Allison Hart, Vice President of Marketing
TeleVox Solutions, West Corporation, Mobile, AL
Since the Hospital Readmission Reduction Program (HRRP) was first announced approximately eight years ago, hospitals across the U.S. have adopted processes that have led to decreases in readmission rates. Following early success, hospitals have seen readmission declines level off in recent years, and many are now searching for ways to continue to drive down readmissions. One underutilized solution that offers opportunities to impact readmissions is using technology to survey patients at various points after leaving the hospital. By sending patients prompts to complete automated surveys shortly after discharge, and also later on, hospital teams can gain valuable insights that can be used to identify issues that could potentially cause patients to readmit. Healthcare teams can then act on the information they collect from surveys by proactively intervening to help keep patients out of the hospital.
As the healthcare industry has learned, many hospital readmissions are preventable. In 2009, before the HRRP was introduced, the average percentage of Medicare patients readmitted to the hospital within 30 days of being discharged was over 19 percent. By 2015, just a few years after the launch of the HRRP, the percentage of readmissions for Medicare patients had dropped below 18 percent. The timing of this drop coincided with a push by hospitals to make improvements in order to avoid readmission penalties that took effect in 2013. The lesson learned from this? Hospital teams can help prevent readmissions, but they have to work proactively (see Figure 1).
There are a number of factors that impact readmissions. Hospitals have worked diligently to address many of those factors by adjusting how they care for patients prior to and after discharge. From ensuring that patients receive high-quality care during their time in the hospital, to improving discharge procedures so patients are better prepared when they leave, to assigning care coordinators to help patients manage their health once they have left the hospital, a multipronged approach has been necessary for driving improvements. But there is more that can be done—and needs to be done—to force further readmission declines.
Patient surveys, or ‘check-ins,’ are a simple and effective addition to hospital readmission reduction plans. They offer a way for medical teams to identify areas of need and provide ongoing support to patients so they do not readmit. Automated surveys allow providers to monitor patients in their home environment, escalate cases when patients are at risk and intervene before patients reach the point of needing acute care. A smart survey strategy involves sending patients a survey within 24-48 hours of their release from the hospital, and then following up with other health monitoring surveys later on as needed.
Whenever a patient transitions from one care setting to another there are risks involved—even when that transition involves leaving the hospital and returning home. The 30-day window after a patient has been discharged from the hospital is known for being a period of vulnerability. If patients are not equipped to manage their health on their own at home (if they do not understand discharge instructions, have questions or concerns about medications, are experiencing pain or other symptoms that they don’t know how to handle) they can quickly get on a path that leads to complications and readmission. Surveying patients within one to two days of their release from the hospital provides a way for healthcare teams to assess patients and determine how well they are coping with their transition out of the hospital. Also, this contact with patients allows teams to recognize and address issues as early as possible.
Automated surveys can be sent to patients using the patient engagement technology hospitals and health systems already have in place and use to send appointment reminders and other communications. With minimal effort from hospital staff, every patient that is released can be sent a message that prompts them to complete a post-discharge survey over the phone or online. Staff can simply generate a daily list of discharged patients and schedule and send each of them an automated survey invitation.
Post-discharge survey check-ins do not need to be long or elaborate. A survey that asks patients whether they are experiencing pain—and whether or not they have been taking prescribed medications— will provide good insight about the likelihood of them returning to the hospital. Therefore, when designing postdischarge surveys, hospitals may want to primarily focus on capturing information related to these areas:
- Pain (or other symptoms)
- Follow-up care
Medication noncompliance is a primary factor that contributes to readmissions. When patients do not pick up and take medications, or they take medications incorrectly, their health may be compromised. Hospitals can use automated post-discharge surveys to see whether patients are following medication orders. An automated survey message might instruct patients to use their phone to respond to the following questions:
- Have you filled and picked up your prescribed medication? Press one for “yes” or two for “no.”
- Have you missed taking any doses of your medication? Press one for “yes” or two for “no.”
- Do you have questions about medication side effects or how to take your medication correctly? Press one for “yes” or two for “no.”
Depending on the capabilities of a hospital’s survey technology, teams may be able to set up alerts and receive notifications when survey responses indicate patients are struggling with medication compliance. This means, for example, that if a patient responds “no” to the first question listed above, staff would be notified, and a care coordinator or other hospital representative could then contact the patient and find out why the prescription was not picked up. In some cases, the issue may be that the patient did not have transportation to the pharmacy, was worried about the cost of medication or even forgot. Whatever the situation is, the hospital staff can help find a solution so the patient can get their medication and begin taking it. A care coordinator may call the pharmacy and arrange for the medication to be delivered, or look into the possibility of reducing costs with a generic drug for the patient. Of course, staff can only intervene and help patients overcome medication barriers when they are aware of problems.
At hospitals across the U.S., pain is one of the top reasons why patients visit the ER. And, similar to medication noncompliance, pain is a common readmission factor. Patients may not speak up immediately if they are experiencing pain. A patient who has just left the hospital may think that some amount of pain is normal. But unmanaged pain can lead to big problems. Significant pain in the hours following discharge is something healthcare teams should know about and monitor. Therefore, it is helpful for hospital teams to use surveys to assess pain. They can do so by using post-discharge surveys to ask patients questions similar to these examples:
- Are you experiencing pain? Press one for “yes” and two for “no.”
