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Patient readmissions and Quality Care - How Quality plays a role in hospital readmissions - By Jessica Smith

Patient safety is the prevention of errors and adverse effects that can harm patients during healthcare. Quality healthcare is defined as doing the right thing for the right person at the right time. Quality healthcare involves ensuring that every aspect of patient care is handled properly. This means delivering the right treatment to the right person at the right moment, using the most appropriate methods available. The goal is to achieve the best possible health outcomes for patients. Patient safety practices are essential components of quality healthcare. They are designed to safeguard patients from accidental injuries or harm that can occur during medical procedures or treatments. These practices include thorough protocols, staff training, and ongoing monitoring to prevent mistakes and ensure that patients receive care that is both safe and effective. By prioritizing safety, healthcare providers aim to create a trustworthy environment for all patients. Improving healthcare quality and safety is a growing focus for the nursing field and healthcare systems as a whole, as medical institutions aim to achieve efficiency, reduce healthcare costs and ensure high-quality patient outcomes.

Working in healthcare, the main focus is to stop patient readmissions and to improve the patients quality of care and by doing so the main three components that is focused on is three long-term goals related to patient quality: reduce preventable hospital admissions and readmissions, reduce the incidence of adverse healthcare-associated conditions, and reduce harm from inappropriate or unnecessary care. You can check out this quick YouTube video for a broad view of reducing hospital readmissions

*[https://youtu.be/3oiBkTnHCw8?si=uoJjMtXjHZRANpF1]*

Addressing the Issue at Hand - Quality and Readmissions

Currently, there isn't a complete method for measuring patient quality in hospitals. However, there are specific guidelines and indicators that hospitals use to assess safety practices, such as making sure patients receive antibiotics at the right time before surgery. Organizations like the Center for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality (AHRQ) have developed these indicators based on research and expert reviews. AHRQ tracks patient safety through a set of measures called Patient Safety Indicators (PSIs), which help monitor the overall quality of healthcare across the country. Each indicator focuses on certain groups of patients, based on their medical conditions and procedures, while excluding others to ensure accurate data. It's important to note that safety events identified by these measures have been linked to higher rates of deaths and increased healthcare costs per admission. When patients find themselves back in the hospital shortly after being discharged, it often reflects underlying issues with the care they received during their stay. A high rate of readmissions can indicate that the quality of care fell short, suggesting that patients might not have received the treatment they needed while hospitalized. Additionally, effective discharge planning is crucial; if this process isn’t handled well, patients may leave without a clear understanding of their aftercare.

Inadequate patient education can also play a significant role. If patients aren’t given proper instructions on how to manage their health conditions at home, including medication management and recognizing warning signs, they are at a higher risk of complications. Furthermore, a lack of coordination in post-discharge care—such as follow-up appointments or support from home health services—can lead to gaps in care. All these factors contribute to a failure to successfully transition patients back to their homes, ultimately resulting in unnecessary readmissions to the hospital. To aid in better targeting spaces in need of quality improvement activities and resources, associations were examined between demographic, clinical and geographic factors of interest and 30-day hospital inpatient readmissions by stratifying by level of the characteristics described below. Hospital quality: Hospital quality for the index hospitalization was determined using CMS’s Hospital Overall Quality Star Ratings, and ranged from 1 star, indicating the lowest quality, to 5 stars, indicating the highest quality. Hospitals missing star ratings included behavioral health hospitals and hospitals that did not submit a minimum threshold of measures needed to calculate an overall star rating. According to the PDF "Impact of hospital readmissions and reduction of initiatives on Vulnerable populations" "There were 436,654 (5.6%) index stays from hospitals for which a quality rating could not be assigned. These claims were excluded from all models that involved stratifying by hospital quality (but were included in all other models). Primary diagnosis at index hospitalization leading to the highest frequency of readmissions: Primary diagnosis at index hospitalization was defined using the AHRQ CCS that groups International Classification of Diseases, 10th Revision (ICD-10) coded diagnoses into one of 285 clinically coherent diagnosis categories (referred to as “single-level CCS diagnosis categories”). The five diagnosis categories leading to the highest frequency of readmission in 2016 were (1) septicemia, (2) congestive heart failure (CHF), (3) chronic obstructive pulmonary disease/bronchiectasis (COPD), (4) complication of device, and (5) pneumonia. Analyses were conducted among each of these five conditions.

