Reducing Hospital Readmissions: A Role for Hospice and Palliative Medicine Practitioners?

Hospices and their palliative medicine specialists have proven, several studies have shown, to be effective at reducing use of hospitals for their patients. In fact, families cite avoiding transitions among multiple settings as one of the benefits of hospice. In a previous post, we've examined the role of palliative medicine physicians in reducing readmissions.
One of the first financial impacts to hospitals resulting from PPACA legislation is a reduction in reimbursement for excessive readmission of Medicare inpatients. Starting with discharges in October 2011, the impact of the payment penalties may be significant.

The Medicare Payment Advisory Commission (MedPAC) has estimated that nearly one out of every five Medicare patients admitted to the hospital is readmitted within 30 days and unplanned readmissions are estimated to cost Medicare approximately $17.4 billion annually. Readmissions have become a widely accepted measure of hospital effectiveness. Although only one of many performance metrics, low readmission rates do correlate with overall clinical excellence.

As part of the CMS value-based purchasing program, 30-day readmission rates are a performance measure already closely watched in the industry. Now PPACA legislation allows CMS to withhold a portion of all inpatient Medicare payments due to excessive readmissions, starting with up to 1 percent in federal fiscal year 2013, and rising to 3 percent in 2015 and beyond.

Hospitals will likely look to post-acute care networks to assist in managing the care of at-risk (for rehospitalization) patients. Should we consider deployment of palliative care specialists (physicians and nurse practitioners) by these networks to visit patients in their homes (especially but not only when a referral has not been made to home health)? If not palliative care practitioners, then who?

Reducing Hospital Readmissions: A Role for Palliative Medicine Physicians

Rehospitalizations among Medicare beneficiaries are prevalent and costly. So concluded a recent study published in the April 2, 2009 issue of NEJM - excellent synopsis here from the Commonwealth Fund. The study found that 20% of Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. Is there a role for palliative medicine physicians? Th experience of Advanced Palliative Care Communities(APCCs), with lower than average rates of hospital readmission and percentage of deaths in a hospital, suggests indeed there is. As does the modest study (abstract cited) below:


Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care
Richard Brumley, MD * , Susan Enguidanos, PhD, MPH † , Paula Jamison, BA † , Rae Seitz, MD ‡ , Nora Morgenstern, MD § , Sherry Saito, MD ‡ , Jan McIlwane, MSW § , Kristine Hillary, RNP * , and Jorge Gonzalez, BA †
* Kaiser Permanente Southern California Medical Group, Downey, California; † Partners in Care Foundation, San Fernando, California; ‡ Kaiser Permanente Hawaii Medical Group, Honolulu, Hawaii; § Kaiser Permanente Colorado Medical Group, Aurora, Colorado.

OBJECTIVES: To determine whether an in-home palliative care intervention for terminally ill patients can improve patient satisfaction, reduce medical care costs, and increase the proportion of patients dying at home.
DESIGN: A randomized, controlled trial.
SETTING: Two health maintenance organizations in two states.
PARTICIPANTS: Homebound, terminally ill patients (N=298) with a prognosis of approximately 1 year or less to live plus one or more hospital or emergency department visits in the previous 12 months.
INTERVENTION: Usual versus in-home palliative care plus usual care delivered by an interdisciplinary team providing pain and symptom relief, patient and family education and training, and an array of medical and social support services.
MEASUREMENTS: Measured outcomes were satisfaction with care, use of medical services, site of death, and costs of care.
RESULTS: Patients randomized to in-home palliative care reported greater improvement in satisfaction with care at 30 and 90 days after enrollment (P<.05) and were more likely to die at home than those receiving usual care (P<.001). In addition, in-home palliative care subjects were less likely to visit the emergency department (P=.01) or be admitted to the hospital than those receiving usual care (P<.001), resulting in significantly lower costs of care for intervention patients (P=.03).

In APCCs, we've found that Palliative Medicine physicians assume a major role in the care (in any setting) of older patients with a hospitalization. What makes these APCCs different? They structure care for those advanced illnesses around the principles of palliative care, rather than hospice eligibility.