Hospital readmissions contribute significant clinical and economic burden to patients and payers.1 Nearly 20 % of Medicare patients are readmitted to the hospital within 30 days of discharge, with heart failure listed as the most common reason for readmission.2 Based on a more than twofold variation in institutional readmission rates adjusted for patient clinical characteristics,3 preventable cardiovascular readmissions alone are estimated to cost the US more than $1 billion per year.4
In response to these statistics, the Office of Management and Budget has identified reduction of readmission rates as one of the pillars of the Medicare reform.5 In 2009, the Centers for Medicare and Medicaid Services (CMS) introduced 30-day risk-adjusted all-cause readmission after hospital discharge as an indicator of quality and efficiency of care (www.hospitalcompare.hhs.gov). Effective October 1, 2012, the Patient Protection and Affordable Care Act will reduce CMS payments to hospitals with excess readmissions of patients previously hospitalized with heart failure, myocardial infarction, and pneumonia.6 These policy changes have made cardiovascular readmissions a top priority for hospital quality improvement efforts.
Despite this intense interest, interventions for improving the transition from the hospital to home and reducing unnecessary readmissions have been poorly defined and challenging to implement because of a variety of factors. First, the structure and financing of medical care in its current form does not necessarily center on the longitudinal health of the patient; rather, reimbursement involves fractured payments based on isolated episodes of care. The diagnostic-related group (DRG) payment system is a prime example, where acute care hospitals are reimbursed for each hospitalization without specific consideration of post-discharge care or recurrent admissions. Not surprisingly, under this system, length of stay has shortened with an increase in hospital readmission rates.7 However, bundled payments to reward care across the inpatient-to-outpatient setting require cost-sharing or even major restructuring in non-integrated health systems where inpatient and ambulatory services may be owned and operated separately. Second, understanding the predictors and causes of readmission has proved more difficult than for many other health events. Readmission models generally have poor prognostic performance,8 highlighting the complex and even stochastic process leading up to readmission.
This unpredictability limits our understanding of the main drivers of readmission and hampers our ability to triage resource-intensive post-discharge care to those patients most likely to be readmitted. Third, the degree to which readmissions can and should be reduced is controversial. The proportion of readmissions that are preventable and, therefore, unnecessary, has been estimated to be as high as 75 %4 and as low as 19 %.9 Finally, efforts to positively impact readmission rates are likely to be complex and resource intensive. There is no magic bullet; isolated interventions using a single approach (e.g., telemonitoring, self-management counseling) have not necessarily reduced readmissions when tested in larger rigorous trials.10,11 Successful readmission interventions have employed multimodal, multidisciplinary approaches.12
Ultimately, reducing readmission is hard work. Effective interventions are likely to require a comprehensive look at care at multiple stages of the patient’s journey: starting at admission, through the acute hospitalization, at the time of discharge, into the home setting, supplemented by appropriate ambulatory follow-up, and potentially orchestrated by bridging interventions.13 Patient education, medication reconciliation, patient-centered discharge instructions, scheduling of follow-up appointments, follow-up telephone calls, patient-activated hotlines, timely communication with ambulatory providers, timely ambulatory provider follow-up, transition coaches, post-discharge home visits, and improved physician continuity across the inpatient and outpatient settings all appear to be important pieces of the readmission puzzle.
Learning from the Door-to-Balloon Model
The Door-to-Balloon (D2B) Alliance demonstrated how a national initiative could rally diverse healthcare entities to come together, find common solutions, and ultimately improve complex care processes that initially seemed insurmountable. As background, percutaneous coronary interventions (PCIs) for acute myocardial infarction are grounded in the principle of rapid coronary reperfusion. There is strong evidence that shorter time from patient presentation (emergency room ‘door’) to coronary artery opening via angioplasty (‘balloon’ inflation in the catheterization laboratory) is associated with better patient outcomes, particularly when these door-to-balloon times are less than 90 minutes. However, despite recommended quality measures being in place for years, as of 2006 only 40 % of hospitals were able to consistently perform primary PCI in less than 90 minutes.