Primary diagnosis at index hospitalization leading to the highest frequency of readmissions: Primary diagnosis at index hospitalization was defined using the AHRQ CCS that groups International Classification of Diseases, 10th Revision (ICD-10) coded diagnoses into one of 285 clinically coherent diagnosis categories (referred to as “single-level CCS diagnosis categories”). The five diagnosis categories leading to the highest frequency of readmission in 2016 were (1) septicemia, (2) congestive heart failure (CHF), (3) chronic obstructive pulmonary disease/bronchiectasis (COPD), (4) complication of device, and (5) pneumonia. Analyses were conducted among each of these five conditions. According to CMS.GOV, they conducted a study, The study focused on exploring the association between race and ethnicity, potentially disabling condition status, dual-eligibility status, and rurality and 30-day hospital inpatient readmissions. These analyses were stratified by hospital quality, select primary diagnoses at index hospitalization, discharge setting, and beneficiary Census division. These characteristics were selected based on their potential to provide guidance for targeted quality improvement interventions. Unadjusted2 logistic regression models were first constructed to determine whether race and ethnicity, potentially disabling condition status, dual-eligibility status, and rurality were associated with 30-day hospital inpatient readmission. Race and ethnicity: The majority (78.0%) of index hospital stays were to beneficiaries who were non-Hispanic White. Beneficiaries who were Black/African American, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native represented 12.5%, 5.8%, 1.6%, and 0.8% of index hospital stays, respectively. However, the readmission rate was highest in Black/African American beneficiaries (19.4%), followed by Hispanic (16.8%), American Indian/Alaska Native (15.9%), Asian (14.3%), and non-Hispanic White (13.8%) beneficiaries. Rurality: Approximately one-fifth (20.8%) of index stays were represented by beneficiaries living in rural areas. Rural-residing beneficiaries had a 13.5% rate of 30-day inpatient readmission versus a 15.0% rate for beneficiaries living in urban areas. Potentially disabling conditions: Forty-four percent of the beneficiary population was identified as having one or more potentially disabling conditions, and this group had a 18.3% rate of readmission. By contrast, beneficiaries without potentially disabling conditions had a rate of readmission of 11.9%. In addition, the proportion of beneficiaries with one or more potentially disabling conditions varied by age group. Among beneficiaries aged 18–64, 36.1% had one or more potentially disabling conditions, compared with 46.3% among those aged 65 and older. In both age groups, the readmission rate was approximately 7 percentage points higher among beneficiaries with one or more potentially disabling conditions than for those who did not have potentially disabling conditions (i.e. beneficiaries 18–64 years with and without potentially disabling conditions: 24.0% readmission versus 17.2% readmission; beneficiaries 65 years and older with and without potentially disabling conditions: 17.0% readmission versus 10.1%

Challenges and Facilitators

I understand that hospital care and discharge planning are crucial aspects of patient experience. Working for temple physicians I encounter a lot of challenges when dealing with patients who were discharged from the hospital, After a patient is discharged from the hospital, we schedule them for what is called transition of care appointments. (TOCS) is when a patient moves from one healthcare setting to another, transition of care appointments help make sure everything goes smoothly. These appointments include in-person visits with a medical professional, as well as other types of meetings like over the phone or through video calls. They also involve follow-up appointments, managing medications, and making sure all the different healthcare providers are working together. It can be challenging to get patients to understand the importance of these appointments. Often, patients express that they have just left the hospital and don't see the point, don't have transportation, or simply don't feel like it. This can lead to hospital readmissions and a decline in their health. This is where primary care providers can help prevent readmissions by intervening before the patient's health worsens, potentially leading to death, as shown in the chart.. It is also important to note that sometimes the quality of care during a patient's initial hospital stay may fall short, which can lead to complications after discharge. In my experience, patients can often get discharged prematurely in order to make room for other patients. This could be due to a shortage of beds in the hospital. As a result, healthcare providers may focus on quickly admitting and discharging patients, sometimes only prescribing medication, which can lead to a lower quality of care and an increased likelihood of the patient needing to return to the hospital. Poor Discharge Planning: Another critical issue is inadequate planning for a patient's transition from hospital to home, which can contribute to readmissions. From my interactions with patients, I've learned that many are discharged from the hospital without clear instructions regarding their next steps. They often mention that they were supposed to follow up with a specialist, but they have no information about the contact details or whether someone will reach out to schedule an appointment. This lack of clarity can significantly impact the patient's post-discharge experience. which can lead to numerous barriors when it comes to healthcare and readmissions.

