McKesson : Five Ways Post-Acute Care Providers Can Minimize Hospital Readmissions

October will usher in a new era of performance transparency and financial risk for Medicare-certified post-acute care providers. That's when provisions of two new federal laws combine to require these providers to publicly report their 30-day hospital readmission rates. If their readmission rates are too high, they will face penalties of up to 2 percent of their Medicare payments.

The first piece of legislation is the Protecting Access to Medicare Act of 2014, which created the skilled nursing facility (SNF) value-based purchasing program. The program pays SNFs based on how well they meet specific clinical performance targets.

The second piece of legislation is the Improving Medicare Post-Acute Care Transformation Act of 2014. It requires SNFs, long-term care hospitals, home-health agencies and inpatient rehabilitation facilities to collect and submit clinical performance data to Medicare.

A post-acute care provider's hospital readmission rate is a performance measure under both laws. It is defined as sending patients who had been discharged to post-acute care settings back to the hospital within 30 days for additional acute-care services.

The Impact of High Readmissions Rates on Post-Acute Care Providers

Hospitals have been working hard to reduce their own readmissions rates since 2012, when Medicare's Hospital Readmissions Reduction Program (HRRP) took effect. HRRP penalizes hospitals with high 30-day readmission rates.

Now, it's the post-acute care sector's turn to learn how to keep its patients as healthy as possible and avoid financial consequences. The consequences include:

• A potential 2 percent reduction in Medicare payments starting October 1, 2018, for higher-than-expected readmission rates the previous federal fiscal year
• A loss of referrals from hospitals that won't send their patients to underperforming post-acute care providers
• A loss of referrals from patients and families who use publicly available readmissions data to make decisions about where to receive post-acute care
• Higher costs from providing additional medical care to patients who were not cared for properly during their post-acute care episode

Clearly, it's in the best financial interest of SNFs, long-term care hospitals and home care agencies to provide the optimum level of care to patients in their own settings.

How Post-Acute Care Providers Can Improve Patient Care

Post-acute care providers should upgrade their clinical operations in order to provide an excellent level of care and avoid the financial implications of not doing so. I recommend that they focus on improving five areas of their operations.

1. Patient assessment. The acuity level of patients being discharged from a hospital to a post-acute care setting is higher now than it's traditionally been. Hospitals are not keeping patients longer than needed and are discharging them with medical needs that can be safely addressed in a non-acute care setting. The patient assessment processes and skills in the post-acute setting must be as effective as possible. In practice, that means studying patients' medical records to fully understand their medical conditions upon admission. That includes knowing their diagnoses, comorbidities, labs and diagnostic test results, physician orders, medications and required therapies. It also includes assessing patients for anything not in their medical records, such as undiagnosed infections or untreated wounds.

2. Care planning. CMS requires each patient to have a care plan written within 48 hours of admission to a post-acute care setting. The care plan, though, is only as good as the patient assessment, which dictates how the patient will be treated. The assessment should measure each patient's risk of readmission based on his or her medical condition. The care plan should aggressively address the clinical risk factors that, left unattended, could send the patient back to the hospital. For many post-acute care providers, that may mean offering services previously not given to patients. One example is intravenous medications. We're seeing more skilled nursing facilities deliver prescription medications through IVs. Another example is nutrition. Without proper nutrition, a patient is not going to improve, so we're seeing greater use of dietary consultants and onsite dieticians.

3. Early intervention. Given their higher acuity, comorbidities and clinical risk factors, the medical condition of patients in post-acute care settings can deteriorate quickly and without obvious warning signs. The result is a return-and potentially preventable-trip to the hospital. Post-acute care providers must improve their ability to detect changes in a patient's condition as early as possible and intervene before the condition worsens. We're seeing more monitoring of vital signs on site, as well as remote monitoring, where patient health data is sent offsite to be interpreted by a clinician. We're also seeing more point-of-care testing in post-acute care settings. Many sites are using CLIA-waived lab tests to run urinalyses to check for infections, blood tests to check glucose levels and blood tests for complete blood counts and metabolic panels. These sites can get test results quickly and make treatment decisions at the point of care, rather than waiting for test results to come back from an offsite lab.

4. Care coordination. Medical research continues to show a correlation between avoidable hospital readmissions and poor patient handoffs and care coordination among providers. The discharge of a hospital patient to a nursing home is an example of a transfer that, if done well, can reduce the chances of a preventable readmission. If done poorly, the chances of returning to the hospital are much greater. One specific area that post-acute care providers should focus on is medication reconciliation. They should know which medications patients were taking before they were admitted to the hospital, what they were taking while they were in the hospital and what they were prescribed upon discharge. Post-acute care providers can deploy digital tools that enable effective communication between them and other providers, including hospitals, doctors and pharmacies, to mitigate the readmission risk of patient handoffs. Some sites are using telemedicine capabilities to discuss patient care with others in real time.

5. Staff competencies. Targeting the first four areas for improvement would be fruitless without the right staff. Post-acute care providers must hire, train, educate and develop employees who excel at the following four competencies:

• Assessing the health status and readmission risk of patients
• Writing and executing care plans that improve patients' health status and reduce their risk of readmission
• Using diagnostic skills, complemented by medical technologies, to detect changes in patients' conditions and intervene as early as possible
• Using personal and digital tools to drive care coordination

The right post-acute employees take it upon themselves to reduce readmissions by getting recommended vaccines and seasonal flu shots to prevent the spread of communicable diseases. They also adhere to infection prevention protocols, including hand hygiene, and ensure that visitors follow the same protocols.

Pursuing these strategies will likely increase operating costs. But if their efforts are successful, post-acute care providers can realize a substantial return on investment as value-based reimbursement models reward them for keeping patients as healthy as possible and out of the hospital.

Related: Learn more about McKesson's patient and clinical care solutions for extended-care providers