Hospital Readmissions & Chronic Condition Management

I would like to discuss the national report on hospital readmissions that came out from Dartmouth Atlas Project (http://www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf).

To start, this is the first time we have had a national report that reflects on the effectiveness of care coordination which affects readmissions. To quickly summarize the report, there was little progress in reducing readmission rates over the five-year period 2004 to 2009 and for some conditions, the readmissions rates have actually increased
nationwide.

When people get older, their health worsens. This is just how life is. With worsening health conditions, patients always have a need to be seen by a doctor in ED for various reasons. Once they leave the ED, they might end up in a nursing home, specialist clinic, hospice, and home or at any other care facility. One of the primary reasons for patients to come back to the ED within 30 days of discharge is poor communication between the various stakeholders who take care of the patients. In most cases, the care that is provided by hospitals are not compensated as most chronic condition patients are uninsured or underinsured. There is a tremendous need to improve care coordination. Another statistics that came out of the report was that many Medicare patients did not see a clinician within 14 days of discharge. This could happen when there is no tracking mechanism that is enforced by the hospital.

Without high-quality care coordination, patients will repeatedly be in and out of the hospital causing a heavy burden on hospital finances as well as increasing the total cost of episodic care. Hospital readmission rates are becoming a standard to evaluate a health systems’ ability to provide high quality coordinated care. To simply state, if hospitals can improve care coordination, the readmission rates will reduce and patients’ lives will improve while reducing costs.

As part of the Affordable Care Act, CMS will cut reimbursements for readmissions within 30 days of discharge. While this is a good step, we need to look at strategies to lower readmissions. Technology plays a major role and helps improve the care coordination process. Health Systems need to have the right set of tools and processes to manage patients once they are discharged. Providing patients with a personal health record is a first step – one that provides the tools that help patients manage their condition easily at home and also the ability for the patient to communicate to their doctor and share their health information with their care team. Then there are tools that hospitals need to outreach to these patients on a case by case basis as most chronic conditions are life long and need to be managed well. Then there is the need to connect patients with their care team irrespective of their location. If these three issues are addressed, then a Chronic Condition Management (CCM) program in any hospital will be successful. A good Chronic Condition Management solution should have good work flow and processes to support care coordination, enable strong patient outreach programs and enable patient self-management by providing the
right tool sets.

Chronic conditions have no definite end and need to be managed, and managed well.