hospital

time Why it’s

readmissions

to focus on  

Bridging the gap between hospital and home

$2 trillion

SOURCE: Fazzi R, Agoglia R, Mazza G, Glading-DiLorenzo J. The Briggs National QualityImprovement/Hospitalization Reduction Study. Caring: National Association for Home�Care magazine. 2006; 25(2):70.  

Approx.  

is spent on healthcare in the U.S. each year.  

1/3 SOURCE: Fazzi R, Agoglia R, Mazza G, Glading-DiLorenzo J.

The Briggs National QualityImprovement/Hospitalization Reduction Study. Caring: National Association for Home�Care magazine. 2006; 25(2):70.  

hospitalizations. is spent on

Flickr: Daquella manera  

SOURCE: Fazzi R, Agoglia R, Mazza G, Glading-DiLorenzo J. The Briggs National QualityImprovement/Hospitalization Reduction Study. Caring: National Association for Home�Care magazine. 2006; 25(2):70.  

of those hospitalizations are

readmissions. 20%  

A hospitalization that occurs within a specified time frame after discharge from the first or

index admission.

SOURCE: American Journal of Medical Quality. Redefining Hospital Readmissions to Better Reflect Clinical Course of Care for Heart Failure Patients.

Hospital Readmission (Definition)

“ I think readmissions are a bellwether of whether we are really

doing the kind of support, education, outreach, and coordination that really

can keep people as healthy as they possibly can [be].”

 Dr. Donald Berwick, Administrator of the

Centers for Medicare and Medicaid Services

stressful. Leaving the hospital  

can be  

Patients may be tired.

Patients may be tired.

…uncertain about their discharge instructions.

 

…nervous about transitioning home.  

Patients may be tired.

…uncertain about their discharge instructions.

 

…nervous about transitioning home.  

Patients may be tired.

…uncertain about their discharge instructions.

  …concerned their condition could worsen.

 

…nervous about transitioning home.  

Patients may be tired.

…uncertain about their discharge instructions.

  …concerned their condition could worsen.

 …unhappy with their hospital experience.

 

…at risk of readmission.  

This is especially true

with Medicare patients.  

 

18-20% of Medicare patients

are re-hospitalized within

30 days of discharge.  

SOURCE: Jencks S, et al. "Rehospitalizations among patients in the Medicare fee-for-service program."�New England Journal of Medicine 2009.

33% readmit within 90 days.

SOURCE: Jencks S, et al. "Rehospitalizations among patients in the Medicare fee-for-service program."�New England Journal of Medicine 2009.

However, many of these readmissions are potentially

avoidable.        

“ Readmissions are not primarily about people being

re-hospitalized because of mistakes made in the hospital. [Readmissions]

are about making transitions effectively.”

Stephen Jencks, M.D., a former senior clinical adviser to CMS.

A potentially preventable re-hospitalization… that in many cases may be prevented with proven

standards of care.

SOURCE: MedPAC (June 2007) Report to the Congress: Promoting Greater Efficiency in Medicare

(Definition) Avoidable Readmission

too common.

readmissions are all  

Avoidable  

In fact, 13% of Medicare re-hospitalizations are

SOURCE: Hackbarth G, Reischauer R, Miller M. Report to Congress: Medicare Payment Policy. Washington, DC: Medicare Payment Advisory Committee; March 2007.

potentially avoidable.

$12 billion! ($7,000 per person)

SOURCE: Recreated from Table 5-2 within: MedPAC (June 2007) Report to the Congress: Promoting Greater Efficiency in Medicare. P 107, from 3M analysis of 2005 Medicare discharge claims.

That’s a cost of about  

What causes these

readmissions? potentially avoidable

Patients don’t follow home care instructions.

Reason #1

complications with

their at home recovery.

Which can cause serious  

medications.

when dealing with  Especially

 

In fact, 2/3 of Medicare readmissions are due to medication non-compliance.

       

SOURCE: Jencks S, et al. "Rehospitalizations among patients in the Medicare fee-for-service program."�New England Journal of Medicine 2009.

adequate follow up or monitoring.

There isn’t  

Reason #2

aren’t seen by physicians promptly after discharge.

Many patients

In fact, 50% of Medicare patients had

no interaction with a physician between discharge and readmission.  

SOURCE: Jencks S, et al. "Rehospitalizations among patients in the Medicare fee-for-service program."�New England Journal of Medicine 2009.

appointments

With no  one to help them  

schedule  and keep those  

gap in care occurs. …a significant  

gap in care occurs. …a significant  

health deteriorates. And patient  

Reason #3

sharing

Hospitals  

aren’t good at

patient care plans.

and Physicians  

physicians

Quite often,  

aren’t kept in the loop about  

discharge plans.

only 3%-20% of hospitals communicate with the

primary care physician.

