A 9/28/11 report by The Dartmouth Atlas Project, funded by the Robert Wood Johnson Foundation, reveals little progress in reducing hospital readmissions and improving care coordination for Medicare patients was made over the five year period (2004-2009). One in five Medicare patients ended up back in the hospital within 30 days of hospital discharge during this five year period according to the Report. The October, 2011 Medicare Home Care Compare website shows that in the second quarter of 2011 in Texas thirty percent (30%) of patients referred to home health were readmitted to the hospital within 30 days.

I am extremely proud of the Home Therapy Austin team for their diligent work on readmission reduction and that we had a 21% re-hospitalization rate for the second quarter of 2011, three percent less than the top 500 agencies in the nation. At this writing, our readmission rate is down to 19% but, this is still not good enough. Medicare is paying home health agencies not only to address the diagnosis but, to prevent adverse events. Re-hospitalizations is one of the most costly potentially avoidable event.

According to the Agency for HealthCare Research Quality (AHRQ), 4.4 million preventable admissions happen each year at an estimated cost of $30B. The same report indicates $1 out of every $10 spent in hospital care is for readmissions.

In previous blogs we have explored this issue including reasons why readmissions occur and strategies to prevent them. The issue of preventing readmissions is the responsibility of all providers that care for the patient across the care continuum. In fact, many of the reasons for re-hospitalizations happen outside of the hospital. Such things as assuring access to community resources, medication compliance, ongoing assessment and observation, home safety and physician involvement are outside the hospital purview.

However, there are important actions that hospitals can and must take if adverse events are to be reduced. The discharge process is the most often discussed opportunity. In fact, the term, discharge planning, is being replaced by a more encompassing term and process called Care Transitions. In short, Care Transitions refers to the manner in which information is exchanged and care transferred for patients that require care across care settings. But, Care Transition is also relevant to how the patient is prepared to go from a care setting (hospital, Skilled Nursing Facility) home without formal care.

Numerous studies clearly show that the lack of a thorough hospital discharge can result in medical error and other adverse events including re-hospitalizations. A review of 94 studies from 1985-2001 revealed that the transition of older adults from hospital to home were associated with increased rates of preventable poor outcomes. Other findings include – 20% of patients discharged from hospital to home with home care had adverse drug events – 30% of patients have a least one medication discrepancy with potential to cause harm – and another study showed that one in five discharges from the hospital had adverse events that could lead to preventable hospital use.

So what is involved in Care Transitions? Various programs reinforce some common components including an assigned Transition Coach, assessment of health literacy and comprehension appropriate training using a method called Teach- Back, medication reconciliation and compliance assistance, a Personal Health Record, involvement of the community physician and an expedient follow up appointment, expedient admission to the post-acute services and the use of Red Flags, an identification of risk factors and status.

Home Therapy Austin has focused, independently, on Care Transitions and offers a defined program. It is our hope that soon we can work with acute care providers to make this process truly collaborative.