Hospitals need better ways to follow patients after discharge

This past April, nearly 800 hospitals throughout the country became responsible for the post-acute care of Medicare beneficiaries receiving a hip or knee replacement. Three months later a new directive required hospitals to do the same for Medicare beneficiaries with heart attacks, coronary bypasses and hip and femur fractures.

The new orthopedic and cardiac bundled payment programs reflect a new economic reality for hospitals, which traditionally had very little responsibility for post-acute care. In many markets across the country, they now will be responsible for the financial and clinical outcomes of patients for nearly three months after discharge.

It is precisely in these critical post-discharge months that health systems have the least control over patient choice or progress.

There are many reasons for that. Many hospitals lack a dedicated staff member to oversee care once a patient is discharged. The hospitals with staffing often rely on the telephone, which may not work very well on its own, even when combined with more sophisticated telemonitoring techniques such as those that remotely track heart rate, blood pressure and other vital signs.

But failing to monitor and engage patients during the three months after surgery could prove costly. It increases the risk of exceeding the targeted bundled price of care, invoking and paying a penalty.

“Hospitals are being forced to see what happens outside their doors,” said Robert Mechanic, senior fellow and director of the Health Industry Forum at Brandeis University, adding that it can be “eye opening.”

The two new policies—the Comprehensive Care for Joint Replacement Model and the Cardiac Rehabilitation Incentive Payment Model—give hospitals financial responsibility for patients from the time they enter the hospital to 90 days after discharge, a period known officially as an episode of care. That includes physician fees, post-acute care facilities and home care agencies.

The model works like this: The hospital and other providers are paid for the services they provide. But then the cost is reconciled with a target price set by the CMS. If the target price is exceeded, then the hospital and providers are financially responsible for a portion of the difference.

But if they meet or beat the target price and hit a quality threshold, they receive a bonus. Both the bonus and penalty escalate over five years until it hits 20% of the difference.

About 480 of the 800 or so hospitals participating in the knee and hip replacement program could face penalties, according to an analysis done by Avalere Health, which also tried to quantify the potential loss. The Washington, D.C.-based research and consulting firm found that about 15% of hospitals in the mid-Atlantic region, for instance, could lose a half a million dollars or more in the second or third year of the program, said Fred Bentley, an Avalere analyst.

The threat of losing money is forcing hospitals to rethink where patients are sent after they are discharged. Patients are usually sent to rehabilitation hospitals, skilled nursing facilities or receive home healthcare services.

But it's often done in an ad hoc way, which can have dire financial consequences. Up to half of the overall cost of an episode is generated through post-acute care, and the cost of that care in different settings varies tremendously.

For instance, the total episode of care, including a stay at a skilled nursing facility after a hospital discharge, costs on average about $29,101 for a hip or knee replacement. The total episode using a home care agency, on the other hand, costs just $16,744, according to Avalere Health.

Readmissions and emergency room visits in the first 90 days after discharge are another huge cost. Northwestern's University Feinberg School of Medicine conducted a survey, looking at Medicare data in Texas, and found that that 22% of patients receiving a hip replacement and 15% of patients receiving a knee replacement ended up back in the emergency room within 90 days.

Shifting the orthopedic and cardiac care programs to a bundled payment for the overall episode of care builds on other Medicare initiatives like the Hospital Readmission Reduction Program, which penalized hospitals up to 3% of reimbursement for an excessive rate of readmissions. It is part of the bigger shift within Medicare to move payment from fee-for-service to paying for quality care.

As hospitals begin to grapple with better management of post-acute care, a key issue that quickly emerges at some hospitals is a shortage of staff to serve as care navigators. This rapidly growing field is responsible for monitoring and coordinating the care of patients after they leave the four walls of the hospital.

Some hospitals have just the opposite problem. They have care navigators, but the patients suffer from multiple chronic conditions and may be being treated at multiple institutions. Each may be deploying their own care navigators to manage their care, according to Susan Nedza, a consultant and health policy researcher at MPA Healthcare Solutions.

Some rely on technological solutions like tele-monitoring that uses phone and remote devices to gauge patients' progress from afar. But studies have raised questions about its effectiveness of tele-monitoring. Two large, high quality clinical trials showed that tele-monitoring did not reduce readmission for patients with heart disease, said Dr. Kumar Dharmarajan, an assistant professor at Yale School of Medicine.

Hospitals throughout the country are now running pilot projects and testing new technologies that can flag potential complications before they turn into emergency room visits or readmissions. This can mean monitoring adherence to a medication regiment via remote control pill bottles, using smart phones to take picture of wounds that might be infected or even use implanted devices that can track vital signs.

“There is a lot of experimentation,” said Dr. Shivan Mehta, an assistant professor and associate chief innovation officer at Penn Medicine, adding that researchers are still trying to pin point the specific “ingredients” that cause someone to be readmitted.

The pilots are trying to facilitate electronic communication between patient and providers through portals or apps where the patient can ask questions and get answers without picking up the phone or going to a doctor's office. They are using computer-generated messages designed to increase patients' understanding: why it's important to take a certain medication on time; why they're being sent home; or why their surgical incision has turned red and is sore.

And what these pilots are revealing is a growing consensus that successful patient monitoring must extend well beyond purely physiological indicators to measure what's going on in their home environment.

In part two, find out about the people and new tools needed for effective post-discharge monitoring.

Lisa Ward is a freelance writer based in Mendham, N.J.