SOURCE: Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in�communication and information transfer between hospital-based and primary care�physicians: implications for patient safety and continuity of care. JAMA. Feb 28�2007; 297(8):831-841.

In fact, one review found that  

And only 12%-34% of primary care physicians have access to

discharge summaries during the first post discharge visit.

SOURCE: Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in�communication and information transfer between hospital-based and primary care�physicians: implications for patient safety and continuity of care. JAMA. Feb 28�2007; 297(8):831-841.

But change is on the horizon.

The Center for Medicare and

Medicaid Services (CMS)

hospitals accountable. is beginning to hold  

Starting October 2012, CMS will begin withholding payments for

excessive readmissions.

1.  Congestive Heart Failure (CHF) 2.  Acute Myocardial Infarction (AMI) 3.  Pneumonia

Focusing first on:

�then adding others in 2014.

4.  Chronic Obstructive Lung Disease 5.  Coronary Bypass Grafting 6.  Percutaneous Coronary Interventions 7.  Vascular Procedures

CMS penalties are based on a

maximum percentage of total inpatient operating

payments.

increase Which will  

over the next  

three years.

2012 = 1% 2013 = 2% 2014 = 3%

Their goal is to incentivize hospitals to improve patient health by

extending care services beyond the hospital setting – thereby

reducing costs.

“ The incentives we're putting into place have created a

whole new way to think about hospital care.”

 Jonathan Blum, deputy administrator of the federal Centers for Medicare & Medicaid Services, or CMS.

not just And it’s  

about the  numbers.  

Patient Experience will play a key role in measuring

the effectiveness of a hospital’s inpatient and discharge planning.

In fact, higher HCAHPS have been associated with a lower 30-day risk of

hospital readmission for:

SOURCE: The American Journal of Managed Care: Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days

Congestive Heart Failure (CHF) Acute Myocardial Infarction (AMI) Pneumonia

CMS penalties,

aftercare to support patients using

it will be critical for hospitals  

To avoid

services.

The subsequent care or maintenance of a patient after a stay in the hospital.

SOURCE: New Oxford American Dictionary

(Definition)

Aftercare

Hospitals need to start thinking of themselves as

care managers.

leading role

And take a  

in managing patient care  

after discharge.

In other words…

expectations Set clear  

on what will happen.

expectations Set clear  

on what will happen.

Stay in  contact  with the patient after discharge.  

expectations Set clear  

on what will happen.

Stay in  contact  with the patient after discharge.  

Keep physicians  

in-the-loop.

expectations Set clear  

on what will happen.

Stay in  contact  with the patient after discharge.  

Keep physicians  

24x7 access

Provide  

to decision support services.

in-the-loop.

“ While timely follow-up is critical, that alone isn’t enough

to prevent readmissions. To be effective, you need a care team that

can connect, evaluate, and escalate patients

to appropriate care and/or administrative resources.”

 Jeff Forbes, President, SironaHealth

Outbound calling programs that rapidly assess a patient's current health status, schedule follow-up care,

and gather feedback on their hospital experience.

SOURCE: SironaHealth

(Definition)

Post Discharge Follow-up

post discharge To be successful,  

calling programs must…  

24-72 hours Follow up  

after discharge

instructions

Review patient discharge  

coaching decision support and  

Provide  

health

Find a Doctor

Schedule Follow Up

Escalate to Urgent or

Emergency Care

Guide to Other

Hospital Services

Facilitate

next steps appropriate

clinician*

Make it easy to  

with a  reconnect  

*in case they develop symptoms after initial call.

informed members

Keep all  

of the care team  

experience

Use  to improve the discharge    

feedback  

“ If we are able to smooth the transitions [after

discharge], those people would stay home where they want to be and

costs would fall because [the patients] are not deteriorating. We have a tremendous

possibility there.”

 Dr. Donald Berwick, Administrator of the

Centers for Medicare and Medicaid Services

We Agree.

Post Discharge Follow Up Services Keep patients healthy, reduce readmissions, improve experiences

Learn more! www.SironaHealth.com/post-discharge

About SironaHealth

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We are a multi-channel health contact center that offers healthcare companies a unified way to coordinate patient care across telephone, web, email, and mobile channels. SironaHealth programs help your patients make the appropriate healthcare choices —�whether it be choosing the proper physician or knowing when they should seek emergency care.

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