Barriers to quality and healthcare readmissions are significant challenges in the healthcare system. Here are some key barriers:

1. Communication Gaps

• Between Providers: Poor communication between hospitals, primary care, and specialists can lead to fragmented care.
• With Patients: Inadequate explanations about discharge instructions can result in misunderstandings.

2. Socioeconomic Factors

• Access to Care: Patients from low-income backgrounds may struggle to access follow-up appointments or necessary medications.
• Health Literacy: A lack of understanding about health conditions can hinder a patient's ability to manage their health post-discharge.

3. Care Coordination Issues

• Lack of Integrated Care Models: Insufficient coordination among different healthcare providers can lead to gaps in care.
• Inconsistent Follow-Up: Failure to schedule timely follow-ups can increase the risk of readmissions.

4. Patient Compliance

• Medication Adherence: Patients may not take prescribed medications correctly due to side effects, cost, or forgetfulness.
• Lifestyle Changes: Difficulty in making necessary lifestyle adjustments can lead to health deterioration.

5. Systemic Challenges

• Resource Limitations: Hospitals may face staffing shortages, which can affect the quality of care.
• Policy Constraints: Regulations and policies may not incentivize effective post-discharge care.

6. Chronic Conditions

• Complexity of Care: Patients with multiple chronic conditions often require tailored care plans, and managing these can be challenging.

7. Technology Barriers

• EHR Interoperability: Poor integration of electronic health records can hinder information sharing.
• Telehealth Access: Limited access to telehealth services can affect follow-up care, especially in rural areas.

Strategies to Address Barriers

• Enhanced Communication: Implementing better handoff protocols and utilizing patient portals for information sharing.
• Patient Education: Providing clear, easy-to-understand discharge instructions and follow-up care plans.
• Improving Access: Expanding telehealth services and addressing transportation issues for follow-up appointments.
• Care Coordination: Employing care managers to assist patients in navigating the healthcare system post-discharge.

Addressing these barriers can help improve care quality and reduce readmissions, ultimately leading to better patient outcomes.

Hospital readmissions can have significant ramifications for both patients and healthcare systems. For Patients this could be Deteriorating Health, Frequent readmissions may signal worsening health, leading to increased morbidity. Emotional Toll, Repeated hospital stays can cause anxiety, depression, and reduced quality of life for patients and their families, also Heightened Risk of Complications Each hospital stay carries risks such as infections, falls, and other complications. Financial Consequences Increased Healthcare Expenditure: Readmissions contribute to higher healthcare costs for patients, insurers, and healthcare systems. Penalties for Hospital, Many payers, including Medicare, impose penalties on hospitals with high readmission rates, affecting their financial viability.

Quality of Care Reputation: Hospitals with a lot of patients coming back after being discharged might not have a good reputation, which can make people trust them less. Quality Metrics: How often patients have to come back to the hospital can show how good the hospital is, and this can affect things like how much money they get and if they get certified as a good hospital. Resource Use Strain on Healthcare Resources: If too many patients have to come back to the hospital, it can make things hard for the hospital and make it so other patients have to wait longer for help. Staff Burden: When hospital workers have to deal with a lot of patients coming back, it can make them feel really tired and unhappy with their jobs.

STAKEHOLDERS AND HOW THEY ARE AFFECTED BY HOSPITAL READMISSIONS

Hospital readmissions involve a bunch of different stakeholders each with their own roles and interests. The key players include patients and families, healthcare providers, hospitals and health systems, payers, policy makers. Each group has specific responsibilities related to reducing readmissions and improving patient care quality. Working together, these groups can come up with better strategies to cut down on readmissions and boost overall care quality. According to a new report by the nonprofit coalition Northeast Business Group on Health (NEBGH). While many readmission reduction efforts are underway in the marketplace, few, if any, have the shared data analytics, integrated care models, robust employee outreach and communication, and the economic sustainability features necessary to reduce readmissions, the report said.

