Hospital leaders are under a lot of stress these days. From concerns about razor-thin operating margins and patient and employee safety to HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores and the Hospital Value-Based Purchasing program -- it all adds up to a lot of things that hospital leaders must worry about simultaneously.
Now comes another addition to hospital leaders' worry list: the critical nature of readmissions.
And now comes another addition to the worry list: the critical nature of readmissions. For decades, many observers have viewed readmission rates as a fair surrogate for quality of care. If you discharged your patients and they didn't need to return, then their care was satisfactory. If you discharged your patients and they were readmitted, then their care could have -- and maybe should have -- been better.
Whether or not this perspective is fair, many legislators in Washington, D.C., have adopted it. As a result, the Affordable Care Act includes provisions that penalize hospitals that have above-average 30-day readmission rates for heart attack, heart failure, and pneumonia by withholding part of their Medicare reimbursement from the Centers for Medicare and Medicaid Services (CMS).
These provisions were created because the assumption is that lower readmission rates generally reflect better care during a patient's hospital stay. This assumption persists despite some hospital leaders' objections that many readmissions occur due to reasons outside a hospital's direct control.
Nevertheless, the Readmissions Reduction Program and its associated penalties are now active. More than 2,000 hospitals will be assessed a penalty ranging from 0.01% to 1% (maximum) of their Medicare reimbursement revenue in FY2013 (based on their 30-day readmission rates from 2008-2011). The penalties will rise to 2% maximum in FY2014 and 3% maximum in FY2015. The magnitude of the penalty will typically range between $100,000 and $1 million annually for hospitals in the first year but triple that two years down the road.
Reducing risk through staff action
To help its clients minimize their chances of being penalized, Gallup undertook a research study to discern the actions that hospital staff could take to best influence positive patient behavior and reduce 30-day readmissions. This research reinforced the critical role that medical adherence plays in affecting readmissions by looking at medical adherence as both an outcome in its own right and as an influence on readmissions.
As part of its research, Gallup surveyed more than 30,000 people, asking them whether they had been hospitalized in the last two years for heart attack, heart failure, or pneumonia. If respondents were admitted for one or more of these conditions, they were asked a series of questions about their experience in the hospital and their interactions with doctors and staff. Respondents were also asked if they had been prescribed medications upon discharge from the hospital and if they were readmitted within one month for their initial condition.
Gallup determined the rate of medical adherence -- which ranged from full adherence to full failure -- based on each person's responses to three key questions. The medical adherence rate was significantly related to the risk of readmission, after controlling for all demographics, health insurance, and previously existing disease burden.
To discover the actions that hospital staff can take to best influence positive patient behavior and reduce 30-day readmissions, Gallup asked specific HCAHPS items designed by CMS as part of their readmission assessment as well as a set of experimental items. The experimental items were developed by Gallup in partnership with the Cancer Treatment Centers of America (CTCA); many of CTCA's top patient-facing professionals helped evaluate the items during Gallup's on-site study of industry best practices.
Gallup's analysis of survey responses showed that staff actions at five crucial touchpoints worked in an additive way to increase medical adherence and reduce 30-day readmission rates. Those touchpoints were measured by these five items:
- When you left the hospital, you had a good understanding of the things you were responsible for in managing your health. (CMS)
- When you left the hospital, you clearly understood the purpose for taking each of your medications. (CMS)
- Your physician effectively communicated the different medical treatment options available for your health condition. (Gallup)
- Even during stressful times, hospital staff equipped you with all the information, resources, and motivation that you needed to maintain proper diet and exercise. (Gallup)
- Hospital staff effectively described what each of your prescribed medications do. (Gallup)
Staff members should always verbalize treatment options, even when only one is the clearest choice.
The two items CMS developed were administered using a 4-point agreement scale, while the three items Gallup developed were administered using a 5-point agreement scale. This resulted in a range of possible scores from 5 to 23. Natural breaks occurred at the following scores:
- 22 to 23: low risk of medical adherence failure and readmission (30% of patients surveyed)
- 14 to 21: moderate risk of medical adherence failure and readmission (60% of patients surveyed)
- 5 to 13: high risk of medical adherence failure and readmission (10% of patients surveyed)
When Gallup analyzed the outcomes based on how hospital staff performed on each of these items, the differences were stark. The likelihood of full medical adherence decreased by 46% and the chance of readmission within 30 days rose 50% among those in the high-risk group compared with those in the low-risk group. In other words, patients who strongly agreed that they experienced the five crucial touchpoints during their stay were about one-third more likely to stick to their medications and were about one-third less likely to return within 30 days than those who disagreed.
What healthcare leaders can do right now
This research definitively demonstrates that staff actions at five crucial touchpoints can significantly increase the likelihood that patients suffering from heart attack, heart failure, and pneumonia will adhere to their medications post-discharge. These staff actions can also decrease the likelihood that patients will be readmitted within 30 days for reasons related to their initial hospital stay.
Here are some common-sense actions leaders can take to increase medical adherence and reduce readmission rates, based on this research:
- Hospital staff should give patients a full explanation of what their prescribed medications are meant to do -- and what they are not meant to do. Patients must get a complete account of how their medications work -- and what the likely health outcome will be if they fail to take all medications on schedule and as directed.
- Staff members should engage patients in a detailed discussion of their post-discharge care, particularly the elements that patients are directly responsible for managing. Whenever possible, hospital staff should include the patients' support network in this discussion as well. Patients' friends and family members are not just custodians of the patients' meds and diet; they are also partners in sustaining -- and perhaps overhauling -- the patients' lifestyle. Motivation and attitude are proven aspects of medication adherence.
- Hospital staff should give patients materials and tools for achieving the highest possible well-being in a way that is customized to patients' needs and most practical for them. Apps for smartphones may be appropriate for some patients, while hard copy background information may work better for others. In all cases, staff members should focus on the patients' conditions when giving them follow-up instructions. When patients feel that their post-care plan is built just for them, they will be more likely to embrace and follow it.
- Staff members should always verbalize treatment options, even when only one is the clearest choice. Patients are more likely to feel empowered when they are given multiple options to choose from, and they are more likely to adhere to their path after they do choose it.
Ultimately, what healthcare leaders must fully understand is that doctors and staff can meaningfully and significantly influence major health outcomes such as medical adherence and 30-day readmission rates. Armed with this knowledge, they can act on these opportunities as vigorously and as directly as possible. Their actions can have substantial positive consequences for their hospital and its patients.
Special thanks to Cancer Treatment Centers of America for their generous and valuable support of this research.
Results are based on a Gallup Panel study consisting of Web surveys completed by 2,995 national adults, aged 18 and older, who experienced an overnight hospital stay for heart attack, heart failure, and/or pneumonia. The study was conducted in multiple waves over the course of 2012. Gallup Panel members are recruited through random selection methods. The panel is weighted so that it is demographically representative of the U.S. adult population. For results based on this sample, one can say with 95% confidence that the maximum margin of sampling error is about ±3 percentage points. Margins of sampling error vary for individual subsamples. In addition to sampling error, question wording and practical difficulties in conducting surveys can introduce error or bias into the findings of public opinion polls.