Re-Hospitalization: What is it, and why is it so worrisome? Part 1

It’s a fact: nursing facility residents sometimes experience potentially avoidable inpatient hospitalizations. These hospitalizations are expensive, disruptive, and disorienting for frail elders and people with disabilities. Nursing facility residents are especially vulnerable to the risks that accompany hospital stays and transitions between nursing facilities and hospitals, including medication errors and hospital-acquired infections.

Even more troublesome are the re-hospitalizations that occur when recovery doesn’t happen the way it should.  

Nursing facilities care for two distinct patient populations – short-stay patients who are recuperating following an acute episode and long-stay residents with complex medical needs. Short-stay patients receive intensive medical or therapeutic care and rehabilitative
services following a hospitalization, and their services are generally covered by Medicare or private payers. Long-stay patients often have complex medical conditions and limitations in activities of daily living and may, in some instances, be cognitively impaired.

Care for long-stay patients is funded principally through Medicaid or individual and family expenditures. As rates of Medicare rehospitalizations have increased, so have hospitalizations of long-stay patients. The average hospitalization rate for long-stay nursing facility residents by state increased from 18.9 percent in 2000 to 20.9 percent in 2004, an increase of almost 11 percent.

Rehospitalization exacts significant costs from patients, particularly elderly patients. The stress of a transfer can lead to medical and emotional setbacks that can delay and extend recovery.

For this reason alone, reducing the rate of readmissions is important.

In an article published in 2009, The New England Journal of Medicine took a look at the problem:

“When legislation was enacted in 1983 establishing prospective payment for hospitals, the incentives for hospitals changed dramatically,” the article begins.  “Cost-based payments for hospital days and services were replaced with a set payment per admission that was based on the patient's diagnosis-related group. The goal of the legislation was to encourage shorter lengths of stay and more efficient care, but policymakers were also concerned about possible increases in readmissions. Higher rates of readmissions, they thought, might be a consequence of the legislation either because patients might be prematurely discharged from the index hospitalization or because services might be “unbundled” by hospitals in an attempt to receive two separate payments for what could have been a single clinical episode. Although little evidence emerged to substantiate either concern, today — two and a half decades later — policymakers are focused on readmissions again, albeit for very different reasons.”

For their study, doctors analyzed Medicare claims data from 2003–2004 and found that  “Readmissions are common, with 20% of hospitalized patients readmitted within 30 days and 56% within a year, and vary considerably, with rates ranging from 13% in Idaho to more than 23% in Washington, DC.”

The doctors wrote in the Journal story that they estimated the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion.

What they deduced was worrisome: “These high rates may result in part,” they said, “from inadequate coordination of care and poor discharge planning, since half of the patients who were readmitted within 30 days had no ambulatory (doctor’s) visit before the rehospitalization.” Those figures back up a “substantial body of other evidence that shows suboptimal coordination of care at the time of discharge.”

Communication is crucial, they noted: “The evidence of … failure to provide close patient follow-up, and of inadequate communication between doctors and patients and among doctors at the time of discharge, has raised concerns that many readmissions may be preventable and has pointed to policy changes that might both improve health outcomes and substantially lower costs.”

Nursing homes are close to our hearts at Blue Sky.  We know the valuable work they do, so in our next blog, we’ll discuss how these facilities have reacted.