The problem of increasing hospital readmissions is now one of the most pressing health care issues in many counties. This necessitates ongoing discussion of quality of medical services. Despite the fact that hospitals do their best to reduce readmission rates, results they manage to achieve are outnumbered by complaints and negative consequences. Readmission costs are too high for the health care system to spare and amount up to $18 billion annually on avoidable rehospitalization cases, according to Medicare statistics (Berenson, Paulus, & Kalman, 2012). Numerous strategies and models have been implemented (including grants and financial penalties) in order to lower the rates of readmissions. However, prevention proves to be the most effective practice. Thus, it is highly important for hospitals to enhance primary care practices as primary care providers have an incomparable impact on readmission statistics (Kansagara et al., 2011).
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Despite the variety of strategies implemented by the administration in order to avoid hospitalization (such as prospective payment and obligatory approval required for admission), the costs of inpatient care account for more than 40% of the overall spending on health care. More than half of hospitalization budget is spent on readmission. Moreover, readmission is one of the most demonstrative indicators of low-quality service (Kripalani, Theobald, Anctil, & Vasilevskis, 2014).
There is a growing need to improve quality reducing inpatient services at the same time. One of the most effective strategies to do it is to identify and target risk groups in order to ensure that they receive the best primary care possible. Thus, the paper at hand is aimed to make the proposal to hospital administration that would include the ways to increase the quality of primary care with the ultimate goal to produce an impact on readmission rates.
The first part of the proposal will highlight the statistical data concerning readmission rates over the recent years. In the second part, the annotated bibliography will briefly discuss the content of the sources on the basis of which the proposal is made. The third part will suggest a plan of innovative interventions that can indirectly influence readmission rates through the improvement of primary care. In conclusion, the key aspects will be summarized.
The following readmission figures collected over the recent years prove the necessity of taking measures (Kansagara et al., 2011):
- In 2013, the number of readmissions was app. 500,000 cases ($7 billion in costs). The major diseases included acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and pneumonia.
- For all the four conditions the cost of Medicare was more than $5 billion.
- From 2009 to 2013, both the number and rate of rehospitaliazation (covered by Medicaid) among patients over 65 decreased by 6%; nevertheless the number still over 1.8 million.
- Readmission level decreased also among maternal patients of any age with private insurance and uninsured patients (by about 9%). The largest decrease, however, was among patients having private insurance coverage (over 15%).
- The greatest increase in readmission cases since 2009 could be observed among nonmaternal patients from 1 to 20 years old with Medicaid (by 8%), private (15%) or no insurance (22%).
- The total number and rate of rehospitalization have been increasing since 2009 among uninsured patients (by 10% on the average).
- The rate of readmission among uninsured nonmaternal patients from 1 to 20 years old has increased by 22%, from 21 to 44 years – by 14%, and remained unchanged for those aged from 45 to 65.
- The total number and rate of readmissions among Medicaid patients has been stable.
Three articles have been chosen for the purpose of developing a proposal on interventions in the primary care system.
Starfield, B. (2012). Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services.
The article proves the importance of primary care orientation that provides a lot of benefits for health care systems of many counties. The author claims that policies of primary care and its functions should correlate in order to guarantee effectiveness. Thus, a standardized measurement of primary care was adopted to estimate the performance. The conclusion made was that innovations to primary care should be introduced continuously as it has an impact on all other aspects of health care system (Starfield, 2012). The article was taken to provide an insight into the scope of influence of primary care.
White, B., Carney, P. A., Flynn, J., Marino, M., & Fields, S. (2014). Reducing hospital readmissions through primary care practice transformation.
The article assesses the impact of a complex multi-faceted intervention on rehospitalisation within 30 days of discharge. It describes clinics that targeted primary care system by improving coordination between nurses and other health care providers. Hospital reports were used to monitor the number and causes of readmission. The results of the practice transformation were recorded during a period of one year. There were two focus groups: the first one consisting of patients admitted to hospitals that introduced intervention activities and the second one including patients of clinics that did not redesign primary care delivery practice. As a result, multicomponent intervention led to the decrease in readmission by 20% (White et al., 2014). The article was chosen to support the idea of the necessity of interventions.
Gilfillan, R. J., Tomcavage, J., Rosenthal, M. B., Davis, D. E., Graham, J., Roy, J. A.,… & Weikel, K. M. (2010). Value and the medical home: effects of transformed primary care.
The article investigates the effectiveness of ProvenHealth Navigator (PHN), a model that includes both health care delivery and finance in order to provide a comprehensive transformation of primary care practices. The results of the model implementation were obtained from 11 intervention sites and 75 focus groups and included total number, rates, and costs of readmission before and after the experiment. 18-percent reduction in readmission rates was achieved (Gilfillan et al., 2010). The article was selected to emphasize the significance of model development that can help increase health care value.
A Proposal for Reduction of Readmission Rates through the Improvement of Primary Care
After a close analysis of the above-mentioned materials, the plan that might be suggested to reduce readmission rates through the improvement of primary care should touch up three major intervention directions:
- deepening the relationships between patients and nurses;
- improving the practice of interaction with the medical system;
- fostering team approach among health care providers to ensure better patient care.
