o you feel significant potential savings and improvements from further reductions in hospital readmissions can be achieved resulting from the level of current initiatives and attention in this regard, or are expectations too high?"

Evidence and our own experience support the fact that readmissions occur for the same reasons everywhere and the lack of coordination outside the physician hospital walls is the culprit.  Unusual as it may sound; Surgeons and Family Practices Physicians often talk about this and are angry at the hospital for not keeping them better informed as to the health status and follow-up with their patients. For hospitals that want to DO something about this so they do not get payment denials or RAC audits, channeling this energy from the doctors is a good starting point. Hospitals that dropped their home health agencies years ago because billing was too complex will need to rethink how they can realign the existing home health or expand their own to take the pressure off of the doctors and their staffs by having these agencies step in formally with skilled nursing and informally with custodial care. This may include cross training people to come to the aid of those with chronic conditions early in the episode instead of having these patients filling the ER.

We have several HMOs and some hospitals who are building "navigator " programs to actually attract and train people who have a special calling to help the sick and are not professional RNs or LPNs but are able to be trained to carefully watch for signs of a chronic care patient losing their way on the path to improved health status. We think of the elderly often when we talk of chronic care but there are millions of younger people with disabilities who have families who have to work full time for the insurance., However these patients still need someone at home to be alert, offer feedback to the PCP's office via one or more Nurse and Nurse Practitioners and then be paid a living wage because if they can save one 25000 dollar admission through good home care and early identification of a problem they have paid for themselves.

At a recent Boston conference, I saw the following schematic on a slide - the current outpatient and inpatient care sets the patient out on the curb when everyone's done and that patient is on his own. There was a start and a stop to the office call. The next slide showed the never ending office call where communication using everything from social networking to more formal patient records is shared regularly, vital signs taken routinely, patient communication sought to have the patient express their level of pain or fear or just plain confusion over "all the fuss".  Is this more thorough and hands-on care sustainable? Yes! As the demographics change and family size drops and the elderly population becomes the majority of patients, the opportunity to refine the loop of a continuous office visit by assigning navigators who will allow a PCP who now has 1500 charts to now handle 400 can be a reality. If the PCP can practice medicine at the top of his or her game with the more complex situations and push down some of the more predictable and less complex care situations to nurses and navigators who are trained to follow quality guidelines and are affordable and can deliver better access for an older and older population, everyone wins.

There is certainly a lot of activity and I believe that some additional marginal improvements can be made replicating and iterating on the one-off and pilot efforts.

 But real, sustainable improvements that don't require constant oversight, monitoring and effort will likely take a shift in marketplace practices driven by payment practices.

 HHS not paying for readmissions caused by "never events" and guarantees like Geisinger's pledge to not charge for readmissions after heart surgery within ninety days are key examples of how to get every facility and practitioner keenly focused on eliminating readmissions.

Yes, expectations are high, but it doesn't mean we shouldn't try to reduce preventable readmissions. According to the Congressional Budget Office, the hospital readmission reductions program is supposed to save Medicare $500 million between now and 2014 and a whopping $7B by 2019. Of course, these savings will be generated through lower Medicare payments to hospitals that have higher than expected readmission rates.

Hospital executives are not happy. They do make some pretty good arguments. Some readmissions are planned and needed. Others are unplanned but necessary -- such as the proverbial "leave the hospital after heart surgery and then get hit by a bus." Hospitals don't want to get dinged for these, and it's hard to argue with them. On the other hand, some arguments get murky. How responsible should hospitals be when community doctors or patients fail to follow discharge instructions? Can hospitals realistically cut readmissions when so much is out of their control?

However, it is possible to reduce preventable readmissions if hospitals address three major issues: discharge planning, length of stay, and closer alignment to physicians. All of these issues relate focusing on the total health of a patient instead of a performing a procedure. Discharge procedures must be revamped so patients and their care givers understand how to manage their health at home. Education and improved case management cost money, but they're necessary investments. Length of stay must also be addressed. In certain cases, another day in the hospital will be better for a patient than a readmission. And finally, closer relations to community physicians will create a better continuum of care. In a recent HRI physician survey, almost 65% of doctors said that hospitals want to partner with them to improve patient outcomes. Improving patient outcomes means ensuring patients don't boomerang right back into the hospital. And, that's a pretty good reason to try.

I'm afraid that we'll see modest and incremental improvements at best until we successfully address the terrible lack of coordination and follow up in both the transition from inpatient to outpatient, and coordinated outpatient management of patients with multiple chronic diseases. Regrettably, many of the approaches to managing patients with multiple complex diseases, who account for a highly disproportionate amount of hospital days and costs, are able to demonstrate improvements in quality, but few demonstrate improvements in overall costs. The exception is nurse-led teams involving multiple clinical disciplines and access to physician support, where both are demonstrated. Other related approaches such as the "Guided Care" study have also demonstrated positive outcomes for both quality and cost, so it can be done. The amount of resources and support necessary to provide that type of service is very high, to say nothing of the ability to leverage knowledge, so it's going to take a long time for it to diffuse into the overall healthcare sector to make a dent in aggregate cost trends.