"To really move the needle on readmissions reduction, stakeholders need to pool their resources and engage in pre-planned management activities that would better identify patients at high risk for readmissions and lead to more efficient use of clinical support resources from both health plans and health systems," Jeremy Nobel, M.D., executive director of the NEBGH's Solutions Center, said in a statement. "Reducing Hospital Readmissions through Stakeholder Collaboration," which includes input from 67 executives from employer organizations, health plans, hospital systems, suppliers and other stakeholders, recommends a series of strategies providers can use to align their readmissions initiatives. The steps will help hospitals better identify patients at high risk for readmissions, engage patients through education and communication and establish a mutually accountable environment that doesn't just penalize hospitals for unnecessary readmissions. A multi-stakeholder cooperative care model must encompass three requirements, according to the report:

• Collaboration in clinical outreach and care: Use assets to identify high-risk patients and support them through the transition of care process.
• Business sustainability: Make sure the chosen financial model is sustainable. Ask questions that address payment, resources, incentive and return on investment.
• Employee engagement and communication: Fully communicate with staff and caregivers and encourage them to embrace new activation models.
• Patients are the main stake holders when it comes to quality care and readmissions. Patients are the ones going through the significant back and forth from home back to the hospital. Patients hold a critical stake in the realm of hospital readmissions, and their engagement significantly impacts outcomes. The following are examples how patients' stakeholder status and the ramifications of their involvement- Direct Health Outcome Influence Care Accountability: Patients assume an active role in managing their health conditions, adhering to treatment regimens, and following discharge directives. Self-Management, their capacity to manage symptoms and discern when to seek assistance can directly impact readmission rates. Communication and Engagement Active Engagement, engaged patients who inquire and actively participate in care-related discussions can contribute to enhanced comprehension and adherence. Feedback Provision: Patients' feedback on their hospital experience can facilitate the identification of areas necessitating improvement in discharge planning and care transitions. Health Literacy Comprehending Conditions, Patients with elevated health literacy are better equipped to manage their conditions and adhere to post-discharge instructions, thereby decreasing the likelihood of readmission. Educational Requirements: Identifying knowledge gaps can enable healthcare providers to tailor educational initiatives to enhance patient outcomes. Social and Economic Factors Resource Accessibility: Patients' socioeconomic status can impede their access to follow-up care, medications, and essential support services, consequently impacting readmission risks. Support Systems, The presence of familial or community support can influence patients' recuperation and capacity to effectively manage health conditions. Advocacy and Influence Healthcare Advocacy: Patients can advocate for themselves and others, thereby influencing hospital policies and practices related to care transitions and readmission prevention. Involvement in Decision-Making: By participating in treatment decisions, patients can ensure that their preferences and needs are addressed. Emotional and Psychological Factors Stress and Anxiety: Readmissions can lead to emotional distress, affecting patients' overall well-being and potentially impeding their recovery. Quality of Life: Frequent hospital visits can disrupt daily life, work, and family responsibilities, leading to broader implications for personal and family health. Healthcare providers also play a significant role in being a stake holder,
• Healthcare providers have a significant influence on hospital readmissions. Their actions and decisions directly affect patient care, outcomes, and healthcare quality. The contributions of different healthcare providers in managing and reducing readmissions are as follows: Physicians provide accurate diagnoses and develop effective treatment plans to manage patients' conditions, they also ensure that discharge instructions are clear and comprehensive, incorporating medication management and follow-up care. Follow-Up Care: Physicians schedule timely follow-up appointments to monitor patient progress and address any early complications. Nurses - Patient Education: Nurses educate patients and their families on managing their conditions, recognizing warning signs, and adhering to treatment plans. - Care Coordination: They facilitate communication between various healthcare providers to ensure continuity of care post-discharge. Monitoring: Nurses observe patients for any signs of deterioration during their hospital stay and intervene as necessary. Care Managers or Case Managers - Holistic Support: They assess patients' needs and coordinate services addressing medical, social, and psychological factors affecting their health. - Post-Discharge Follow-Up: Care managers ensure patients have access to follow-up appointments and necessary resources, such as transportation or home health services. - Personalized Care Plans: They develop individualized care plans that consider patients' unique circumstances and challenges.

Payers - The impact of high readmission rates on healthcare systems is significant, especially for payers. High readmission rates can lead to increased healthcare costs for payers, as they often cover the expenses associated with additional hospital stays. In addition, many payers, including Medicare and Medicaid, impose penalties on hospitals with high readmission rates, which can affect reimbursement and provider funding. Payers also use readmission rates as quality metrics to assess provider performance, which can influence contract negotiations and reimbursement rates. As the healthcare system shifts towards value-based care, payers are incentivizing providers to reduce readmissions through bonus structures or shared savings programs.

Payers analyze claims data to identify trends in readmissions, helping to inform strategies for reducing unnecessary hospitalizations. They may invest in programs that support care coordination, such as telehealth services or home health support, to prevent readmissions.

