Although inpatient providers have shouldered the bulk of the clinical and financial responsibility for reducing hospital readmissions, the outpatient care team led by physicians needs to play a more active role toward that goal, according to an expert panel recently assembled by the American Medical Association.

For example, immediately following discharge from a hospital, patients often are at risk for developing medical problems that require a return hospital visit. Insufficient communication and coordination among providers often exacerbate that medically perilous potential. Recent studies have shown that as many as 20% of all patients discharged from the hospital are readmitted with 30 days for more care.

Hospitals’ medical personnel have taken the lead in revamping care-transition processes because they are responding, in part, to financial pressure from the CMS, which oversees the Medicare and Medicaid programs. The agency penalizes hospitals with a reduction in their Medicare payments if their readmissions in heart failure, heart attack, and pneumonia are higher than expected.

“Yet inpatient teams face important limitations in ensuring safe transitions to ambulatory settings” because they do not control patient-care decisions outside the hospital, the AMA panel noted in its final 77-page report “There and Home Again, Safely.” 

“We call this a non-linear closed loop. You ought to think of the care transition as taking place when the person is still in their home and then they transition into the hospital and transition back out of the hospital,” explains Matthew Wynia, M.D., director of physician and patient engagement and former director of patient safety at the AMA.

The AMA panel concluded that “the ambulatory practice has responsibilities throughout this loop,” he adds, which are:

  • Measuring patients’ health status—both before and after a hospital stay.
  • Helping patients set health goals.
  • Managing patients’ medications.
  • Teaching patients how to take care of their health.
  • Coordinating the work of inpatient and outpatient teams.

These tasks “…are going to reoccur over and over again over the course of  (a patient’s) lifetime. This is why they are particularly well suited to being led by the ambulatory practice rather than the inpatient team because they rely on the development of rapport and a relationship over time,” Wynia says.

Ambulatory medical providers have not performed these tasks consistently because they have not been compensated for them, according to Wynia.  However, that situation changed in January when CMS announced that Medicare would reimburse ambulatory care providers for care transitions. The agency adopted two recently created Current Procedural Terminology (CPT) codes (99495 and 99496), which cover such tasks as discussing care plans with patients or referring them to community services.

While the CPT codes provide compensation under the current fee-for-service payment system, many health systems also are creating pay-for-performance structures and processes targeted at patient safety generally and hospital readmissions specifically.

Advocate Health Care, Oak Brook, IL, is one such organization.  The 10-hospital system has been revamping care transitions for several years, focusing on both the inpatient and outpatient settings. For example, Advocate’s compensation model incents physicians employed by its affiliated Advocate Physician Partners to focus on care transitions, including those advocated by the AMA panel, according to Rishi Sikka, M.D., vice president of clinical transformation at Advocate.

Advocate also has deployed enterprise care managers, who are located at hospitals and some of the physician practices, to help coordinate services for patients at high risk for readmission. For example, the care managers ensure that patients understand their medical conditions and how to care for themselves, their medications and know how to take them, when their medical or therapy appointments are and have transportation lined up to get to them.

“They are really an active co-pilot with the physician and with the patient,” Sikka says.

To determine which patients are at high risk for readmission, Advocates relies on both physicians’ judgment and a risk-prediction tool.  Advocate’s tool, which was developed internally, scores patients’ level of risk based on several dozen elements, including whether they have high-risk medical conditions, such as cancer, or take high-risk medications, such as warfarin or insulin.

As a result these and other initiatives, the 30-day, all-cause readmission rate at Advocate has dropped to 10.4% of 130,690 discharges in 2012 from 12.4% of 123,452 discharges in 2010.

“I think you have to recognize the direction that healthcare is going. It is really more in a direction of population health and keeping people healthy, and this is in alignment with that,” Sikka says. “And, it’s the right thing to do for patients.”