- If zero means you are having no pain and 10 is the worst possible pain, how would you rate your pain? Use the number keys to enter your pain level.
- Press one if your pain is getting worse. Press two if your pain level is staying the same. Press three if your pain is improving.
Patients with high pain symptoms can be flagged for monitoring or contacted proactively. By getting ahead of pain problems, healthcare teams can take steps to help patients reduce symptoms, identify any serious issues and potentially prevent readmissions.
Hospitals can also take advantage of opportunities to use post-discharge surveys to ask patients about their plans for follow-up care. This might mean patients would answer questions like:
- Do you understand the instructions given to you about obtaining follow-up care services? Press one for “yes” and two for “no.”
- Do you have a follow-up care appointment scheduled with your primary care physician or specialist? Press one for “yes” and two for “no.”
There are many reasons why patients neglect orders to follow up with their primary care doctor or a specialist. They may not feel it is a priority, they may have concerns about the cost of treatment (especially if they have recently acquired a large amount of healthcare expenses from being hospitalized), they may not know who to contact to schedule an appointment. The list goes on and on. Because follow-up care is so valuable and plays a key role in preventing readmissions, hospital teams are encouraged to verify that patients have plans in place for follow-up appointments. For patients that do not have appointments scheduled or plans to receive follow-up care, healthcare teams can take action and assist with appointment scheduling or other efforts that will help patients get the appropriate care. Timing is important—asking probing questions about follow-up care should happen within a day or two of a patient’s release from the hospital.
Ultimately, the goal behind post-discharge surveys is to connect with patients and learn about their transition experience and their state of health. Without this contact, hospital teams have little information about how patients are faring. As a result, minor problems can easily grow into larger issues that require more complex, expensive, invasive solutions—including readmittance to the hospital.
Not only is it critical for hospitals to follow up with patients in the first 48 hours after discharge from the hospital, but healthcare teams should continue to check in regularly with patients during the 30-day window following discharge when the risk for readmission is highest. A survey by West found that half (50 percent) of acute care professionals believe that a lack of follow-up by hospitals during this time is a leading factor that contributes to readmissions. Another 32 percent said that insufficient communication after discharge is at least partly to blame for readmissions. Despite these opinions, only 39 percent of hospitals say they follow up with every discharged patient Reaching out to patients and prompting them to complete monitoring surveys during the 30 days after discharge enables healthcare teams to identify issues and, if it becomes necessary, intervene. Unfortunately, not all healthcare teams realize the benefits of using monitoring surveys, nor do they know that their existing patient engagement technology can be used to execute these types of surveys.
When surveys are used for ongoing monitoring, they can be tailored to individuals based on their specific health needs and conditions. For example, following discharge from the hospital, a patient with congestive heart failure (CHF) might receive an automated survey phone call once or twice per week with questions related to their chronic condition. These surveys should consist of ten questions or less that focus on known risks that are common among individuals with CHF. Because weight gain can indicate problems in CHF patients, one survey question might instruct patients to: Press one if they are at their usual weight, press two if their weight has increased up to two pounds from their usual weight, or press three if their weight has increased three or more pounds from their usual weight in the past week. Patients could also be asked to respond in a similar way to questions about their sleep, whether they are experiencing swelling, or having difficulty breathing. The idea is to use known signs that indicate potential problems in CHF patients to identify issues before they turn into major problems for patients. With data from these surveys in hand, healthcare teams can closely monitor conditions that put patients at an increased risk of readmission.
Many things can go wrong in the days and weeks after a patient has been discharged. Medical professionals need to connect with patients in order to monitor their health and proactively address issues before they escalate into larger problems that cause patients to be readmitted. Regular monitoring surveys provide teams an easy way of doing that.
The initial drop in readmission rates that occurred over several years in hospitals across the country is positive. But there is potential to do more and hospitals have motivation to work for further readmission reductions. Preventable hospital readmissions are not only bad for patients, but they also carry substantial financial penalties. As the healthcare industry continues to embrace value-based payment models, hospitals are being held accountable for the long-term health of their patients, and they are facing pressure to keep patients engaged, in compliance with care plans, and out of the hospital. In 2017 alone, hospitals faced an estimated $528 million in Medicare readmissions penalties. These penalties affected about half of all hospitals in the United States. To avoid future penalties, hospitals need to become more actively involved in post-discharge care. They can do this, in part, by leveraging surveys to improve patient engagement and monitoring.
Readmission penalties are not the only motivation hospitals have to continue fighting for further readmission reductions. CMS has been posting individual hospital readmission rates on its Hospital Compare website, in addition to other measures of quality and patient satisfaction, since 2009. Designed for use by Medicare consumers as well as researchers, the Hospital Compare website provides comparisons of each hospital’s Medicare readmission performance to the national average by indicating whether the hospital is ‘better/worse/no different’ than the U.S. national rate. This means that patients have access to performance data that may influence their opinions of hospitals and their decisions on where to go for care.
Every hospital wants to prevent avoidable readmissions. Those organizations that commit to expanding their outreach and monitoring efforts should be able to further reduce readmissions at their facility. Most hospitals already have the technology they need to begin contacting patients with proactive survey check-ins. By pairing their existing technology with a survey strategy that includes outreach immediately after discharge and on an ongoing basis, hospital teams can positively impact readmission rates.