Williams co-wrote an April 2, 2009 New England Journal of Medicine report that estimated unplanned rehospitalizations cost Medicare $17.4 billion in 2004.
The effort targeting unplanned or preventable hospitalizations and emergency department visits 30 days after discharge comes as the federal government is targeting readmissions as a way to improve quality. The now-stalled Senate healthcare overhaul bill would cut hospital reimbursement for certain types of readmissions in 2012.
Scott Flanders, president of the Society of Hospital Medicine and a University of Michigan professor of medicine, said his organization is aware of how, in the contentious context of healthcare reform, preventing readmissions has sometimes been cast as an attempt to “ration” healthcare.
“We're careful to use the terms ‘unnecessary' or ‘unplanned readmissions' because some readmissions are necessary and some are planned,” Flanders said, adding that patients certainly don't see this effort as rationing. “Being in a hospital is very stressful and, once they get back home, it's very frustrating to end up back in a hospital.”
Project BOOST was launched as a six-hospital pilot in September 2008 and expanded to 24 other sites last March. Flanders said physician practices affiliated with participating hospitals are being recruited to take part in the program and that more than 15 hospitals have already expressed interest in participating. Williams said the hospitals and practices will be selected in late April or May, the program will be rolled out in the fall and that, after a year, measurable performance data should be available.
Many of the hospitals involved are still using paper charts Williams said, but about 10 are using an electronic health-record system developed by Cerner Corp. and have formed their own work group of sorts while another three or four hospitals that are using an EHR from Epic Systems Corp. are in the process of being linked together as well.
“One of the objectives is to allow people not to have to reinvent the wheel over and over again,” Williams said, adding that if participating hospitals and outpatient physicians are using an EHR, the Project BOOST tool kit has to be integrated into it. “It's essential to integrate it into the work flow and that it not be an add-on to current work, otherwise it's almost doomed to failure.”
Williams criticized as too narrow a CMS program aimed at preventing readmissions after 30 days of discharge for patients with heart attacks, heart failure or pneumonia.
“Only 8% to 9% of patients fall into those condition categories,” Williams said. “When heart patients are rehospitalized within 30 days, it's often for a different reason than their heart.”
The Society of Hospital Medicine reports that at Atlanta's 481-bed Piedmont Hospital, the rate of unplanned readmissions among patients under 70 years old participating in Project BOOST was 8.5% compared with 25.5% among nonparticipants.
For patients older than 70, the rates are 22% for participants compared with 26% for nonparticipants. At 428-bed SSM St. Mary's Medical Center in St. Louis, where the program's tool kit was implemented in the 33-bed hospitalist unit, unplanned 30-day readmissions dropped to 7% from 12% in three months with patient-satisfaction scores rising to 68% from 52%, the Society of Hospital Medicine said.
Although Project BOOST has been implemented already in some fashion across 30 individual hospitals, Williams noted that the Michigan program will have the institutions concentrated in one state and united by a single payer, and Flanders noted that including outpatient physicians is also a new approach.
One of the tenants of the program is to schedule a follow-up doctor visit within one to two weeks of discharge, which Williams said is particularly helpful with frail elderly patients with multiple conditions, but the program is sailing in “uncharted territory” and what works best for any particular patient is still being determined.
“We honestly don't know what the ‘secret sauce' is, if you will, that will decrease readmissions,” Williams said. “The key issue isn't mandating that a patient see their doctor after discharge, it's good communication so they know who to contact and what to do—instead of saying, ‘I feel bad, so I'm going to call 911 and go back to the hospital.' ”
Williams added that this communication boosts patient satisfaction as well as decreasing readmissions. “They want to know why they were in the hospital in the first place,” he explained. “They want to know what to do and what's happening if they develop symptoms or get side effects from their medications.”
Flanders said Project BOOST uses the “teach back” method where, after this information is explained to them and to their family members by a nurse or pharmacist, the patient must explain back their condition and what drugs they're taking and why. “They're told: ‘Tell me what I just told you,' ” he said.
Williams said last week he visited the 451-bed Sanford University of South Dakota Medical Center in Sioux Falls, where the pharmacy department has taken a very active role in this part of the program and it appears to be working quite well.
Flanders added that reducing readmissions is a complicated puzzle that will take teamwork to solve. “One thing we've recognized that hospital readmission is a complex thing and they are not due to a single factor but multiple factors that come together in a perfect storm,” he said. “The understanding that this isn't an easy problem to fix is a common finding.”
Project BOOST is not the only program looking at this issue in Michigan. While the Michigan Blues is funding the implementation of the Society of Hospital Medicine program, the Commonwealth Fund helped finance an Institute for Healthcare Improvement program at hospitals in Massachusetts, Michigan and Washington state, dubbed State Action on Avoidable Rehospitalizations Initiatives.
Flanders said the two programs are very similar but not directly related and some hospitals may be participating in both. Also, he said participants in both programs will be sharing information on their respective successes and failures.
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