A number of articles in the past few days have brought attention to the need to reduce hospital readmissions and improve quality of care within, and during transitions between, care settings.

An article in Monday’s Globe looked at preventable readmissions. According to the Institute for Healthcare Improvement, which is coordinating a national program to improve transitions and reduce readmissions, more than 10% of Massachusetts patients are back in the hospital within a month of being discharged. Twenty-two Massachusetts hospitals are participating in the IHI initiative to examine why this happens and what can be done to prevent such readmissions. Nationally, one in five Medicare patients returns to the hospital within a month of being discharged, costing over $15 billion.

The upside down financial incentives, where hospitals now profit from readmissions, inhibits hospitals that want to do the right thing from putting enough resources into preventing readmissions. We continue to believe that the quickest, most effective low-hanging fruit to improve quality and lower costs would be for Massachusetts to join other states in reducing payments to hospitals with high rates of preventable readmissions. This has been mulled over by state policymakers, but no firm steps have been taken beyond a task force working on recommending a measure of preventable readmissions.

There are many reasons why readmissions occur, but more broadly it is often because of a lack of coordination and oversight of care once the patient is discharged, whether the patient goes back home, with or without home health care, to a nursing home or rehab center, or to another hospital. The Globe article describes some of the pilot projects around the country that seek to improve transitions and reduce readmissions. One of these initiatives, the Care Transitions Program, is also cited in a NY Times article last week. The article focuses on the need to improve transitions of care especially for older adults with chronic conditions. The article points out that discharges from hospitals are often rushed and poorly coordinated, often leaving the still-vulnerable and recovering patient to manage his or her own care, including new medications, follow-up appointments, and keeping track of new or worrisome symptoms, with little coordination from a designated care provider. As the article points out, discharge planning often falls in the space between “billable events” and therefore does not get the time and attention it deserves. The Times article offers advice for patients and caregivers who are dealing with transitions, from making sure they know about new medications and how to take them, to putting together their own discharge plan, to making sure the primary care physician is fully informed about the patient and ready to begin his or her care post-discharge.

A second NY Times article looks at hallucinations that occur in hospitalized patients. Often called “hospital delirium,” it mostly affects older adults. It is estimated that one-third of patients over 70, and more often those in ICUs or post-surgery, experience hospital delirium. There are many potential causes, including infections, surgery, pneumonia, new medications, and also disorienting changes like sleep interruptions, isolation, changing rooms, and being without eyeglasses or dentures. As the article points out, patients experiencing delirium are hospitalized longer, more often sent to nursing homes, and more likely to develop dementia later on (and also, though not specifically mentioned, probably more likely to be readmitted to the hospital). Some 35%-40% of these patients die within a year. A number of hospitals have put processes in place to try to prevent delirium, including making sure patients have eyeglasses and hearing aids, making adjustments to schedules, light and noise so patients can sleep, and helping patients to engage in physical and cognitive activities.

The takeaway from all of these articles is that there are many hospitals and other care providers looking at how to improve quality of care within settings (eg. reducing delirium in hospital patients) and during transitions between settings (eg. thorough and coordinated discharge planning with fully informed care providers and patients/caregivers) but, for the most part, financial incentives in a fee-for-service system are still not aligned with making sure this work gets done. The goals of pilot programs in national health reform and of payment and delivery system reform in Massachusetts are to always put the patient at the center of the care process so that the patient’s health and well-being come first. Once that starts happening, health and quality of life will improve and costs will come down as fewer patients are unnecessarily readmitted to hospitals and their care is properly provided for in a coordinated outpatient setting.
-Deborah Wachenheim