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 Whitepaper: Solving the Root Causes for Preventable 30-day Readmissions

Telemedicine gives providers an edge in reducing unnecessary hospital readmissions.

 

Reducing the number of preventable 30-day hospital readmissions and Return to Acute care settings 
(RTAs) is a top national priority. Reasons are multifold, but in their experience, TeleHealth Solution physicians have found that about 68 percent of readmissions shouldn’t be considered medically necessary. Other reasons include rising costs and patients’ increased risk of complication, especially for those in the geriatric population.

Skilled nursing facilities (SNFs) are one of the most significant points of initiation for 30-day hospital readmissions and RTAs, where 25 percent of patients nationwide are readmitted within 30 days. In order to address problems associated with readmissions, it is important to examine the reasons they occur.

SNF Readmissions: Root Causes 

A 2016 study examined SNF readmission rates using the Improving Medicare Post-Acute Care Transformation (IMPACT) Act model of quality improvement. The study, “Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations,” was published in a 2016 issue of JAMDA, the official journal of AMDA - The Society for Post-Acute and Long-Term Care Medicine. Staff at participating SNFs conducted root-cause analyses of each readmission to determine causes, preventability, and organizational issues that exacerbated the need for RTA. 

Clinically, the leading reasons staff gave for transferring care included abnormal vitals (33.4 percent), altered mental state (27.9 percent), shortness of breath (23.3 percent), uncontrolled pain (18.5 percent), functional decline (15.6 percent), behavioral symptoms (15.1 percent), fever (12.1 percent), and decreased oral intake (11.7 percent). As multiple causes were checked, the percentages do not equal 100 percent. 

Preventable Transfers

In 60.9 percent of readmission cases, no laboratory or test results were reported or conducted. Where results were reported, the highest percentage of these were abnormal pulse oximetry, which occurred in 16.3 percent of RTA patients. When asked to examine each readmission, staff members at the various SNFs were asked the following question: “In retrospect, does your team think this transfer might have been prevented?” Their answers were surprising.

“Twenty-three percent of readmissions were identified as potentially preventable,” the study said. “The most common opportunities for improvement identified were 1.) staff recognized that the condition might have been managed in the facility with existing resources (36 percent); 2.) discussion of care preferences could have occurred earlier and/or advance directives could have been in place (27 percent); 3.) necessary resources to manage the condition were unavailable (25 percent); 4.) the change could have been detected earlier (23 percent); and 5.) communication could have been better (18 percent),” the study found.

Telemedicine in the SNF setting

Telemedicine may provide some answers to avoiding hospital readmissions. Early adopting SNFs have started implementing telemedicine partnerships, allowing off-site providers to provide medical services in order to reduce readmissions.

The most successful care model uses telehospitalists, who have the training and experience to determine the difference between a situation that needs ongoing monitoring and treating in place versus an emergency requiring RTA. By offering SNF staff support during evening and weekend hours when in-house providers are not available, telemedicine allows real-time video examination, consultation, and supervised monitoring. 

Telehospitalists have the ability to order any tests that a facility is capable of providing, and have ongoing communication with staff when managing a patient. Even when an RTA cannot be avoided, telehospitalist physicians can communicate with emergency departments and hospitals, reducing the need for full readmission, helping patients receive needed services quicker, and avoiding lost information during care transfer.

Notes from the Emerging Field

To understand how telehospitalist support can be effective at avoiding unnecessary hospital admissions, it is helpful to consider some clinical cases stemming from a telemedicine partnership with a SNF in Ohio. 

In the eight months between August 2017 and April 2018, nursing staff at the SNF made 452 total calls to telehospitalists at TeleHealth Solution, a North Carolina-based telemedicine company. During these calls, nursing staff and the telehospitalist speak over the phone for a consultation, discussing symptoms, lab and test results, and other details of the patient’s history and case.

If needed, the physician elevates the phone call to a real-time video examination. This elevation in care was required in 39 total cases during the reporting period. Each of these would have resulted in a likely emergency admission without the intervention of the telehospitalist. Instead, in 32 cases, the partnership allowed patients to be managed on-site and avoided an RTA.

