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Q&A: Lowering hospital readmissions by improving care transitions

From the September ACP Hospitalist, copyright © 2009 by the American College of Physicians

By Jessica Berthold

Patients who are discharged from the hospital for cardiac conditions have a decent chance of seeing their favorite doctor or nurse again soon. According to a CMS analysis of claims data, 25% of heart failure patients and 20% of acute myocardial infarction (MI) patients return to the hospital within 30 days of discharge.

CMS drew attention to these figures back in July, when it posted data on its Hospital Compare Web site showing whether a given hospital’s readmissions rate is “better than,” “no different from,” or “worse than” the U.S. national average. Now, the American College of Cardiology (ACC) and Institute for Healthcare Improvement, along with strategic partners including the ACP, are getting into the act. This fall, they are launching the national “Hospital to Home,” or H2H, quality initiative, which aims to reduce the 30-day, all-cause hospital readmission rate for patients discharged with heart failure or acute MI. The campaign’s goal is a 20% reduction by December 2012.

John Rumsfeld, FACP

John Rumsfeld, FACP



Modeled after ACC’s D2B Alliance, which successfully lowered door-to-balloon times for patients with acute MI, H2H aims to create a community of hospitals, health care systems and providers who share strategies on improving transitions from the hospital to the home—which in turn should help cut down on readmissions. Interested parties can enroll any time online.

John Rumsfeld, FACP, is the chief science officer for the ACC’s National Cardiovascular Data Registries, professor of medicine at the University of Colorado Denver Health Sciences Center, and co-chair of the H2H quality initiative. He recently spoke with ACP Hospitalist.

Q: How did the H2H initiative come about?

A: It is a convergence of several factors. There’s been lots of evidence about the burden rehospitalization places on patients and families, and the fact that it’s a marker for a much worse prognosis for patients. Patients are much more likely to die following readmission for heart failure or heart attack. On a societal level, we are seeing that readmission accounts for a large burden of health care costs; this has been a primary focus of the Obama administration’s push for payment reform. And there is good evidence that a significant proportion of rehospitalization is unnecessary and therefore potentially preventable.

So there are lots of efforts going on around the country right now, with researchers and hospital systems working on this issue, but it’s happening in many different silos, and we really don’t have national dissemination or sharing of best practices yet. So that is what H2H is going to be about; it isn’t intended to be prescriptive. It’s intended to be a rallying point, a commitment to improving transitions where we bring together everything that is known as far as evidence, and offer a core strategy toolkit that people can customize to their own system.

Q: Can you explain a bit about how it will work?

A: First, the initiative focuses on ensuring three things: that patients are familiar with, and have access to, their medications; that they have follow-up visits scheduled shortly after discharge; and that they fully understand any symptoms that would require medical attention. We’ll then map each of these three priorities to proven tactics or toolkits that hospitals and systems and practices can use. We’ll then further map to specific programs—many of which will come from our strategic partners—that already have been shown to reduce unnecessary rehospitalizations. These so-called “best practices” will be shared among the H2H community.

Q: Can you give an example of one of the specific tactics a hospital might use?

A: As just one example, a hospital might make a commitment to designate a person on staff to call that patient within 72 hours after discharge. During that call, the staff member would check to see if the patient understands [his or her] medication instructions, has any problems or questions, and has a follow-up appointment scheduled with an outpatient physician. It sounds simple, but this type of support in the transition from the inpatient to the outpatient setting rarely happens.

Q: Why does H2H focus on those who have been discharged with the conditions of heart failure or acute MI, and why a 30-day time period?

A: Cardiovascular rehospitalizations make up a large proportion of the most frequent rehospitalizations that are felt to be potentially preventable, with heart failure leading the pack. Existing research suggests that a significant proportion of rehospitalization happens early, which is why we have targeted the 30-day time period. The 30-day period also “mirrors” the publicly reported rehospitalization measures by CMS for heart failure and MI. It is also hoped that if we can reduce 30-day rehospitalization rates, this will translate into lower rehospitalization over longer periods.

