Friday, May 1, 2015

Population Health Management and Readmissions

A physician welcoming the
patient back to the hospital
Years ago, the Disease Management Care Blog had to readmit a recently discharged elderly patient back to the hospital.  It paged the colleague who originally discharged the patient and she offered up an important insight: the patient was so ill and feeble that it was remarkable that the patient made it out of the hospital in the first place.

Later, when the tut-tuting hospital quality assurance nurses started to swarm, the DMCB provocatively informed them that readmissions were the price of doing business.

That's why the DMCB liked this New England Journal of Medicine article that questions the overall wisdom of Medicare's national focus on reducing readmissions. Authors Karen Joynt and Ashish Jha make some good points:

1. What is the evidence? While a "readmission" is widely viewed as a failure of not having gotten it right the first time, in-depth chart reviews of readmitted patients reveal that only 12% - 25% are truly preventable.

2. Multiple causes: Not getting it right the first time is less of a cause than absent families, poor community supports and lingering poverty.

3. Death is the most effective solution: Hospitals that perform well in keeping patients with end-stage illness alive are ironically destined to have higher readmission rates.

4. Priorities: Trying to reduce readmissions will consume hospitals' time and resources better spent on other patient safety initiatives. 

Drs. Joynt and Jha have two good recommendations:

1. Focus on those readmissions occurring within 3-7 days.  Those patients are more likely the victims of poor discharge planning that is under the hospitals' control.

2. Alter diagnosis related group payments to include a "warranty" that covers the likelihood of readmission within a few days of discharge.

And, as is common among the health care academia, one good recommendation was missed:

3. Medicare should learn how to adopt, incent and pay for "best practices" from population health management interventions like this and this that lead to meaningful decreases in readmissions for the patients who are at greatest risk.  What's more, the DMCB believes that if hospitals (and their spawn, ACOs) can "outsource" this to a third party who can provide this on a turnkey basis, they can better devote their attention to other critical patient safety needs.

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