Perfecting post-acute care

Hospitalists take bigger role in postdischarge decisions.

As he pulled into the hospital's parking garage before work on a recent morning, hospitalist Ryan Greysen, MD, thought about one of his patients slated for discharge that day, a middle-aged man recovering from a major stroke. The stroke had caused dramatic and sudden changes in the man's cognitive and functional abilities, and he was about to undergo an extensive period of rehabilitation in a skilled nursing facility (SNF).

“I did the best I could to ensure a really good handoff to the receiving MD but, ultimately, I wondered, ‘Why isn't it easier for me to remain connected to this patient and his family?’” said Dr. Greysen, a hospitalist at the University of California San Francisco (UCSF) medical center.

Photo by Thinkstock
Photo by Thinkstock

It's a familiar dilemma for many hospitalists. When seriously ill patients are discharged to SNFs for rehabilitation or ongoing care, physicians might like to spend more time on the discharge process, but they're often forced to hand off some of the details in order to focus on other patients and new admissions.

“As hospitalists, we try to provide really good care for our patients as they're leaving the hospital, but we wind up feeling stuck and frustrated because often we're working against a system that's not set up to work that way,” said Dr. Greysen. “We unintentionally but understandably get disengaged.”

Over the past decade, hospitals have implemented multiple successful interventions aimed at reducing preventable readmissions, but those reforms have largely focused on systems rather than individual physicians, noted Dr. Greysen and Allen Detsky, MD, PhD, in a perspective in the October 2015 Journal of Hospital Medicine.

As a result, hospitalists often lack the guidance and support they need to fully engage in postdischarge planning.

In addition to lack of time, hospitalists often have too little information about post-acute care options to make informed decisions, said Leora Horwitz, MD, MHS, FACP, associate professor in the departments of population health and medicine at New York University School of Medicine. Until recently, it has been difficult for hospitalists to access details on the type or quality of care provided at the different facilities to which they routinely refer patients.

“We have historically done a poor job of understanding the differential outcomes at various nursing homes,” said Dr. Horwitz, who studies transitions of care. “Tracking outcomes and giving feedback to community facilities is relatively new, and it could make a real difference in the kind of care patients get.”

Zeroing in on post-acute costs

Figuring out how to improve post-acute care has become a bigger inpatient priority since the Centers for Medicare and Medicaid Services (CMS) began holding some hospitals financially accountable for entire episodes of care. Under the Bundled Payment for Care Improvement Initiative, participating hospitals are rewarded for meeting quality and cost targets during hospitalization and up to 90 days after discharge.

Another factor that's putting more emphasis on post-acute care is the addition of efficiency measures to CMS’ Value-Based Purchasing Program. Medicare Spending Per Beneficiary data, which include all Medicare spending from 3 days prior to admission through 30 days postdischarge, now account for 25% of a hospital's overall score.

Whether a hospital suffers or benefits financially from these programs will largely depend on how well it contains postdischarge spending, according to a research letter published in November 2015 by JAMA Internal Medicine. Using Medicare data from 2014 and 2015, researchers found that for hospitals with the highest costs per episode of care, the difference could be attributed to postdischarge care.

While that finding may appear to entirely implicate postdischarge care, other research indicates that hospitalists play a role as well. A 2011 study found that while hospitalist care produces cost savings for hospitals by lowering length of stay, those savings are often offset by higher costs after discharge. The study, published in Annals of Internal Medicine, found that patients cared for by hospitalists versus primary care physicians were more likely to be readmitted, admitted to the emergency department, and discharged to a nursing home.

Bundled payments may change that dynamic, said the study's senior author, James Goodwin, MD, professor in the department of internal medicine and division of geriatric medicine at the University of Texas Medical Branch in Galveston. The new payment model may also trigger a reexamination of the role hospitalists play in the post-acute period.

“If a hospital gets reimbursed for an event that includes hospitalization and the period after discharge, including discharge to a SNF, then its incentive to get that patient out as quickly as possible is balanced by the incentive to control posthospital costs,” he said. “So much is driven by reimbursement that as soon as the payment system changes, practice changes with it.”

As a case in point, after joining Medicare's bundled payment pilot program in 2013, NYU Langone Medical Center drastically lowered its referrals to facility-based care, according to a study published in the January JAMA Internal Medicine. Faced with financial incentives to select home care, when appropriate, the medical center lowered discharge rates to post-acute care facilities following cardiac valve and major joint replacement by 49% and 34%, respectively, with no negative impact on readmissions.

The key was encouraging hospitalists to think more carefully about the level of care patients needed rather than reflexively sending them to specialized facilities, said Dr. Horwitz, coauthor of the study.