A team of cardiovascular outcomes researchers evaluated hospitals with best practices and identified key processes of care that were associated with shorter D2B times.14 Six of these strategies became the core of the D2B Alliance (www.d2balliance.org). The goal was to achieve D2B times of ≤90 minutes for at least 75 % of non-transfer primary PCI patients with ST-segment elevation myocardial infarction (STEMI) in all participating hospitals performing primary PCI. This national initiative, supported by the American College of Cardiology (ACC), facilitated local implementation of the D2B quality improvement strategies at more than 1,100 hospitals. D2B’s success also relied on national data collection so that benchmarked performance data could be fed back to participating institutions. Ultimately, this led to the widespread adoption of the key D2B processes of care, with resultant improvements in D2B times nationally, reaching the goal of the initiative.15 Perhaps most importantly, the D2B Alliance showed how hospitals could work collaboratively to generate practical solutions that improve healthcare quality for all.
The genesis of the Hospital to Home (H2H) Initiative has multiple similarities to the beginnings of the D2B Alliance. Hospital readmission measures are felt to be below expectations. Optimal strategies for improving care have yet to be clearly defined. Transitions in care after hospitalization span the inpatient and outpatients settings and, thus, solutions would appear to require care coordination between traditionally separate silos of care (as was needed in D2B with ambulance services, emergency departments, and catheterization laboratories). There are important differences as well. All-cause readmission following cardiovascular hospital discharge is a far more heterogeneous entity than a process of care for patients with STEMI. The timeframe is 30 days or more for most readmission measures, compared with a couple of hours for D2B. Furthermore, the number of care providers involved in the care of patients hospitalized with heart failure or myocardial infarction from admission to 30-days post-discharge is at least one order of magnitude higher. This suggests that, although D2B provides a model, efforts to tackle preventable readmissions must be tailored to the unique challenges posed by the post-acute care setting.
The Hospital to Home Community is Born
The H2H Quality Initiative (www.h2hquality.org) was launched in 2009 as a national rallying point and learning program to help clinical providers and healthcare institutions begin to improve transitions of care and reduce unnecessary readmissions. The program was conceived by Dr Harlan Krumholz, who also led the D2B Alliance, and was launched as a partnership of the ACC and the Institute for Healthcare Improvement. From its inception, H2H recognized the importance of seeking a broad range of additional strategic partners and, therefore, proactively sought input and participation from specialty societies, nursing organizations, hospital associations, integrated health systems, payers, and patient and family caregiver organizations. H2H enjoys the support of 34 partners and 24 quality improvement organizations.
H2H is purposely designed to be complementary to other existing cardiovascular and readmission quality improvement activities. Public reporting by CMS’s Hospital Compare provides institutional risk-standardized readmission rates for heart failure and myocardial infarction for fee-for-service Medicare patients; Hospital Compare also reports risk-standardized mortality rates in tandem, as both are important measures of outcomes, but they do not necessarily run together or reflect the same quality domains.16 These outcome measures are paired with core process measures, as mandated by the Joint Commission. All this information is potentially supplemented by participation in other heart failure and myocardial infarction quality initiatives and data feedback mechanisms, including the ACC’s National Cardiovascular Data Registry (NCDR) and the American Heart Association’s Get With The Guidelines (GWTG) and Taking the Failure Out of Heart Failure (TARGET:HF) initiatives.
Goals, Objectives, and Core Concepts
The primary goal of H2H is to reduce all-cause readmission rates among patients discharged with heart failure or acute myocardial infarction by 20 % by 2012. Several objectives guide H2H and its participants toward this goal: bring together what is known from experts, the literature, and best practices; leverage an array of national initiatives that are all contributing to reducing readmissions; create a web-based interactive community of hospitals, office practices, and other care providers in the community to share tactics, resources toolkits, and best practices; and catalyze action to improve the transition to home for patients discharged with heart failure or acute myocardial infarction.
From its inception, H2H has focused on three ’core concepts’ that are felt to provide primary opportunities for improvement:
- Is the patient familiar and competent with his or her medications and does he or she have access to them?
- Does the patient have a follow-up visit scheduled within a week of discharge and is he or she able to get there?
- Does the patient fully comprehend signs and symptoms that require medical attention, and whom to contact if they occur?
These core concepts were designed to help organize discussion and potential solutions around key patient-centered care domains with a well established or emerging evidence-base.13
Early Successes
At the time of its launch in 2009, H2H chose to focus on building awareness and creating a vibrant community that could share information, experiences, and potential solutions. Rather than imposing and advocating specific strategies from the start, the H2H project first sought the input of its participants. At its core, H2H is a central clearinghouse of information and tools, building on what others are doing and have done to improve care transitions and reduce readmissions.
