Arete Rehabilitation in the Forefront: Learn How to Lower Readmission Rates
Readmission is defined as a subsequent hospital readmission within thirty days following an original admission. Medicare beneficiaries have the largest share of total readmissions and associated costs. One in five Medicare patients will be readmitted to the hospital. Estimates of costs resulting in readmissions are $26 billion with $18 billion in costs that could be avoided if care is properly provided the first time.
A readmission may result from incomplete treatment, inaccurate diagnosis of the underlying problem or poor coordination of services at the time of the discharge or after. Poor follow-up after discharge has been cited as the primary reason for readmission.
A focus of the Affordable Care Act involves reducing hospital readmissions in order to increase cost savings. Hospital readmissions also impact a patient and family’s quality of life requiring increased care giving, financial costs and added stress. Furthermore, the risk of hospital acquired infections and delirium increases among older adults.
The most recent data has identified congestive heart failure, pneumonia, and acute myocardial infarct as the three most common diagnoses for hospital readmission. Following these three conditions are:
• Chronic Obstructive Pulmonary Disease Exacerbation (COPD)
• Cardiac Dysrhythmias
• Urinary Tract Infections
• Renal Failure
• Cerebral Vascular Accident
Glow As You Go: An Innovative Program to Reduce Readmissions
Arete Rehabilitation is taking the lead in reducing hospital readmissions through Glow As You Go, an innovative program. Hospital readmissions are costly and can often be prevented with a thorough review and analysis from multiple providers. Prior to a patient’s discharge from the hospital and admission to a skilled nursing facility, the Arete therapy team gathers information about the prospective patient with the requirement to complete the medical information review and hospital team interview within 24 hours of admission. The therapy team calls the hospital to elicit key information.
The Initial Transitions Process
The initial information gathered includes traditional patient information such as demographics, diagnosis, and medical history. The uniqueness of the program lies in its attempt to connect with key members of a patient’s hospital-based team for a warm patient handoff with telephonic communication. Most notably, the main goals of the initial transition process are to get at the reason behind why the particular patient was admitted to the hospital, and to determine what can be done to prevent that person from getting readmitted.
Patient and Caregiver Education to Prevent Readmissions
Once the patient is admitted to the facility, the therapy team complete a unique transitions evaluation through which the foundation for the remainder of the program is based. This information is used to decide whether the patient or caregiver should be educated regarding their diagnosis, identifying red flags, and how to respond to their red flags. In the case where a patient does not have a support system or caregiver, the team determines the best way to provide support for that patient.
The team works with nursing to reconcile medications prior to discharge from the skilled facility, setting up MD appointments for follow-up including transportation, and ensuring that all information gathered is relayed to the next healthcare team designated to support the patient.
Finding the Root Cause
Identifying the root cause of a readmission requires refined investigative skills, and is not often an easy task. For example, one Arete case involved an elderly woman with dementia who had been readmitted to the hospital from the nursing facility. This case required gathering pertinent information and meticulous analysis to uncover the underlying problem.
The patient had initially been admitted to the hospital for dehydration and a urinary tract infection. By gathering additional information, it was discovered that the patient had been on a thickened liquid diet, which can result in malabsorption with risk of dehydration. Due to cognitive impairments, the patient was unable to communicate her thirst. Furthermore, the staff had not been adequately educated in providing additional and alternative hydration for the patient.
After discovering the root cause, thickened liquids were discontinued and the patient was put on a Frazier Free Water Protocol with an oral hygiene program to prevent further dehydration and aspiration risk.
The Role of Therapy in Reducing Hospital Readmissions
The role of therapy in reducing hospital readmissions cannot be over emphasized, and requires a paradigm shift in our thought process. In a recently published study, researchers used Medicare claims and cost data to evaluate spending on specific services to determine how those costs are related to quality of care.
The results found that extra spending on occupational therapy is the only one of 19 services to have had a “statistically significant association with lower readmission rates for three medical conditions: heart failure, pneumonia, and acute myocardial infarction.
