For years hospitals have been pressed to move patients out fast, yet hopefully healthy enough to not need to return. Now the federal government has upped the ante: these acute care providers will be penalized for "excessive" readmissions within 30 days, and rewarded for cutting their numbers.
The expectation is realistic, or so is the case in California, according to Medical Care. A July 2012 article in that journal reported 47 percent of readmissions in 18 Kaiser Permanente California hospitals were potentially preventable; with 11 percent assessed as "very" or "completely preventable."
Akin Demehin, the American Hospital Association's (AHA) policy director, agrees hospitals can do better in several scenarios.
"There are areas where we can avoid [commonly seen] readmissions, even with the highest risk patients, like helping them to better manage their medications; ensuring follow up doctors' visits; and making sure there are support structures at home," said Demehin.
Hospitals are getting creatively proactive to address the issues, such as in the medication management scenario referenced by Demehin.
Western Maryland Health System is among providers who offer bedside prescription delivery through a local pharmacy. Then the Cumberland hospital has its own pharmacist educate patients who are typically on a dozen or more drugs that change, challenging them and their multiple doctors to keep track, according to Karen Howsare, director of Nursing/Care Coordination for Western Maryland Health System.
"Through this initiative when patients leave, they have a list of exactly what to take, when and how much. And they already have their prescriptions in hand," she said.
But the challenges don't end yet, so hospitals stay involved. St Johns Hospital in Springfield, Illinois watches patients from computer screens once they've gone home -- at least their heart failure patients, the population with the highest readmissions in most hospitals nationwide.
They are keeping tabs with telescales -- scales that actually "talk" to patients and their nurses.
"The device is connected to a phone line, with patients asked questions like, 'Are you more short of breath today?' 'Do you need to talk to a nurse?' said Susan Hickey, a certified heart failure nurse at St. Johns.
"Their answers and weight are transmitted to our computer, and we can watch from the screen anywhere. I've gone to medical conferences, sat in a church parking lot before church and reviewed symptoms. And I follow up with an immediate phone call, if warranted," said Hickey.
She finds telescales especially helpful with patients who do not realize that even one fast food burger can put three pounds of fluid on them.
"The scale gets them to finally understand. They get that aha moment; 'My lifestyle is causing these problems.' And they are adjusting to stay out of the emergency room," said Hickey, adding that 90 percent of patients buy into the program one they realize they feel hugely better and aren't returning to the hospital three or four times a year as before.
"They also see we care. Some of these people live alone, and we may be their only contact during the day. We not only ask about their health, but we chat about their time in the service, their pets or whatever is important to them. They come to trust us and know they can call if they may be in trouble," said Hickey.
Lee Memorial Health System not only watches patients from home using technology, but teaches them to take their own vitals, using equipment attached to home monitors. A recorded voice walks them through the process.
It's technology with a human touch, according to Cathy Brady, Telehealth and Lifeline program manager at Lee Memorial Health System Home Health.
"Patients get a sense of security. They know we are monitoring them, and that if something is amiss, we will call," she said. Thirty-day readmission rates for the Fort Myers health system's telehealth patients were 7 percent the first quarter of Fiscal Year 2014 and 6 percent the second quarter. The national average for all readmissions (not just telehealth patients) was just under 18 percent during the first eight months of Fiscal Year 2013, the most recent data from Centers for Medicare & Medicaid Services.
Marshall Medical Center staff literally show up at patients' doors--even a doctor makes house calls.
Though Penny Lehrman is the person who drops by most often.
She is a nurse and clinical director of the Placerville, California hospital's Community Care Network, composed of this traveling multidisciplinary team.
"I ask patients their goals to motivate them to stay healthy. And we talk about how they can reach them," said Lehrman.
She has taken on roles from IT teacher when a patient wanted to learn to Skype with her granddaughter -- to friend and coach when someone asked, "Will you walk me down my driveway? I just want to be able to start getting my mail."
Besides repurposing their own staff in the community, Marshall Medical has deployed hospice, skilled nursing facilities and others to coordinate care and prevent hospitalizations.
"We are even training volunteers in the community as health coaches. They will become our Skypers and walkers. They will be trained to learn if patients need assistance and report to me so I can facilitate what is needed," said Lehrman.
By enlisting their own staff and the community via the network, Marshall Medical hopes to create a domino effect.
"One person reaches 10 people. They reach 10 more, and they reach 10 more. It takes partnerships to keep an entire community healthy," said Lehrman.
Getting hospitals involved beyond the confines of their own walls makes sense, according to Kassie Waters, Marshall Medical's director of Quality Management.
"If we do it the right way the first time, the patient will likely not need to be readmitted. They get the best care. And for the hospital, reducing one readmission potentially saves hundreds of thousands of dollars."