Med Center Lowers Readmission Rates

Karen Rago of UC-San Francisco had an important task: help lower readmission rates of older heart failure patients. It’s one of the targets for health care reform, and the medical center wanted to see how hard it would be to do it.

Pretty hard, Rago said — at least at first.

“We started with a grant, and the aim was to reduce readmission rates at 30 and at 90 days,” Rago said. “That didn’t look like it was going to happen.”

Rago kept at it, and said that once medical center staff got used to the new systems, the new way of handling cardiac failure patients, the curve of success started to arc upward.

The UCSF team has reduced readmission rates by about 30%, which means more elderly patients now get to spend their days at home instead of making trip after trip to the hospital. It has made care simpler, has saved Medicare about $1 million on just 41 patients, has made life better for patients and is a large bright area in UCSF’s health reform puzzle.

“I couldn’t have been more excited,” Rago said. “If I look at the first four months, when you look at the trend line, the number of patients has steadily decreased. Every hospital is going to face this over the next year or so, and it’s the right thing to do for patients. They want to be home. What they want from us is they don’t want to be in the hospital.”

The pilot effort started by hiring two nurses to figure out which patients were the ones being readmitted. They had some difficulty figuring that out, Rago said, because there were multiple gaps in how nurses filled out the assessment form.

Eventually they determined that most readmits were coming from skilled nursing facilities. They also found that those patients’ doctors weren’t ordering home care, or their case managers were saying they weren’t allowed to order home care. Now, Rago said, every single patient over age 65 who had heart failure is supposed to automatically get a home care visit.

“At one skilled nursing facility, many of the heart-failure patients didn’t have a low-salt diet,” she said. That was hard to track down, and surprisingly hard to institutionalize. “Now on the cardio-pulmonary floor, we have a sticker, so everyone knows that’s one of our heart-failure patients.”

Her targeted patients all have an appointment with their physician within seven days of leaving the hospital. A gerontologist visits patients in their home within a day of leaving the hospital, and checks patients’ medications and understanding of their own care. Patients also get a relentless education, Rago said.

“We have a lot of discharge teaching,” she said, and a lot of the self-evaluation is simplified for them — “green in the good zone, yellow in the caution zone,” Rago said, “and if it’s in the red, they show up in the ER.”

Patient education didn’t just include the patient, she said. “We found it was really important to educate the main caregiver, find out who the learner is, and sometimes it’s not the patient,” Rago said.

“We used the teach-back method, where everyone teaching the patients — the nurse, the pharmacist — they ask the patient to teach them what we just taught them,” Rago said. “That way we assess the understanding.”

Getting palliative care involved early on also helped keep readmissions down.

Ironically, Rago said, the successful effort was not a money-maker for UCSF.

“It’s revenue loss right now,” Rago said. “My calculation is that, on 41 patients, Medicare saved $1 million, but UCSF actually lost a little money.”

That all changes in just over a year, when Medicare stops paying for a high rate of readmissions. “The financial incentive kicks in in 2013,” Rago said.

The financial factor may have been one of the motivators to do the test, but that’s no reason for providers, Rago said.

“For us, it was a great thing to do for patients. I guess one other thing it did do, it opened beds for other patients. And [this system] started with the heart failure group, and now there’s a huge amount of collaboration with other groups.”