Within two short years, more than 1,000 unique hospitals and 2,000 individuals in all 50 states and the District of Columbia have formally registered for H2H. This includes public and private institutions, urban and rural medical centers, isolated acute care hospitals, and hospitals from integrated healthcare systems (including Veterans Administration hospitals). A handful of hospitals from outside the US have also joined.
In part from H2H’s efforts to increase awareness around transitions of care, but also in response to major policy changes involving readmission measures, activity within H2H has continued to grow. A major success has been the H2H email list serve, which enjoys a high volume of traffic on a variety of topics. In addition to email strings started by participants, H2H poses three key discussion topics per month.
Specific Strategies
Building from this collective community knowledge, H2H is now ‘challenging’ practitioners to better understand and tackle readmission problems by trying specific tools and improvement strategies through H2H ‘challenge projects’. In 2011, H2H started offering toolkits, instructional webinars, and surveys to capture and share experiences with others around key domains of transitional care. A new challenge project is launched every six months, composed of one toolkit and three webinars. The webinars build on each other, beginning with introductory information, then outlining strategies and potential solutions, and finishing with lessons learned. Self-assessment surveys help hospitals understand gaps and measure improvement.
The first of these challenge projects to be launched was ‘See You in 7’. Its goal is to have all patients who have been discharged with a diagnosis of heart failure or myocardial infarction to complete a follow-up appointment within one week of discharge. To engage the challenge, hospitals have to create systems for accurately and completely identifying patients hospitalized with these diagnoses in real time, provide ambulatory capacity to see these patients within the seven-day period, ensure that discharging providers reliably make these appointments, confirm that patients understand the importance of making these appointments and have transportation to get there, and finally collect information on the effectiveness of these activities.
More recently, the ‘Mind Your Meds’ challenge project was launched to improve post-discharge medication management. The goal is to ensure that all self-administered medications are safely and accurately taken. To meet this goal, hospitals have to optimize medication prescribing at discharge (tailored to patient indications and contraindications), reconcile medications so that everyone is working from the same correct list, and facilitate patient adherence to medications by addressing health literacy, access, and cost barriers. Interprofessional teams of physicians, nurses, pharmacists, and other care providers are identified as a central tool in meeting the goal.
H2H has also begun to endorse more resource-intensive multimodal interventions that hospitals may wish to consider. One such intervention is the Grand-Aides™ Program, which is designed to provide personalized post-discharge care through a mature layperson trained to be a nurse extender. The Grand-Aides make home visits starting with the day of discharge. These Grand-Aides promote adherence and help deliver care under the close supervision of a nurse practitioner using protocols and telemedicine.
The Future
With readmission reimbursement penalties set to go into effect in the coming months, interest in hospital transitions and readmissions promises to increase. Therefore, it is not surprising that the H2H Initiative continues to grow. Additional Challenge Projects are planned. With H2H entering its third year, its National Committee will attempt to evaluate the impact of the program, in particular what headway has been made toward its primary goal of reducing unnecessary readmissions by 20 %.
As we continue to learn more about readmissions, H2H will need to continue to adapt. One of the more interesting developments related to readmission measures is the increasingly perceived need to assess readmission rates within the context of overall hospitalization. Although cardiovascular readmission rates have remained relatively static over time, it appears that, overall, heart failure hospitalization rates, at least within the Medicare population, have declined significantly over the past decade;17 as such, total readmissions have also proportionately decreased, even though published readmission rates appear unchanged. Furthermore, recent data show that one of the most important predictors of institutional readmission rates is the background rate of total hospitalization, even after adjustment for case mix.18 Although the current shift to include the 30 days after hospital discharge in the evaluation of acute hospitalization has critically focused our attention on the gaps in transitional care, future solutions to the problem of hospital readmissions may require a more global view of the hospitalization–readmission period, including the time before index hospitalization and beyond 30 days.
Conclusion
Transitions of care for patients hospitalized with heart failure and myocardial infarction are an important focus for high-quality healthcare. The H2H Initiative, along with other national initiatives and public policy changes, has brought much needed attention to the importance of high-quality transitional care. Although optimal strategies to prevent unnecessary readmissions still require further refinement, H2H has succeeded in creating a diverse and energetic community that is proactively sharing existing knowledge and best practices.