Preventable hospitalisation: the US initiative
AT THIS WEEK’S RELEASE of the final report from the National Health and Hospitals Reform Commission, the prime minister made no commitments about his government’s response to the report’s recommendations about a federal takeover of health services. For the time being his reaction to this proposal and the extent to which he would be prepared to adopt it remain unknown.
Much of the drive for such a takeover has been about countering the cost and blame-shifting that is an integral part of the current division of funding and management responsibilities. But any proposed reforms must be patient-centred and focused on better coordination of care and improved patient outcomes.
One possibility is that outpatient services attached to public hospitals and community health centres, which are now run by the states, would move to federal funding control. This could boost the coordination of patient services between general practitioners and specialists, hospital out-patient services and community, family and child health centres.
In this light it is interesting to consider the initiatives in the health care bills currently under consideration in the US Congress, which are aimed at delivering quality, coordinated health care services, especially to those segments of the population most at risk.
From the Australian perspective, the most interesting and relevant provision in the bill may be the one aimed at reducing potentially preventable hospital readmissions for Medicare beneficiaries (people aged 65 and over). This provision requires the Secretary of Health and Human Services to develop a detailed plan on how to implement the bundling of payments to hospitals, post-acute providers such as rehabilitation and home care services, transition care providers and nursing homes, and doctors.
Under this new payment system, acute and post-acute providers and doctors will receive incentives to fund a range of services, but will face funding cuts if the percentage of potentially preventable readmissions is not addressed.
The aim is to ensure that older patients with chronic illness are not simply discharged from hospital but get the additional follow-up care they need to stay out of hospital: care coordination services to assist in the transition from hospital to other settings, translators and interpreters, better discharge planning along with summaries of care and medication orders provided to patients and their carers, and measures to ensure that patients see a doctor within a week of discharge.
Unplanned hospital readmissions within thirty days of discharge are considered a sentinel event for poor quality. In the United States in 2006 there were 4.4 million such hospital visits, costing $30.8 billion. Two-thirds of these were for patients aged over 65, and 30 per cent of the cost was attributable to seven conditions, including pneumonia, heart attack and heart failure, and vascular problems.
Discharge from hospital is a critical and vulnerable care juncture for patients, who may suddenly be expected to assume a self-management role in recovery with little support and preparation. Often they do not know which doctor to call with questions as it is not always clear who is responsible for and informed about the patient’s care and medications.
Discharge is also a time when patients are more likely to be receptive to health care recommendations. But despite the needs and opportunities associated with this transition, there is little investment by hospitals, doctors and the funders of health care, both public and private, in managing the transition. This is as true in Australia as it is in the United States.
Several pilot studies conducted in Australia in 1998 and 1999 showed that multidisciplinary, home-based interventions using nurses decreased the frequency of unplanned readmissions and out-of-hospital deaths in older patients with various chronic illnesses and were particularly cost-effective among high-risk patients with heart failure. But this useful information has languished in the archives of the journals in which it was published.
In Australia, there are Medicare items to help with discharge planning and care coordination, but they are little used. In 2008 general practitioners claimed for only 970 discharge case conferences on behalf of their patients. The Department of Health and Ageing shows little interest in investigating why these items are so little used.
As the Rudd government moves forward on health care reform, there is an opportunity to address this issue of unplanned hospital readmissions through the implementation of appropriate programs, teamwork and incentives. The ultimate aim should not be cost saving or face saving, although both will result, but better quality care and outcomes for patients. •
Lesley Russell is the Menzies Foundation Fellow at the Menzies Centre for Health Policy, University of Sydney/Australian National University, and a research associate at the US Studies Centre, University of Sydney. She is currently working in Washington DC. This article was published in the Canberra Times on 27 July and has been updated to reflect the release of the NHHRC report on that day.
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