions from PAC (post-acute care) facilities,” the authors write. “PAC facilities may be substituting for prolonged hospital care in some cases.”
Addressing Readmission Rates Among Seniors
Preventing readmission whenever possible benefits both patients and hospitals. Policymakers and providers see readmission reduction as an opportunity to reduce overall healthcare system costs through quality improvement. Researchers, hospital administrators, CMS and managed care programs have made readmissions a top priority over the past few years.
In the press release for the Northwestern study, for example, Dr. De Oliveira urged medical teams to give seniors clearer, more understandable discharge instructions and to evaluate all patients’ ability to provide care for themselves after surgery.
Medicare hopes to address the issue by reducing payments to hospitals with high readmission rates. The Hospital Readmissions Reduction Program (HRRP) requires CMS to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals demonstrating excessive readmission rates.
A team approach could reduce readmissions due to falls, according to one study. Researchers from Henry Ford Hospital in Detroit analyzed data from 558 patients, half of whom were 80 years and older from 2012-14. The hospital employs a team approach to injury care, including specialists in trauma, geriatrics, physical and occupational therapy, and pharmacy. The specialists collaborate on a care plan and engage family in care planning to ensure safer discharge to home.
The scientists found that the 30-day readmission rate for falls decreased 10 percent from 2012-13 under the program, and remained unchanged in 2014. The 30-90 day readmission rate from 2012-13 also dropped before it rose slightly in 2014.
Reducing readmission rates among seniors – and the problems associated with readmission – requires collaborative effort on the parts of patients, doctors and nurses, administrators, policymakers and coverage providers.