The researchers point out that occupational therapy “focuses on a vital issue related to readmission rates; can the patient be discharged safely into his or her environment?” If not occupational therapists address issues from physical barriers to daily function to support networks. Occupational therapy provides six particular interventions that can successfully reduce readmissions:
1. Provision of recommendations and training for caregivers
2. Determination of whether patients can safely live independently, or require further rehabilitation or nursing care
3. Addressing existing disabilities with assistive devices so patients can safely perform ADLs (using the bathroom, bathing, dressing, preparing a meal)
4. Coordination with physical therapists to increase intensity of inpatient rehabilitation
5. Performance of home safety assessments prior to discharge to suggest modifications and equipment needs
6. Assessment of cognition and the ability to physically manipulate objects such as medications and containers, provide training for adaptive techniques including low vision, and embedding routines for improved medication adherence
Furthermore, occupational therapy directly focuses on ensuring that the patient and his/her caregivers are ready to cope physically, mentally and emotionally with the return home after discharge. Helping ensure a successful transition home is a “vital issue related to readmission rates,” according to the study.
Physical therapy can reduce fall risk prior to discharge when addressing:
• Gait training
• Training in safe and appropriate use of adaptive devices
• Bed mobility
Medication mismanagement is a common reason for hospital readmissions. Physical therapists can play a role in providing information about heart rate and blood pressure changes during activity and how it might influence medications such as anticoagulants that could increase a fall risk.
As physical therapists focus on reducing hospital readmissions, goals and plan of care need to change to reflect that focus. For example, instead of establishing a goal for a patient to ambulate 200 feet with a diagnosis of COPD, physical therapists coach patients to maintain or increase functional mobility without increasing signs and symptoms of exacerbation. Physical therapists can progress ambulation while monitoring:
• Breath sounds
• Oxygen saturation levels
• Pain scale levels before, during and after activity-gradually increasing activity tolerance while managing the condition.
A patient’s physical functioning is only included in 19-26% of discharge summaries. PT recommendations are missing from an average 55% of discharge summaries which impacts the coordination of community rehabilitation services and resulting readmissions. Discharge planning is one of the most important factors in successful transitions for patients. It has been proposed that PT’s communicate complex conditions to patients in a way that they can understand.
Speech Language Pathologists play an important role in reducing readmissions in the following ways:
• Creating materials to assist in health literacy especially discharge instructions
• Evaluation of swallowing disorders which can result in aspiration pneumonia and recommend special diets
• Evaluate cognitive impairments and develop compensatory strategies especially with medication management
• Evaluate communication impairments (receptive and expressive) and develop compensatory strategies
• Training and educating caregivers in precautions and compensatory strategies
Lower health literacy has been associated with increased hospital readmissions; therefore SLP’s are the primary profession to address deficits with comprehension and limited language among patient populations. In the discussion of the Arete patient, SLP played a pivotal in evaluating whether the patient absolutely required her thickened-liquid diet that subsequently resulted in dehydration or if a trial of an alternative method would be more beneficial for the patient. In conjunction with occupational therapists, SLP’s evaluate cognitive function and develop strategies to increase safe discharge to home and after.
Arete Rehabilitation is to be commended for taking the initiative to develop the Glow As You Go program and becoming accountable in reducing readmissions. By systematically tailored communication from initiation to completion with all key members surrounding the patient, and getting at the ‘why’ behind an admission, Arete is reducing patient readmissions. Further, by utilizing the present facility team members, they are creating a both a cost-effective and revenue-sustaining program within a skilled nursing facility, as the services provided are billable per Medicare guidelines.
To date, the Arete team has been successful with twenty-six out of thirty-two patients in reducing readmission after 30 days. As the therapy team hones their investigative skills, more successes will follow in reducing readmissions. The novel and innovative transitions program serves as an inspiration in the endeavor to improve quality health care and cost savings.
Arête Rehabilitation Conference Call 3/30/17
Dening, Jedha: Role of Physical Therapy in Reducing Hospital Readmissions 12/18/16. www.rehabalterniatives.com
PT in Motion: There’s No Place Like Home: Reducing Hospital Readmission Rates. www.apta.org/PT in Motion/201511/Feature/Hospital Readmission
Rogers, A., T., Bai, G., Lavin, R.A, & Anderson, G.F. (2016, September 2) Higher hospital spending on occupational therapy is ssociated with lower readmission rates. Medical Care Research and Review,1-19. www.aota.org