Policymakers also play a crucial role in addressing readmission rates. They create regulations and guidelines that can influence hospital practices regarding readmissions, such as penalties for high rates under Medicare. Policymakers may allocate funding for initiatives aimed at improving care transitions and reducing readmissions. They often support community health programs that address social determinants of health, which can impact readmission rates. Enacting laws that promote integrated care models and support for patients with chronic conditions can help reduce the risk of readmissions. Furthermore, policymakers can fund and promote research on effective strategies for reducing readmissions, informing best practices in healthcare. They can also mandate reporting of readmission rates, increasing transparency and accountability for healthcare providers. In conclusion, the involvement of payers and policymakers is crucial in driving systemic changes that ultimately benefit patients and the healthcare system as a whole. Recognizing their roles can help healthcare systems better align their strategies to reduce readmissions, improve care quality, and ensure more efficient use of healthcare resources.

SOLUTIONS TO BETTER QUALITY AND HOSPITAL READMISSIONS

Reducing hospital readmission rates is a crucial objective for healthcare systems aiming to enhance patient outcomes and reduce overall healthcare costs. As we approach 2024, it is essential for healthcare leaders to focus on strategies that prevent unnecessary readmissions by addressing the root causes and improving continuity of care. One effective approach is to implement comprehensive discharge planning processes that begin at admission. Tailoring discharge plans to each patient’s specific health needs ensures that they understand their medications, follow-up care, and whom to contact in case of complications. Investing in patient education during and after hospitalization is also crucial. Ensuring that patients and their caregivers understand their conditions, management strategies, and warning signs of potential complications can significantly reduce readmission rates. Enhancing communication channels between hospital staff and outpatient care providers is another important strategy. Sharing detailed discharge summaries and care plans can help ensure continuity of care and prevent gaps that lead to readmissions. Establishing protocols for follow-up appointments within a week of discharge, particularly for patients with high-risk conditions, and utilizing remote monitoring technologies to track patients’ health status after discharge are also effective strategies. These tools provide real-time data to healthcare providers, allowing for timely interventions. Collaborating with community organizations to provide support services such as home healthcare, transportation, and meal delivery can help patients adhere to post-discharge instructions and manage their conditions effectively. Using predictive analytics to identify patients at high risk of readmission and developing targeted interventions, ensuring effective medication reconciliation during and after discharge, and soliciting and analyzing patient feedback on their hospital stay and discharge process are additional important strategies. Lastly, it is crucial to regularly review readmission data and outcomes of implemented strategies to allow for timely adjustments and continuous improvement. According to the CDC.

CONCLUSION

Reducing hospital readmissions necessitates a comprehensive approach that encompasses the enhancement of care coordination, patient education, and overall healthcare quality. To address this issue, several key recommendations can be implemented. Firstly, it is imperative to enhance discharge planning. This involves ensuring that patients receive clear, easy-to-understand instructions upon discharge, including medication management and follow-up appointments. In addition, involving a team of healthcare professionals (nurses, physicians, social workers, etc.) in the discharge process to address various aspects of patient care is essential. Improving care coordination is another critical aspect. Implementing care transitions programs that facilitate smooth transitions from hospital to home, including follow-up calls and home visits, can significantly benefit patients. Furthermore, developing integrated care teams that incorporate primary care providers, specialists, and social services can effectively manage patients' ongoing needs. Patient education and engagement play a pivotal role in reducing hospital readmissions. Providing health literacy initiatives tailored to patients' literacy levels ensures they comprehend their health conditions and treatment plans. Encouraging shared decision-making and active participation from patients in their treatment decisions fosters a sense of ownership over their health. Strengthening follow-up care is also imperative. Ensuring that follow-up appointments are scheduled before discharge, ideally within a week, and offering telehealth services for follow-up visits can facilitate easier access to care for patients without transportation barriers. Addressing social determinants of health is crucial in reducing readmissions. Connecting patients with community resources to address social determinants that may contribute to health issues, such as housing, transportation, and nutrition, and regularly assessing patients for social needs that may impact their health and providing appropriate referrals are important steps in this process. Optimizing medication management is vital in preventing readmissions. Conducting thorough medication reconciliation at discharge to prevent errors and ensuring patients understand their regimens, as well as involving pharmacists in the discharge process to review medication plans and counsel patients on proper use, can significantly impact patient outcomes. Utilizing data and analytics is also important. Using data analytics to identify trends in readmissions, focusing on high-risk populations and conditions, and implementing quality improvement projects based on data insights to address specific areas contributing to readmissions can lead to significant improvements in healthcare quality.