Here are examples of cases where admissions were avoided.

Case 1: Problem: Respiratory failure exacerbated by chronic obstructive pulmonary disease (COPD)
Solution: Partnership to counsel family, maintain comfort, implement hospice

A patient was experiencing respiratory failure exacerbated by COPD. Facility staff reached out to the telehospitalist because the patient’s saturation levels were down to 82 percent. The telehospitalists were able to work with staff to titrate oxygen levels, add additional medications to manage the respiratory failure, and to keep the patient comfortable until the family could arrive at bedside. Despite the patient reaching 5 liters of oxygen with only a saturation rate of 90 percent, the telehospitalists were able to avoid admission by consulting with the family, providing hospice orders, and allowing the patient to remain comfortably in the SNF. 

Case 2 Problem: Memory care patient’s accidental ingestion of medications
Solution: Telehospitalist performed on-site treatment and monitoring

Nursing staff called telehospitalists after a patient accidentally ingested a large quantity of her roommate’s medications. These were a combination of antipsychotics, mood stabilizers, benzodiazepenes, and antiepileptic drugs, and they interacted with the patient’s own medications. 

The telehospitalist—the physician on call working virtually—spoke with poison control and confirmed that the majority of the ingested medications carried risk of cardiac side effects. He instructed the staff to run an electrocardiogram (EKG) and viewed the EKG in real time on his screen. He then evaluated the patient’s cardiac intervals. 

Working through staff, the physician administered a significant amount of intravenous fluids, checked labs, and routinely checked the patient’s EKG to ensure there were no adverse side effects. The patient returned to her baseline with no long-term side effects. Without this coverage, the patient would have required hospital admission for observation.

In the 32 cases where hospital admission was avoided, it was estimated the partnership saved the SNF $76,704 in lost revenue*, not including penalties related to the Protecting Access to Medicare Act of 2014 (PAMA), reduced star ratings, and credibility among referring hospitals. Under PAMA, SNFs will be penalized starting October 2018 for 30-day preventable readmissions. 

When Admission is Necessary

In order for these partnerships to be effective, both telehospitalists and staff have to feel comfortable implementing an RTA when necessary. In the seven cases in this partnership where hospital admission occurred, the circumstances were as follows: 
  1. ​Patient septic, required admission to the intensive care unit (ICU). 
  2. Patient had acute neurological symptoms. 
  3. Patient needed emergency endoscopy due to active gastrointestical bleeding.
  4. Patient had respiratory failure and required ICU admission. 
  5. Patient hypoxic and hypotensive, likely aspiration pneumonia. 
  6. Patient had acute hypoxic respiratory failure, with saturations dropping to the mid 80s despite an non rebreather mask, used for low oxygen saturation. 
  7. Patient had fall with head trauma and lacerations. 
In all of these cases, an on-site physician would have been extremely unlikely to avoid an admission, given the facility’s available equipment and the level of care provided. In fact, although telehospitalists provided coverage at this SNF during evenings, nights, and weekends—making the physicians responsible for patient outcomes during more than half of each week—the cases they managed accounted for only 5.9 percent of the 117 hospital inpatient admissions from this SNF during the study period. 

Conclusion

If SNFs are to follow the standard quality improvement mandate of providing better care for every patient every day while lowering costs, they must be able to provide the services and expertise needed to manage patients’ changes in acuity without resorting to unnecessary admissions. 

In order for treating-in-place to become the standard of care, with reduced risks and improved patient outcomes, SNFs require physician support at all hours. With today’s technology, that support does not have to include in-person staffing. The result is improved patient experiences and outcomes, lowered risks, and lowered costs. 
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Scott Whitaker is chief marketing and communications officer at TeleHealth Solution. He can be reached at 1-833-633-3497 ext. 2 or Whitaker@TeleHealthSolution.com.

*Method of calculation is average length of stay (5.1 days) multiplied by Medicare reimbursement ($470/day) multiplied by number of admissions avoided. 
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