A new emphasis on social factors to reduce readmissions

There are many ways hospitals can use technology to track and engage patients after they leave the building. Smartphones can monitor physiological functions. Surgical implants can spot early warning signs. Texts can facilitate quick communication.

But there are limits to what hospitals can expect from current technology.

Large, randomized clinical trials have posted disappointing results when it comes to tele-monitoring's effect on overall readmissions rates. This may seem counterintuitive. Many devices can spot early psychological warning signs, but re-admission rates are often driven by a complex web of determinants, many of which are not biological.

Acknowledging this complexity and using technology to facilitate a multipronged approach could improve the overall likelihood of success. Also, technological interventions could account for non-medical variables that play an important role in readmission.

“Hospitals need to take a holistic approach,” said Dr. Kumar Dharmarajan, an assistant professor at Yale School of Medicine.

Hospitals have several new financial incentives to use technology to monitor and engage patients after they are discharged from the hospital. This year the CMS mandated that almost 800 hospitals throughout the country participate in the Comprehensive Care for Joint Replacement Model, making them responsible for patients' clinical and financial outcomes during an entire episode of care. That's from the time they enter the hospital for a knee or hip replacement to the 90 days after discharge.

Three months later, the CMS issued another directive, the Cardiac Rehabilitation Incentive Payment Model, requiring many hospitals to do the same for Medicare beneficiaries with heart attacks, coronary bypasses, hip and femur fractures. These programs build on other Medicare initiatives, like the Hospital Readmission Reduction Program, which also penalized hospitals for readmissions. It is also part of a bigger shift in Medicare payment to move away from fee for service to paying for quality care.

There have certainly been big advances in remote monitoring. The Lancet earlier this year published a second study by Dr. William Abraham, director of Ohio State University Wexner Medical Center's cardiovascular medicine division, showing an implantable monitoring device measuring pulmonary artery pressure reduced hospitalization due to heart failure.

But use of such devices, while medically beneficial, is not a silver bullet for all patients with heart failure. In fact, two-thirds of heart failure patients are readmitted back to hospital for reasons other than heart failure, said Dharmarajan. His research, published in JAMA in 2013, showed that hospital readmissions for Medicare fee-for-service beneficiaries with heart failure, acute myocardial infarction (heart attack) or pneumonia were driven by a diverse spectrum of diagnoses that usually differed from the initial cause of hospitalization and often involved different physiologic systems entirely.

A study published last February in JAMA reinforced this point. Led by Dr. Michael Ong, an associate professor in residence at UCLA's department of medicine, a clinical trial looked at 1,437 patients who had been hospitalized with chronic heart failure. Half the patients used remote devices tracking heart rate, blood pressure and other vital signs. They also received coaching from nurses via regularly scheduled phone calls.

The control group received care as usual. The study found that tele-monitoring didn't effect re-admission within 180 days or 30 days of discharge or mortality rates within 180 days of discharge. Other large clinical trials have had similar results.

“The main takeaway (from Ong's study) is that readmissions for chronic heart failure are multifactorial and difficult to reduce,” said Dr. Shivan Mehta, associate chief innovation officer at Penn Medicine, adding that remote monitoring should be viewed as a single component of a larger strategy that also includes social factors.

Economic security (the ability to pay for healthcare and other necessities), physical environment (safe neighborhood, access to doctors, grocers and transportation) and a person's social network (support from friends and family) greatly influence an individual's overall health. A recent report by Harry Heiman and Samantha Artiga at the Kaiser Family Foundation concluded a person's ZIP code might be “a stronger predictor of a person's health than their genetic code.”

Heart failure is still a major killer. It is also big cause of readmission and a focus of many CMS policies to stem hospital readmissions. Consequently, the body of research about readmission is more extensive than it is for many other morbidities. Still these findings are likely to be generally applicable.

Instead of focusing on a specific intervention, leading hospitals are taking a multipronged approach to reducing readmissions, involving many different specialists.

Northwestern Memorial Hospital and Northwestern Medicine's Lake Forest Hospital, for example, attempt to call heart failure patients within 48 hours of discharge, said Dr. Hanna Alps Jackson, program director, value-based delivery at Northwestern Memorial HealthCare. A pharmacist places the call if the patient was recently diagnosed with heart failure, began a new heart failure medication or has a complex medication regimen.

The hospital also tries to schedule follow up visits with cardiologists before the patient is even discharged from the hospital. To better understand patients' motivations, members of the cardiology teams have been trained by one of the hospital's behavioral psychologists to ask probing questions in a non-threatening way.

Technology is beginning to play a big role in this process. It can help providers coordinate with one another, improve patient outreach and even monitor for psychological warning signs. But it is important to remember that it acts as a complement and not a replacement for human interaction, said Mathew Fenty, director of innovation and strategic partnerships at St. Luke's University Health Network in Bethlehem, Pa.

New studies are also trying to incorporate non-medical factors into their technological interventions. A clinical trial done by University of Pennsylvania called Heartstrong is trying to use patients' social networks to encourage them to take their medicine.

Medication adherence is monitored via an electronic pill bottle. If a patient fails to take their medicine, family or friends are sent messages encouraging them to contact the patient. Patients are also entered into a lottery where they could win $5 or $50 if they take their medicine.

Failure to take medication is a big driver of readmissions. But just reminding patients to take their medication may not be enough. Patients may be skeptical over the treatment plan, in denial about the severity of their illness, depressed, unable to afford a prescribed medication or lack access to transportation that can to get them to a pharmacy.

As researchers begin to identify, track and better understand these key variables—be they social, physiological or biological—the hope is that one day hospitals will use the data to improve their risk assessment models and pinpoint who is most at risk of being readmitted to the hospital.

In part four, learn how failure mothered an effective post-discharge monitoring tool.

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