Connected Health: Expanding its Role to Prevent 30-day Hospital Readmissions
Friday, August 22, 2008
| Allison McDonough, MD
About the author - Allison McDonough, MD is a physician at MGH Revere HealthCare Center, and Medical Director of Chronic Disease Management for Partners HealthCare.
Control of Medicare spending is an increasingly urgent goal for the U.S. healthcare system, and is the focus of many debates and pilot programs. Decreasing the rate of readmission within a 30 day window has become a major focus in Washington, with potential to deny or limit Medicare payment for readmissions deemed avoidable. Connected health can contribute significantly to preventing such readmissions by improving monitoring of patients after discharge. It is poised to provide additional benefit by assisting with access to timely ambulatory care for high risk patients, and could also play a role in medication reconciliation after discharge.
There is ample room for improvement in 30 day readmission rates. In 2005, an average of 18% of patients were readmitted within 30 days of their hospital discharge, with a range of 14% at the 10th percentile to 21% at the 90th percentile (Commonwealth Fund National Scorecard on U.S. health system performance, 2008). Medicare estimates that 13% of these readmissions were “potentially avoidable,” based on the IPPS rule, with major areas of concern including poor communication with patients at discharge, especially around medications, and inadequate post hospital discharge monitoring. Prevention of these avoidable readmissions could save Medicare about $12 billion per year. (Report on Medicare Compliance, Volume 17, Number 24, June 30, 2008)
We now have the opportunity to develop robust and comprehensive programs to address these areas, and in the process create a system of more efficient, effective, safe, and patient focused care. For the 9th Statement of Work for the Quality Improvement Organizations, CMS has incorporated care coordination targeting general hospital readmission rates for heart failure, acute MI, and pneumonia. The National Quality Forum is expected to approve a measurement approach for preventable readmission soon, which will allow evaluation and public reporting by CMS. Two bills have been submitted to committee in congress which, if enacted, would limit payment for preventable readmissions.
What needs can connected health address for recently hospitalized patients?
Post Hospital Discharge Monitoring: Remote daily measurement of vital signs and symptoms in the heart failure population has shown great promise already in reducing readmissions, through improved monitoring as well as patient education. The effectiveness of telemonitoring in other populations should be explored. IT platforms which facilitate interactions with Primary Care Providers will enhance the effectiveness and efficiency of telemonitoring. These interactions may also improve patients’ access to timely ambulatory care, avoiding Emergency Department visits and readmissions.
Post Hospital Discharge Medication Reconciliation: Improvement of discharge planning and followup has focused on providing inpatient discharge facilitators, improving discharge paperwork, and arranging post hospital discharge phone interventions for medication reconciliation, symptom review, and followup appointment reminders. These have been shown to have significant effect in decreasing Medicare readmission rates. Continued investigation into how best to structure telephonic interactions is needed. Documentation of these encounters in the primary EMR will have tremendous potential to streamline and enhance this process.
Questions remain: How can we expand telemonitoring to other disease populations, such as COPD, AMI? How can we leverage existing programs and technologies to further assist with discharge education and medication reconciliation? What is the best way to structure telephone based interventions for recently discharged patients?
I look forward to hearing your perspectives.