Cedars-Sinai Medical Center Reducing 30-day Readmissions and Improving Patient Health

Heart failure and acute myocardial infarction are two of three conditions at the center of the Medicare pay for performance bull’s eye. As the penalties expand to include other conditions, there’s much to learn from foibles and successes from hospitals across the country. How do you reduce 30-day all-cause readmission? It’s a complex challenge but one that Cedars-Sinai Medical Center in Los Angeles has met.

Most hospitals and health systems were caught off-guard when the Accountable Care Act dictated the first Medicare readmission financial penalties that started in October 2012. Many facilities launched into projects after the announcement in 2010, only to realize later they were way off the mark. “Health systems were told there was a financial penalty at stake and given the metric – but not told of the mechanisms to improve the numbers and get there,” recalls Bruce Samuels, MD, team leader of a 30-day readmission task force at Cedars-Sinai Health System.

Cedars-Sinai launched a 30-day readmissions task force in 2009 to craft a plan to keep patients out of the hospital for 30 days and far beyond. The natural initial strategy was to focus on the management of patients that fit into the targeted disease states, with clinicians working to improve their patients’ physical health before the patients went home. But they realized quickly that wasn’t helping. “As a hospital, we were comfortable with inpatients but didn’t have any mechanism to help once they were discharged,” Samuels recalls.

The team realized the focus needed to be on those patients, “who had been discharged but started to become ‘wobbly’,” Samuels says, “and how to prevent them from being readmitted. We formed a ‘Wobble Team’ and we focused on finding partners who could help us take care of those vulnerable patients at home or post-discharge.”

A skilled nursing facility (SNF) and home health agency became Cedars-Sinai’s new partners to coordinate and extend care resources outside of the hospital. Very quickly, the skilled nursing component became “wildly successful,” Samuel recounts. A staff of nurse practitioners hired by Cedars were assigned to care for select patients discharged to the SNF, with a protocol to round onsite at the SNF within 24-hours of hospital discharge. They assessed patients and emphasized their accessibility if questions arose. This worked. After a three-month test of change at a single SNF, the send-back rate was reduced from 15 to 20 percent to 10 percent. After analyzing the subsequent data, and finding out that most of that 10 percent were routed to the ER on a Saturday or Sunday, nurse practitioners started covering weekends as well. Now the program has been expanded to seven SNFs, and the readmission rate has remained in the single digits.

When home care was most appropriate for a patient, Cedars-Sinai partnered with a single home health agency (HHA) in another test of change. After agreeing to go above and beyond the usual delivery of care, a protocol was established which front-loaded seven “touchpoints” (visits or calls) within the first two weeks of returning home. Patients met with home care agency representatives prior to hospital discharge to ease the transition. In between home visits, home care workers checked in with patients via phone, including weekend calls and visits. “With all touch-points accomplished, readmits are less than 12 percent,” he notes. Cedars-Sinai has now rolled out this model successfully to an additional six home health agencies.

Efficiencies in the cath lab

The cath lab is another place to watch and innovate—especially as hospitals will be judged on PCI based on the NCDR Registry. Penalties arrive in FY2016. “This is the first time we are being judged on a procedure, not a disease state,” Samuels notes.

Published hospital readmission rates for coronary stent placement run about 15 percent, a figure Samuels calls “surprisingly high for a surgical procedure.” Of those patients, about 12 percent had a post procedure complication and over 35 percent had a cardiac cause related to the initial hospitalization. We don’t know with certainty what number end up requiring a repeat revascularization—one large registry from New York State showed 32 percent of the readmitted patients ended up back in the catheterization lab.

If the right things are done right for the right patients, patients won’t need to be readmitted—a simple concept, but a challenge to execute and quantify, according to Samuels. “Post procedural complications are inevitable, but we can work to minimize their occurrence:  We need to focus our efforts on doing what we can to avoid stent thrombosis, geographic misses that result in ischemic events, edge dissections, vascular access complications and nephrotoxicity from contrast.”

Cedars-Sinai uses a combination of guidelines and technology to help physicians make treatment decisions during PCI. Fractional flow reserve (FFR) and intravascular ultrasound (IVUS) are two tools that help clinicians decide which lesions to stent and assure the intervention is appropriate. With FFR, that means lesions with an FFR lower than 0.80 get a stent. Samuels cites the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study that found physiologically driven PCI via FFR was more successful than angiographically driven PCI, with routine FFR in addition to angiography improving outcomes of PCI at one year.

IVUS shows its value in measuring lesions and plaque characteristics. “We see increased use of IVUS in the cath lab to be sure stents are correctly sized and well placed,” he says. “It is good common sense. IVUS may have a small impact, perhaps a couple of percentage points on reducing readmissions in these patients, but that may be all you need to get below mandated benchmarks and thus avoid penalties. It may cost a little upfront to add an additional technology but it reduces readmissions and revascularizations that don’t subtract from the bottom line.”

Samuels says now is the time to put systems and technology in place that will help to reduce readmissions rates related to PCI. “Administrators are bringing a chair up to the table to discuss how systems can help in appropriate use and stent deployment, also in groin management, medications and nephrotoxicity. Avoid the penalties by focusing on systems you can implement to alleviate all readmissions. Target the cath lab.”

He also challenges physicians to make 30-day admissions the endpoint of clinical trials. “With all of the economic realities of readmissions, this is where we are headed and we need the data to show us the right path.” Reducing hospital readmissions is a complex dance. It comes down to tactics, teamwork and time—and now is the time.