On the bright side, many of the problems are known, and achieving success is merely a matter of steadily building care management capability, linking the disparate parts together, using "smart" algorithms or neural networks to anticipate problems in a large cohort if different people, the use of telemonitoring and other individually-based remote clinical sensors, a real live rootin' tootin' ubiquitous electronic medical record system, ensuring actual coordination instead of endlessly talking about coordination, realigning the way we pay for care, having China agree to forgive all our debt, and changing our culture. Might take until Labor Day or even Thanksgiving.

FYI - For those interested in an excellent overview of the array of interventions available, and their impact on cost and quality, I highly recommend the synthesis of existing literature created for the Robert Wood Johnson Foundation titled "Care Management of Patients with Complex Health Care Needs," Research Synthesis Report No. 19, December 2009 (www.policysynthesis.org). [NB: I have no relationship with RWJF] It's about as succinct an overview as you'll find.

Our national performance with avoidable hospital readmissions is unambiguous - we have much room to improve. For specific conditions in some areas around the country, we could see 50% or more reductions in readmissions rates with better quality outcomes. So what is holding us back? The answer is three-fold:

1. Most hospitals are working at the margins of improvement because the costs of comprehensive programs are significant and the financial benefits are low or even potentially negative. This is an unsustainable problem that must be fixed either through policy or new payment models in order to see major breakthroughs.

2. Major reductions in readmission rates require new relationships and strategies to interact with new partners. We estimate that 50-75% of the ultimate causes of readmission are non-clinical in nature and related to the support structure and ability of different stakeholders to coordinate and support patients. Community service organizations (area agencies on aging, meals on wheels, etc.) are important linkages that need to be nurtured.

3. Patients and their families are an underdeveloped resource, mainly because we address their needs and engagement in a standardized, one-size-fits-all manner. We'll need to customize activation of "home caregivers" based on their individual ideas of independence, self-mastery and degree of support at home. Many chronic care patients refuse coaching, follow-up calls, coordination and system navigation because of long-held beliefs of how care should be delivered.

The result is that large reductions in readmission rates are going to take years - this is new territory and it is complex. To make a successful impact on results and cost, steady progress over several years will be needed to change the "system". Here's how we'd start:

1.  Require hospitals to select one or two "partners" to address avoidable readmissions in a more comprehensive manner. The partners to choose need to be based on local needs, readmission patterns, experience and interest. It could be a skilled nursing facility, or a community organization like a senior center, religious organization or social support agency. Partners should meet at least monthly and talk about handoffs, coordination and who else needs to be brought into the conversation.

2.  "Diagnose" system breakdowns by talking to patients and their families about the specific details of the process leading to readmission. Ask them who told them to go to the Emergency Department? What happened when they called their doctor's office? What kind of challenges did they experience managing their medications?

3.  Determine the level of engagement with patients and families. Too much information and instructions overwhelms some, while others look to the Internet for more complete answers. Tailoring teaching and coaching to the unique local needs of the "learners" will yield far more than pre-printed handouts of common issues leading to preventable readmissions.
   The answer to the question really is another question - how much do we really want to improve? It is more a matter of the will of the organizations and health care system than it is about executing known effective practices. It would be great to imagine health care when there are less full emergency departments, fewer ambulance trips, and patients figuring out how they will spend their extra hours out of the hospital because we reduced avoidable readmissions?

We don't think that the expectations are too high regarding readmissions to facilities.

As predictive models and other data are used to identify individuals at greater risk for hospitalizations are being used more intelligently and in conjunction with clinicians who can act on this information, we have seen a trend in lowering the readmission rates for some conditions.

We continue to monitor and support the use of data to help drive these decisions and are working with the vendors to assess their methodology in order to improve clinical outcomes.

Upcoming Webinars: 

• Leveraging Physician Performance Analytics to Drive Clinical Practice Change, August 31, 2011
• Integrating Risk Adjustment and Quality of Care Initiatives, September 13, 2011
• Successfully Deploying Social Network Analytics, September 21, 2011
• PwC Health Insurance Exchange Research and Strategies, September 22, 2011
• Social Media and Readmissions: Roles, Limits, and Opportunities, September 27, 2011
• Medical Home Web Summit, November 3, 2011
• Accountable Care Organization Web Summit, December 8, 2011
• CD-ROMs of Past Events