Among the myriad efforts at performance improvement in our hospital system, none loom larger than those aimed at preventing readmissions. While clinicians have long known that patients’ outcomes suffer when they are readmitted to the acute care hospital, now hospital outcomes will also suffer – financially, by up to 2% of Medicare billings for FY 2014, with greater penalties in future years.
Our system expects to lose $575,000 for FY 2013, when the penalty is a more modest 1% of Medicare billings. Efforts to prevent readmissions to date have focused primarily on finding and eliminating process gaps: Have we adequately educated the patient and family about medications, treatments, follow-up appointments? Are there transportation challenges? Can the patient afford and obtain medications? National efforts have addressed the most common gaps. These efforts are very effective for the patient whose illness trajectory is one of slow and steady improvement.
As patients enter the final phase of a serious illness, the trajectory is progressive decline, despite available treatments. Trajectory of decline is characterized by functional decline, loss of lean body mass, and the need for frequent medical care (hospitalization, ED and physician visits). These patients have multiple transitions between and among health care settings. Recent analysis of data from the Centers for Medicare and Medicaid Services was discouraging: Though hospice at time of death doubled between 2000 and 2009, nearly a third of those patients were in hospice 3 or fewer days. Forty percent of those short-stay patients were discharged to hospice from an ICU. Fourteen percent of Medicare decedents in 2009 had at least one transition of care in the last 3 days of life (JAMA 309:470-77).
On the palliative care service, we encounter a group of patients who are frequently readmitted, not because of process gaps, but because they are too ill to live well outside of the hospital without significant assistance. For these patients, the readmission is a symptom, not the problem.
The problem is that the patient is dying. How can we better manage the transition away from acute care for the patient whose death is expected? Often these patients are readmitted because we have not provided an alternative to hospital admission for the next crisis. Medicare skilled nursing facilities, and long-term acute care and rehabilitation hospitals, are designed to care for patients whose conditions are improving, and as a result, they rapidly transfer declining patients back to the acute care hospital.
Hospice, as an interdisciplinary 24-hour model of care, is uniquely positioned to treat symptoms and assist the patient and family to cope with distress and grief. Hospices are required to provide respite to caregivers as well as options for inpatient care when the patient’s symptoms cannot be reasonably managed in another setting. Hospice admission within 30 days of death significantly reduces the likelihood of 30-day readmission, subsequent ICU admission, and death in the hospital (Health Aff. 2013;32:552-61). Greater reduction in the likelihood of these outcomes is seen with hospice admission at least 53 days before death. Ironically, hospice patients have demonstrated longer life expectancy than their disease-matched counterparts (J. Pain Symptom Manage. 2007;33:238-46).
Patients with serious, progressive illness need concrete information about the natural history of the illness, its expected course and prognosis, and the potential impact of proposed treatments on morbidity as well as mortality. Understanding what is expected in the illness often alters the choices patients make about treatment and postacute care. After disease education, a patient and family can select goals of care and treatment options that align with their preferences. When asked, most laypersons prefer to die at home, comfortably, with their family. For these patients, the question is not "Do you want to die?" but "How do you want to die?" These conversations are difficult for all involved (physician, patient, family), but allow patients to make truly informed decisions about their care, and to decide what is most important as death approaches.
Lacking complete information, patients are often subjected to a merry-go-round of transfers between the acute and postacute environments, with increased caregiver stress. Attention to goals of care results in fewer readmissions, higher satisfaction, and better outcomes for patients and health care organizations.
Palliative care teams can provide consultative assistance with these conversations, and may be available to provide additional training to health care providers as well. If your institution does not have a palliative care team, look to a board-certified palliative medicine clinician in your community (often the hospice medical director) for consultation and guidance.
Dr. Fredholm and Dr. Bekanich are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.