Coordination between hospital and out-of-hospital care is crucial to reducing hospital readmissions, Anita Morris, director of practice transformation in UMass Medical School’s Office of Healthcare Innovation and Quality, says in an article in Managed Healthcare Executive.
The Dec. 20 article said the Centers for Medicare and Medicaid Services estimate that nearly one in five Medicare patients is readmitted to a hospital within 30 days, with the cost of preventable readmissions at $17 billion. Medicare began penalizing hospitals for excessive readmissions in 2012, and more than 2,000 hospitals received payment penalties during the initial phase, according to the article.
Coordination, particularly with primary care providers, is “a large umbrella issue,” Morris told Managed Healthcare Executive. Communication is important when a patient transfers out of a hospital and back to primary care, and she recommends that hospital personnel communicate directly with the primary care physician.
“The first line of defense is for the patient to have clear information about what medications they’re taking,” Morris said. Medication reconciliation should be done at discharge with both the hospital and the primary care provider to ensure patients adhere to regimens as prescribed, she said. If the reconciliation doesn’t take place, the patient might only take previous medications or take the previous medications with the new ones.
Many patients at high risk for hospital readmission have medical complexity, such as chronic health conditions, behavioral health issues or multiple medications, Morris told Managed Healthcare Executive. Along with medical complexity, patients at high risk for readmission may have social complexity, which could mean a high-risk patient has no transportation to get home from the hospital or pick up prescription medications. A two- or three-day delay in starting antibiotics could affect the patient’s clinical outcome, Morris said.
“It takes time and effort to build up those processes and that communication,” Morris told Managed Healthcare Executive. “It doesn’t happen by itself.”
The Office of Healthcare Innovation and Quality, a unit within UMass Medical School’s Commonwealth Medicine division, provides training, technical assistance and shared learning for provider organizations that are implementing new care delivery models.