Thus, the following interventions are proposed:
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- Changing resource conservation methods. It is typical of hospitals to spare scarce resources. Unfortunately, as a result of this, a lot of patients do not receive everything they need. Therefore, the first intervention on the list would be to teach nurses to conserve resources using methods that do not threaten patients’ health. High-quality primary care presupposes that patients receive due treatment and readmission preventive care.
- Individualizing care. Nurses that have a purpose of improving primary care must approach each patient individually and decide who needs longer appointments as well as subsequent phone and home calls.
- Paying higher attention to complaints. Nurses cannot neglect complaints if they want to achieve reduction of readmissions. In the advanced primary care system, complaints are viewed as a valuable constituent of patients’ feedback.
- Increasing the responsibility of insourcing. Nurses must be able to make important decisions within the scope that their training allows.
- Staying closer to patients. All health care providers (especially nurses as they are in close contact with patients) should do their best to establish effective communication with patients, who must be informed about the treatment plan, progress, and changes introduced. The better the patient is informed – the more chances he/she has to provide adequate self-care that helps avoid readmission.
- Upshifting the roles of personnel. The improvement of primary care demands that each provider must work at the highest level he/she can demonstrate within the scope of the education and training received. In most cases that do not require the physician’s intervention, due measures can be taken by a nurse practitioner. As a result, he/she can prevent some cases of readmission by addressing the problem quickly and professionally.
- Encouraging interaction of health care providers. Open office environment is highly recommended as it necessitates continuous communication and experience exchange.
- Introducing compensations and incentives. In order to increase job satisfaction, nurses should receive incentives going beyond financial. Comprehensive improvements for patients could facilitate their task.
- Investing money in people, not office equipment. Advanced primary care should be concentrated on the quality of services (which is especially important for patients from risk groups). Shiny office space with luxurious non-medical equipment have no effect on readmission rates.
- Understanding peculiarities of each particular community. Sometimes, general methods of improvement fail because the community has specific needs. For instance, the hospital is remote from the residential area, which means that readmissions might happen because of inability to visit health care provider for follow-up services. In this case, it is much more effective to invest in follow-up home care provided by nurses than in inpatient care.
- Paying due attention to consistency. It is a proven fact that readmission rates are lower among patients whose care was always provided by one and the same specialist. It is easier for a nurse practitioner to track and manage condition of patients he/she already knows well.
- Shortening the period of time available for completing discharge summaries. It is generally accepted that discharge summaries should be completed within 30 days after the patient’s discharge, which means that the results of the analysis that they provide are no longer applicable. Retrospective analysis should be replaced by the real-time one. When the information has already been collected by the time of discharge, it is easier to find factors that can lead to readmission and prolong hospitalization in order to eliminate them.
- Introducing the concept of transitional care. It is a common belief that as soon as the patient is discharged health care providers are done with him/her and can switch to other patients. It is essential to promote the policy of transition, which implies shared responsibility for the patient’s well-being after the discharge. Primary care should go beyond inpatient services as readmission usually happens because of the lack of medical attention in a post-discharge period.
- Providing patients with required medication on discharge. This is one of the ways to boost the quality of transitional care. Patients should be sent home with the supply of medications (enough for 30 days) with clear instructions of timing, dosage and side effects. The cost of this intervention (which is crucial for high-risk patients) should be absorbed by hospitals as it would allow avoiding much greater expenses caused by readmission.
- Developing a follow-up program before the discharge. Follow-up nurse visits after the discharge should be scheduled in advance for the patient to adjust to this time frame.
- Promoting telehealth. Nurses must teach their patients to use video monitors for communication not after the discharge but during their stay in the hospital. It especially concerns elderly patients who are not technically advanced and generally distrust modern technologies. They should feel comfortable using various devices that can assist in keeping track of their condition after the discharge.
Despite occasional reductions in readmission rates in certain groups of patients, the issue remains pressing as it is associated with high costs and hospital reputation. Financial incentives as well as penalties do not lead to any long-lasting transformations (however, they might be effective in certain cases). Based on the research of multi-faceted primary care improvements, I have presented a set of measures that can be taken in order to influence readmission rates indirectly – through providing a better-quality inpatient care. The more risk factors are eliminated during hospital stay – the less chances patients have to return.
Berenson, R. A., Paulus, R. A., & Kalman, N. S. (2012). Medicare’s readmissions-reduction program – a positive alternative. New England Journal of Medicine, 366(15), 1364-1366.
Gilfillan, R. J., Tomcavage, J., Rosenthal, M. B., Davis, D. E., Graham, J., Roy, J. A.,… & Weikel, K. M. (2010). Value and the medical home: effects of transformed primary care. The American Journal of Managed Care, 16(8), 607-614.
Kansagara, D., Englander, H., Salanitro, A., Kagen, D., Theobald, C., Freeman, M., & Kripalani, S. (2011). Risk prediction models for hospital readmission: a systematic review. Jama, 306(15), 1688-1698.
Kripalani, S., Theobald, C. N., Anctil, B., & Vasilevskis, E. E. (2014). Reducing hospital readmission: current strategies and future directions. Annual Review of Medicine, 65, 471-485.
Starfield, B. (2012). Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gaceta Sanitaria, 26, 20-26.
White, B., Carney, P. A., Flynn, J., Marino, M., & Fields, S. (2014). Reducing hospital readmissions through primary care practice transformation. Journal of Family Practice, 63(2), 67-75.