The American Health Care Association recently announced an update to its National Quality Initiative, a multi-year effort designed to further improve quality of care and the patient experience in America’s long-term and post-acute care centers. Since the launch of the Initiative in 2012, members have been challenged to meet measurable targets in key areas such as hospitalizations.
While significant improvements have been made, the AHCA says that more must be done. The next phase of the effort continues to challenge providers to achieve quantitative results in key areas by March 2021. Objectives are aligned with federal mandates linking financial outcomes to quality performance, including the goal to safely reduce long-stay and short-stay hospitalizations.
The goal of reducing hospital readmissions is shared by the Centers for Medicare & Medicaid Services, health systems and payers alike. In fact, CMS will begin incentivizing skilled nursing facilities October 1, 2018, under the SNF Value-Based Purchasing (VBP) Program to reduce readmissions.
This program aims to reward quality and improve healthcare in SNFs. Top performing facilities will receive incentives through payment adjustments, while lower performing facilities will receive payments that are less than what they otherwise would have received without the Program.
CMS will withhold 2 percent of SNF Medicare payments starting October 1, 2018, to fund the incentive payment pool, and will then redistribute payments back to SNFs.
Discharging patients from the hospital is a complex process fraught with challenges and involves over 35 million hospital discharges annually in the United States – with unplanned readmissions costing $15 to 20 billion annually. Preventing avoidable readmissions has the potential to profoundly improve patients’ quality of life and the financial well-being of healthcare systems.
Providers have long understood the negative impact of hospital readmissions for patients and their facilities and have been focused on reducing hospital readmissions. Since the launch of the AHCA Quality Initiative in 2012, AHCA reports that their SNF members have safely prevented more than 142,000 individuals from returning to the hospital — a 12% reduction since 2011.
Hospital readmissions put beneficiaries at risk for complications, and have the potential for negative physical, emotional, and psychological impacts on patients and their caregivers. Readmission to the hospital interrupts the SNF patient’s therapy and care plan, causes anxiety and discomfort, and exposes the patient to hospital-acquired adverse events, such as loss of functional status, healthcare-associated infections, and medication errors.
What’s more, high readmission rates are stressful for staff and can tarnish the reputation of the SNF and its ability to participate in health system networks, which in turn impacts occupancy and the financial health of the facility.
Incorporating palliative care
Care transitions require a set of actions designed to ensure coordination and continuity. They should be based on a comprehensive care plan and the availability of well-trained practitioners who have current information about the patient’s treatment goals, preferences, and health or clinical status. They include logistical arrangements and education of patient and family, as well as coordination among the health professionals involved in the transition. In effect, transitions of care are a subpart of the broader concept of care coordination.
To safely reduce readmissions, improve performance in VBP and stave off CMS reductions in reimbursement, SNFs will most likely need to implement multi-pronged strategies that may include interpretation of CMS reports, use of technology to identify high risk patients for re-admission, assessment tools, process improvement and staff education.
Palliative care is a beneficial addition to a SNF readmission strategy. One study focused on 474,829 nursing home decedents found that 19% had at least one burdensome transition.
Researchers concluded that while healthcare transitions in the last months of life are common, they can be burdensome, potentially of limited clinical benefit for patients with advanced cognitive and functional impairment and are associated with markers of poor quality in end-of-life care.
Patterns of transition were considered burdensome if they occurred in the last three days of life, if there was a lack of continuity in nursing homes after hospitalization in the last 90 days of life, or if there were multiple hospitalizations in the last 90 days of life.
Moreover, palliative care providers support a solid hand-off between hospital and the SNF through patient assessment that includes medication review, pain and symptom management and collaborating and communicating with the patients’ PCP to address any immediate needs. Studies have shown that increased coordination can lead to a decrease in readmissions to the hospital.
Palliative care providers can support a readmission strategy through conducting goals of care conversations and completing advance care directives with patients and their families. This is a key point: Palliative care draws upon clinician expertise in conducting sensitive conversations that better align treatment options with personal goals of care.
Enhanced care coordination results from getting patients and caregivers information on the types of treatments that are available, helping them to decide what treatments match their personal preferences, and completing advance directives that put into writing one’s personal wishes regarding treatment. Identifying and documenting when patients prefer to avoid further hospitalizations and adopt a comfort care approach can reduce readmissions that are unwanted and unnecessary.
Good news for healthcare system
Given the increased focus on readmission rates and incentives to improve care quality, readmission rates have declined almost 20% for patients hospitalized with heart attacks, heart failure and pneumonia. One study looked at six million hospitalizations from over 5,000 hospitals over a seven-year period, and found no evidence that the reduction in hospital readmissions resulted in greater risk of dying for patients recently discharged.
In fact, hospitals that reduced readmissions the most were, if anything, more likely to reduce mortality after hospitalization. To lower readmissions, hospitals focused on better preparing patients and families for discharge and improved the integration and coordination of care from hospital to home and other settings such as SNFs. Success hinges on health care professionals being willing to engage with patients and families to promote truly patient-centered, high-quality care.
Central to this process, effective palliative care advances both care coordination and care transitions by supporting patients and caregivers in the identification of issues that impact timely care interventions, avert unnecessary hospitalizations and readmissions, support patient preferences and choices, and avoid duplication of services. Ultimately, this approach uses resources more effectively while improving overall care quality, patient satisfaction and outcomes.
Cyndi Seiwert is the Chief Operating Officer at Turn-Key Health.