Becker's Clinical Quality & Infection Control

14 14 T he Patient Protection and Affordable Care Act has forced hospitals to seriously reassess readmissions. Programs specific to preventing readmissions for heart failure, heart attacks and pneumonia are now commonplace in hospitals across the country. However, these pro- grams, while effective at the very start, often begin to plateau, leaving clinicians scrambling to rede- sign care-reinforcing readmissions programs at a time when penalties are increasing to their highest levels yet. Eiran Gorodeski, MD, is the former director of Heart Care at Home, a transitional care program established by Cleveland Clinic that helped con- nect patients to quality care during their moves from hospital to home or a post-acute care facil- ity. However, Heart Care at Home didn't create the post-acute care outcomes Cleveland Clinic had hoped to see, according to Dr. Gorodeski. So in 2013, the health system stopped using the program. A programmatic failure isn't necessarily a bad thing, however. "The way we've been looking at readmissions has been evolving," says Dr. Goro- deski, who is also head of the Cleveland Clinic Center for Connected Care Transitional care is vital. Since 2010, the Cleve- land Clinic has put plenty of effort into reduc- ing readmissions according to the sticks and carrots of the PPACA. According to Dr. Goro- deski, only when fines were put into place did hospitals begin taking readmission reduction seriously. Cleveland Clinic created Heart Care at home in response to fines for high readmission rates of heart attack and heart failure patients. The pro- gram was driven mostly by telehealth, and it was somewhat effective. But beyond an initial drop in readmission rates, further iterations of the pro- gram didn't produce additional improvements in care. "That was when the lightbulb went off: this is probably not the right approach," says Dr. Gorodeski. "The lessons we will carry forward from the pro- gram are not necessarily lessons that have any- thing to do with heart care," he says. What they do have to do with is improving care coordination. Dr. Gorodeski cites the example of a particular nurse practitioner's work from Heart Care at Home as being especially eye-opening. "When we sent her into people's homes, it really improved outcomes. She was really coordinating care at a very high level, managing medications and teach- ing patients in a much more sophisticated way than other providers." The nurse practitioner helped reinforce the idea that, in Dr. Gorodeski's words, "It's not about the disease, it's about the patient." Dr. Gorodeski believes the answer to readmis- sions lies in implementing parallel solutions for care coordination. "The focus has been what we should do about single condition readmissions. It's a good thing that is going to go away: it's been a distraction. How to reduce [single] readmis- sions misses the point." A patient-centered, rather than a condition-centered, mindset in the midst of care transitions is key, he says. To keep reducing readmissions, Dr. Gorodeski also suggests partnering with skilled nursing facilties; 17 percent of all patients go to skilled nursing facilities. It's therefore important to con- sider value and quality when discharging patients to these facilities. "There's more and more data that patients who go to low-value SNFs have worse outcomes," he says Finally, he warns hospitals to be very careful in choosing supplementary technology. Telehealth may produce plenty of data, but whether that data is important, necessary or useful is a vital consid- eration. "Essentially, hospitals need to understand Medi- care and other payers are going to be moving away from specific admissions. Don't waste your time developing interventions that focus on diseases, or you're going to miss the boat. Instead, come up with ways to improve care coordination in paral- lel across the continuum," he says. "Cater to the patient population, beware of glittery technology and focus." n When Readmission Programs Fail, What's Next? By Ellie Rizzo Joe Torre Forrest Sawyer Barry Arbuckle, PhD Toby Cosgrove, MD Keynote speakers include: Becker's Hospital review 5th annual Meeting May 15-17, 2014 Swissôtel • Chicago, Illinois The Most Business- and Quality-Focused Meeting in the Hospital and Health System Arena 100+ sessions and 190+ speakers Register by April 1 for Early Registration Discounts For more information visit, www.BeckershospitalReview.com and click on "Conferences"

• Cover