Reducing Long-Term Care Readmissions through Clinical Integration

Asad Zaman, M.D., is a member of the board of directors of Advocate South Suburban Physician Partners and the immediate past chair of the department of medicine at Advocate South Suburban Hospital in Hazel Crest, Ill. He is also the medical director of Crestwood Care Centre, Crestwood, Ill. 

Lucy Zielinski is a vice president at Health Directions LLC, Oakbrook Terrace, Ill.

"Jane" was driving across country when soreness in her groin forced an unplanned stop in the Chicago area. An urgent care physician discovered an infected abscess and sent her to a hospital for emergency drainage surgery. At 7 p.m., Jane was discharged to a long-term care facility for wound care and intravenous antibiotics. The admitting physician gave orders to continue her medications per discharge instructions.

The next day at 11 a.m., the physician walked into the facility's rehab unit and found Jane in agony. Because of a discrepancy in the drug formulary, the pharmacy had not delivered any medications. The patient had received no antibiotics and no pain medications for 16 hours! The physician had no choice but to send Jane back to the hospital.

Unfortunately, care gaps like this are an everyday problem in many LTC facilities. When Medicare readmission penalties begin this October, such lapses will become a problem for hospitals, too.

Cooperating with LTCs

LTC facilities are a leading source of hospital readmissions in the United States. According to the Congressional Research Service, major factors include poor communication at discharge and inadequate follow-up care by LTC providers. Under traditional fee-for-service payment systems, poor post-acute care did not affect hospital revenue. But as Medicare phases in readmission penalties for heart attacks, heart failure and pneumonia, and as other payers launch bundled payments, hospitals will have a financial stake in the care patients receive in LTC facilities.

How can acute care hospitals reduce readmissions from long-term care facilities? The following are five ways hospitals can cooperate with LTC providers to solve care problems.

  1. Bring LTCs up to speed.
  2. Pay attention to care delays.
  3. Strengthen communication.
  4. Create low-tech workarounds.
  5. Think outside the box.

Bring LTCs Up to Speed

Most LTC facilities do not have the resources or expertise to rapidly improve the quality of their care. So, to reduce readmissions and avoid financial penalties, hospitals need to help LTC organizations improve care processes.

One option is to allocate clinical staff to oversee LTC relationships. Appoint a physician to serve as the medical director of post-acute care, and assign nurse managers to facilities that receive a high volume of hospital discharges. Give these caregivers responsibility for working with LTC staff to bring patient care up to par. Nurses should help LTC managers create written care protocols (for feeding tubes, Foley catheters, central lines, and so forth) and reengineer workflows to prevent care lapses.

Pay Attention to Care Delays

Hospitals can assist LTC facilities in reducing delays by helping them streamline clinical processes.

Let's return to the abscess patient. The formulary problem was only one cause of the care delay that sent Jane back to the hospital. The other problem was that LTC protocols required the admitting physician to approve all medication orders. This is the process in most LTC facilities, and it can delay medication administration by 4 to 6 hours and even longer during evening and nighttime shifts. The process often leads to patients' missing one or two doses during hospital-to-LTC transitions.

One solution is to place medication management in the hands of the discharging physician. During a care transition, the discharging physician orders a patient's medications so prescriptions are available upon patient arrival at the LTC facility. The admitting physician is informed of the order, but his or her input is not required.

Strengthen Communication

Simple improvements to communication also can strengthen continuity of care. Focus on communicating readmission risks.

One possibility is to reconfigure the inpatient electronic medical record to organize the physician plan notes into an inpatient plan and an outpatient plan. When the hospital discharges a patient to an LTC facility, have the system automatically extract the outpatient plan notes to the discharge summary. The plan notes serve as a care checklist for LTC staff. Discharging physicians also can list readmission risks in the discharge summary, enabling LTC staff to actively manage risks that could send a patient back to the hospital.

Create Low-Tech Workarounds

In the future, electronic tools will help hospitals and LTC facilities coordinate care. Right now, however, very few LTC facilities have an EMR. Hospitals should find low-tech solutions to the problem of coordinated care.

Terri Jacobsen, director of the MetroChicago Health Information Exchange, recently offered several ideas for working within current limitations. "In most systems right now, the technology for patient handoffs is not seamless," she said. "One way for hospitals to provide LTC facilities with accurate care and medication information could be simply to print out the continuity of care document from the inpatient EMR and send it along with the patient."

Some health information exchanges are developing portal applications. These portals, Jacobsen noted, could allow LTC providers to download hospital discharge information, even if they do not have an EMR.

Personal health records pose another solution. "One possible model is for LTC facilities to set up PHRs for all their patients," Jacobsen said. "If hospitals had the ability to push discharge information into a patient's PHR, the LTC facility could then access it. This wouldn't solve all the medication problems, but it would be another way for LTC providers to get patient data."

Think Outside the Box

Solving the problem of readmissions will take creative thinking. Hospitals should take a fresh look at the resources available to provide appropriate care in nonhospital settings.

Roger Holloway, co-director of the Illinois Health Information Technology Regional Extension Center, is developing a system that would provide wireless monitors to patients who are at high risk of hospital readmission. The monitors would transmit biometrics like pulse, blood pressure, blood sugar, oximetry and EKG data to local emergency medical services staff. Under the plan, any metrics falling outside a predetermined range would trigger a response from EMS.

"EMS could either assess the patient by phone or visit the patient's home," Holloway said. "They might end up deciding the patient really needs to go to the hospital, but crews with paramedic-level skills can do a lot on the scene without transfer." The system would take advantage of existing capacity in many EMS departments, and it could be extended to patients in LTC facilities.

New Partnerships

Until recently, the relationship between hospitals and LTC facilities was one-sided. LTCs courted hospitals for admissions, and hospitals did not have to worry about what happened after a patient was discharged to an LTC facility.

Accountable care is changing the dynamics of this relationship. Hospitals now need LTC partners that can deliver high-quality care and keep readmissions down. Strong collaborative partnerships will benefit hospitals and LTC facilities alike — and help them both provide better care to patients.