Hospitals put a new focus on follow-ups to avoid Medicare fines

URBANA — You expect nurses to check up on you while you're in the hospital, but how about after you check out?

Some high-risk patients are getting extra attention from nurses these days after they've been discharged, as local hospitals work to reduce their numbers of readmissions.

Roughly two-thirds of the nation's hospitals, among them Carle Foundation Hospital and the two Provena hospitals in Urbana and Danville, began paying new fines to Medicare on Oct. 1 for having too many patients returning for care within 30 days after discharge.

Provena United Samaritans Medical Center is paying the maximum penalty of 1 percent of its Medicare revenue.

That's expected to cost the Danville hospital about $208,000 for the 12 months through the end of next September, according to Deb Schimerowski, chief financial officer for United Samaritans and its sister hospital, Provena Covenant Medical Center.

Covenant and Carle will each be penalized about one-fifth of 1 percent of their Medicare money, with Covenant at 0.20 and Carle at 0.21 percent.

That's expected to cost Covenant about $48,000 and Carle $109,000 for the 12 months ahead, Schimerowski and Carle officials said.

Medicare based fines on each hospital's readmissions for heart attack, congestive heart failure and pneumonia patients during 2008-2011.

While the penalty percentage is small, many hospitals say they can't really afford to lose any money.

"Not very much, really, but still something," said Dr. Jared Rogers, Covenant's chief medical officer. "Hospitals operate on a very small margin."

Schimerowski said hospitals didn't have the readmissions issue on their radar screens prior to the past year, and now the penalties will add to other financial pressures.

"There are so many initiatives right now that are starting to pull dollars away from us," she said. "By the time you go through the budgeting, budgets are going to be very challenging for 2013."

Big leverage

Statewide, hospitals collectively are projected to lose $20 million from the Medicare penalty this year, the Illinois Hospital Association has said.

Not all state hospitals are being fined; those not facing any penalties include Sarah Bush Lincoln Health Center in Mattoon, Decatur Memorial Hospital and Memorial Medical Center in Springfield.

But it's clear Medicare has Illinois hospitals' attention on readmissions in a big way.

Medicare "represents the largest payer for health care in the U.S. and has considerable leverage to encourage change in the health care market, period," said Derek Robinson, executive director of the state hospital association's Quality Care Institute.

About three-fourths of the state association's member hospitals are involved in one or more IHA programs to reduce readmissions, Robinson said.

Sarah Bush Lincoln said it's been working with the state association on Project RED — Re-Engineer Discharges — to better coordinate discharge planning among health care providers, patients and family caregivers. Both Provena hospitals also have been working with that program.

"Hospitals are focused on readmissions, and they're not just focused on three diagnoses," Robinson said.

Reducing readmissions

Among the three conditions Medicare included in readmissions data, heart failure is the condition most prone to readmissions, Rogers said. Pneumonia patients often get better after taking an antibiotic, and heart attack patients have often had some kind of intervention

"Most times, you won't have a readmission," Rogers said of heart attack patients. "If you modify your lifestyle, you've dodged a bullet."

Not so for heart failure patients, who are discharged with a condition much more difficult to control, he said.

Carle, Covenant and United Samaritans have all worked on reducing readmissions through intensive interaction between nurses and congestive heart failure patients, both before and after the patients leave the hospital. That means nurses checking with patients after they go home — to make sure critical elements of their condition, such as weight control, are on track, and their care is being coordinated through the health care system.

The nurses even check to see if the patients need rides to their doctors' appointments, all three hospitals say.

"It's a hands-on management of their condition," said Rosemary Meridith, director of quality management at Covenant.

Carle's "nurse navigators" who work with patients in this way are like air-traffic controllers in the health care world, said Beth Edrington, vice president of consulting and performance improvements at Carle.

Carle also has worked on cutting readmissions through such things as:

— A council reviewing readmissions on a monthly basis so any problems spotted can be fixed. For example, Edrington said, some patients coming back to the hospital from a nursing home might be failing to get a special diet they need.

— Providing scales for congestive heart failure patients who need them.

— Referring patients to a congenital heart failure clinic for extra care.

Home monitoring

Sarah Bush Lincoln, through an affiliation with St. John's Hospital in Springfield, said it has offered a program through which congestive heart failure patients step on a scale at home, and their weight measurement is transmitted to a nurse.

Water weight gain can be an issue for these patients, and the nurse can launch a quick intervention for a weight gain of several pounds in a day.

Carle just launched a similar program.

Here's how it works, according to Carle: Congestive heart failure patients who are being signed up take a monitor home in which they enter their weight and blood pressure. The monitor asks them questions about how they're feeling, and the information is transmitted each evening to a nurse.

The monitors have parameters for each patient, and when information falls outside the parameters, it instructs the patient to call their doctors. Nurses then follow up with the patient in the morning.

Molly Nicholson, vice president of patient care and chief nurse executive at United Samaritans, said that hospital has already achieved some measurable success on cutting readmissions through Project RED. The hospital also hired a specialist a year ago to work with its providers to make sure core measures — those that have been researched and shown to improve care — are being followed for heart attack patients, said hospital spokeswoman Gretchen Yordy.

United Samaritans has cut its readmissions for heart attacks from 21.2 percent during the 2008-2011 period to 10 percent (on total admissions) during the first quarter of this year, according to numbers supplied by Yordy. Heart failure readmissions for the same period declined from 26.8 percent to 18 percent.

Pneumonia readmissions remain at 22 percent. Both United Samaritans and Covenant say cutting those is next on their lists.

United Samaritans is also planning to build a $600,000 chronic disease clinic to more closely monitor higher-risk patients dismissed from the hospital. Fundraising for that project is under way, Nicholson said.

Not all readmissions are in a hospital's control, said Lynne Barnes, vice president of hospital operations. But with efforts under way at Carle, she projects that hospital will be in a fairly good position when Medicare takes another look.

For hospitals that don't show improvement, penalties are set to expand to a maximum of 2 percent for the 2014 program year starting next October, and a maximum of 3 percent for the 2015 year.

"The good thing is, there's not a one of us that does not want to elevate the level of care," Edrington said.

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