“Patients discharged to post-acute care after major surgery often are not as comorbid or medically frail as other patients we tend to see on the medicine service,” she acknowledged. “But our study shows that we should at least be thoughtful about how much patients are really going to benefit before we send them to a skilled nursing facility.”

Barriers to engagement

Hospitals have tried many interventions over the past decade to improve patient outcomes after discharge and lower the risk of readmission. However, noted Drs. Greysen and Detsky in the JHM article, most of those efforts involved implementing new procedures, such as reconciling medications or making postdischarge phone calls, rather than changing the way physicians practice.

For hospitalists, the biggest barrier to engaging in post-acute care is limited time and energy, the authors wrote. Hospitalists, despite feeling responsible for how their patients fare after discharge, are hard pressed to focus on the details of disposition amid the rapid pace and complexity of their everyday practice.

“A lot of times it's the occupational therapists, case managers, or others on the care team that have the most input into a patient's level of function and what tasks they will be able to do when they leave the hospital,” said Dr. Greysen. “Hospitalists often rely on their input to figure out where to discharge a patient, especially those who are seriously ill and have ongoing care needs.”

Shared electronic health record (EHR) systems have helped to some extent by cutting down on time spent looking for information in patient records. However, noted Dr. Goodwin, the systems have not significantly improved communication among individual clinicians, which is an essential component of discharge planning.

“We are gaining a growing understanding of the limitations of EHRs,” he said. “In the abstract they're wonderful, but in reality they haven't worked very well for improving communication across transitions because they overwhelm us with too much information while burying key findings.”

Potential solutions

Faced with new incentives to save money during the post-acute period, hospitals are encouraging clinicians to be more discriminating about which facilities receive their patients requiring ongoing care. Instead of referring based on historical patterns, they are increasingly making more evidence-based choices based on highest quality and lowest cost.

“The nursing homes patients currently go to are not the always the highest financially efficient ones, but that's likely to change now that hospitals are accountable for every dollar spent in the post-acute phase,” said Chuck Bongiovanni, MSW, MBA, CEO of the assisted living placement firm CarePatrol Franchise Systems. “Discharge planners should ask every facility for their numbers and share that data with hospitalists and others on the care team.”

At NYU, hospital staff are looking at outcomes data more closely, sending feedback to community facilities, and asking for explanations for excessive readmissions, said Dr. Horwitz. The health system is also becoming more directly involved in post-acute operations by having 1 of its geriatric cardiologists work on the staff of several of its highest-volume referring facilities.

“We are increasingly aligning our disease protocols with the SNFs that we work with,” she said. “We want to truly understand the quality of care patients are getting there.”

At Virginia Hospital Center in Arlington, Va., administrators recently partnered with health care technology company Aidin, based in New York, to create a competitive marketplace for post-acute care services, said Jeffrey DiLisi, MD, the hospital's chief medical officer.

Patients needing post-acute care are presented with a list of SNFs within a 20- to 30-mile radius of the hospital along with corresponding data from public databases, such as Medicare's Home Health Compare and Nursing Home Compare, which store data on all Medicare- and Medicaid-certified facilities.

“Giving physicians that data to show to patients is a way to drive volume to the highest-quality post-acute providers while also showing those providers that we're serious about quality,” said Dr. DiLisi.

Using data to select post-acute care makes the discharge process more objective and transparent, noted Mr. Bongiovanni. It allows patients and clinicians to make choices based on concrete metrics, such as length of stay, readmissions, and trips to the emergency department.

That information can also prompt meaningful discussions between hospitalists and clinicians at SNFs. If a SNF has higher admissions to the emergency department than other facilities, for example, the hospitalist should probe further about its level of services.

“Some portion of readmissions can potentially be avoided if we know what's available at the SNF,” said Dr. Horwitz. For example, a patient who develops symptoms of pneumonia does not necessarily have to be sent to the hospital if the post-acute facility is capable of administering antibiotics and intravenous fluids.

“Relatively simple things like understanding what's available can change the type of care we give our patients,” she said. To help hospitalists find that information, NYU created a resource guide listing the various services offered at facilities in their local area.

In addition to these steps, hospitals are also starting to embrace niche roles for hospitalists focused on post-acute care. For most hospitalists, however, helping to improve the quality and efficiency of post-acute care requires a personal commitment, said Dr. Greysen. It's difficult to justify an extended phone call with an outpatient clinician or family member, for example, when the emergency department is full and patients are waiting to be admitted.

“As an individual hospitalist, I have to remind myself not to just let patients move down the conveyor belt towards discharge,” he said. “I need to pay attention and ask questions because patients transitioning to acute rehab with multiple complex care needs often really need my help.”