Q: How are readmissions related to transitions of care?

A: Research suggests a significant proportion of cardiovascular readmissions may be preventable because they are related to poor transitions of care. That is, when someone goes home from the hospital after, say, a heart attack, he or she doesn’t have early enough follow-up, or a good handoff to the primary care physician or cardiologist specialist. Often those physicians don’t know what happened to their patients in the hospital, how their medications were altered, the results of key tests and so forth. Patients are often confused about their medications and the plan for follow-up. It ends up that following a period of intense care in the hospital, many patients have virtually no care in the early follow-up period, yet they still have a condition like heart failure which needs ongoing care to avoid decompensation and rehospitalization.

Q: Why are transitions of care such a common downfall for hospitals?

A: For years, we’ve had a tremendous focus on doing the best we can while somebody is in the hospital. Most quality measures are about what we do up to the point of discharge. That is fine, but then we fall down. Many of us would like to get rid of the term “discharge” altogether, because it implies a discharge of responsibility. We need to focus on care from the patient’s perspective as a continuum—in this case, requiring an effective transition from inpatient to outpatient care.

I think hospitals feel a tremendous amount of responsibility, and many put a tremendous amount of resources into getting patients ready for discharge by going over medications and doing patient education. But in reality, unfortunately, these things are often hurried. Patients are handed a piece of paper and told “Here is your discharge contract.” They’ve been sick, lying in a hospital bed, not in their own environment, and they sign it. It’s not a point of learning or information. So there needs to be something in the transition period, not just up to discharge.

Q: Is it an issue of hospital staff not following existing transition protocols, or are there no firm protocols in place?

A: As far as exact algorithms about what to do during the transition period, we really don’t have those in place, and we need them. There are groups like the National Quality Forum that are working on transitions-of-care measures, which should be generalizable, whether you are in the hospital for heart failure, heart attack or pneumonia. And even though H2H has a cardiovascular focus, we expect that the strategies to improve transitions will be generalizable to other conditions as well.

Q: How did the H2H planning group come to focus on the three aspects it chose as key elements of a successful transition?

A: There is a lot of evidence to suggest there is confusion around medications—understanding which medicines to take and exactly how to get them. We may go over this with patients in the hospital, but this is a difficult time to ensure that patients and families fully understand the medication and follow-up plan, and can execute it once out of the hospital. Once they are in the home environment, and have a chance to take a deep breath, it’s different. This is a key time to ensure understanding of medications, follow-up, and symptom management. My own father was a physician who had been admitted to the hospital with heart failure, had signed his discharge contract upon leaving the hospital, and still was confused about which medications to take once he was home. He’d been taking medications before he went to the hospital, and gotten new ones while in the hospital, and it wasn’t clear to him which to take and for how long, or when he needed to follow up with his outpatient doctors, who weren’t involved with his hospital care. And this was obviously someone with medical expertise.

Q: Do you think some hospitals may be reluctant to try to reduce readmission rates because they fear they will lose money by doing so?

A: If this initiative had occurred two or three years ago, I believe there may have been more hesitation. Now, in the current health care climate in the U.S., readmissions have become a primary target for cost reduction, and rehospitalizaiton rates are publically reported. There is clear pressure to reduce unnecessary rehospitalizations. I think the administration sees that reducing unnecessary readmissions is the right thing for patients and the health care system as a whole, and so it will be incentivized. Also, we can’t forget that many rehospitalizations are for sicker patients who appropriately need to go back to the hospital. So part of this is recognizing appropriate and inappropriate readmissions.

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Three questions

The H2H initiative focuses on developing a “learning community” centered around three core questions that will be tied to tactics and best practices for implementation, according to John Rumsfeld, FACP, its co-chair. The questions are

  • Is the patient familiar and competent with his or her medication, and does she or he have access to it?
  • Does the patient have a follow-up visit scheduled within a week of discharge, and is he or she able to get there?
  • Does the patient fully comprehend signs and symptoms that require medical attention, and know whom to contact if they occur?

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