The US healthcare system has been in need of a serious renovation for some time. When you consider the effect of the building silver tsunami population and its potential need of healthcare, the system could definitely use some attention.
Enter the Centers for Medicare and Medicaid Services (CMS). CMS is an agency within the US Department of Health & Human Services responsible for administration of several key federal health care programs including Medicare (the federal health insurance program for seniors), Medicaid (the federal needs-based program), Children’s Health Insurance Program (CHIP), and the Health Insurance Portability and Accountability Act (HIPAA).
The Affordable Care Act in October 2012 added the Hospital Readmissions Reduction Program requiring CMS to reduce payments to hospitals who have excessive readmission rates. A readmission is defined as a reentry to a hospital, the same or another facility, within 30 days of discharge. Key diagnoses have been targeted, including acute MI (heart attack), heart failure and pneumonia.
The penalty for excess readmissions, based on national averages, is a decrease in reimbursement to the facility from programs covered by CMS.
State of Readmissions for Seniors
It has been reported that, in 2010, one out of eight Medicare patients were readmitted in 30 days following surgery and one out of six following medical care.
Readmission rates cost Medicare an estimated $17.4 billion a year.
There are many theories about what causes hospital readmissions, especially in seniors. Programs have been designed to target the possible causes of readmissions that you and your senior may have already seen.
While readmission of our senior loved ones may be a costly statistic for the hospital, the bottom line for us is there has been a downturn in health serious enough that a return is needed. That means helping our seniors avoid readmission after they get out of the hospital should be a priority for us as family caregivers.
Improving Transitions for Health
One of the potential gaps that could lead to hospital readmission rates for older adults is the discharge process when leaving the hospital. There seem to be many potential cracks in the system.
- The patient education process may not be successful and the treatment plan not clear to the patient upon discharge. This could be a failure to communicate the plan to the patient or family caregiver, confusing documentation or discharge instructions, or unrecognized inability to carry out the treatment plan.
- When unable to carry out a prescribed treatment plan due to transportation problems for follow-up visits, lack of finances to purchase medicine or equipment, lack of caregiver support, inaccessibility to medical support, or other access issue no community support or network outreach to accomplish the treatment plan is made by the hospital. Referrals to community resources are not provided to maintain the continuum of care.
- High risk patients were not identified by the hospital and treatment plans were never created to address their needs.
- No follow-up is provided to be sure treatment plan is followed, obstacles to success removed or monitoring of medical status done to prevent re-hospitalization.
Interventions for Success
Most healthcare organizations have initiated programs to reduce the rate of readmission within 30 days for our seniors. Not only are they concerned about our senior’s well-being but, realistically, their own financial bottom line. Every readmission can negatively impact their reimbursement.
What steps have they taken?
- They have increased their vigilance in identifying high risk patients through improved observation, diagnosis tracking and assessments.
- They are implementing programs of education updating the discharge forms so that they are clear and concise for seniors and family caregivers. The new information is more specific about follow-up appointments and treatment goals.
- They are actually making the appointments for seniors before they are discharged not relying on us to remember to make a timely appointment.
- They tell patients more clearly what their role is in their own care, when to call the doctor if something goes wrong, when to take medications or not to them, when to weigh themselves or track their vital signs and what to do when the results are not normal.
- They are beginning to give education and not just instructions.
- They are taking a bit more time to talk about the discharge process, beginning it right away and reinforcing it throughout the hospital stay instead of waiting until we are packed to go and probably not listening well.
- They are communicating among themselves better. Electronic medical records can more easily and accurately track the care we have received, the medications our seniors are now taking and were in the past, which tests or treatments have been performed, which providers or consultants have been involved in the care of our senior loved ones, and what was the prescribed treatment. Providers in the hospital or in private offices now have access to our senior’s medical records and can make better health decisions based on real time data.
Innovative Approaches to Care
Many organizations are providing the patients with new technology and digital monitoring devices that can be tracked by caregivers or by the healthcare provider remotely. They are making sure we can operate our blood pressure machine, blood glucose self-monitoring devices, or even giving us scales to weigh ourselves on each morning to prevent heart failure from causing an admission.
More and more remote monitoring devices and apps are being provided to patients to help them stay in control of their disease process before it becomes a crisis. Technology alone isn’t the entire answer to improving follow up care, of course, but keeping the link between the healthcare team and discharged seniors can help keep situations from reaching the level where the seniors need to return to the hospital.
When a return to the hospital is needed, what many hospitals are also doing to circumvent penalties is admitting seniors and others in an observation level of care instead of a true admission. They can then provide care within 24 hours getting the crisis under control then discharging a senior home again without taking a hit against their readmission numbers.
An observation stay does not count as a readmission even when the diagnosis is the same in the same facility. Insurers often view an observation stay as an outpatient service, which can mean a higher bill for the patient who may be charged per test or x-ray instead of bundled as a diagnosis fee. This a la carte fee structure can be costly for seniors, who may not realize this is happening until the bills start to arrive.
This may prove to be a tricky and costly loophole for seniors and family caregivers, who may want to monitor the situation to ensure care is provided without bills piling up.
In this new healthcare environment, many family caregivers are asked to be the driver of our senior’s healthcare. We are going to be asked to be hands on caregivers, record keepers, medication managers, and billing agents to be sure that our senior’s healthcare is well coordinated — or we will end up paying the piper both in hospital readmissions and money.
When it comes to the health of our senior loved ones, prevention and quality medical management is in our hands!