Advancing Toward a Hospital Discharge Quality Guarantee

When a patient is discharged from the hospital, he or she has every reasonable expectation that a potentially avoidable readmission won’t happen. However, by some estimates, nearly 20% of Medicare patients are readmitted within 30 days, and nearly 34% within 90 days, leading to more than $17 billion in potentially avoidable costs.1

If healthcare were viewed through the same lens as we view products or services, would these numbers have resulted in a healthcare “product recall” long ago? At its root, does healthcare have a quality assurance (QA) and quality control (QC) problem and/or an obligation, and should patients expect a quality guarantee at the time of discharge?

If we look to industries such as transportation, manufacturing, pharmaceuticals and agriculture, for example, quality assessments occur at multiple points along the assembly line, so that the exact point where a failure occurs can be pinpointed in near-real-time. It has become such a standard to apply quality assurance and quality control processes in these industries that not doing so would be a violation of accepted practice and consumer trust. 

Certainly, healthcare is a different creature than other industries, and in healthcare, we’re dealing with the nuances of human beings. Yet, why is it that in healthcare, the use of QA and QC tends to be limited to processes such as clinical laboratory reporting, medication dispensing and inpatient error reduction, but not to the last mile of the process of healthcare itself: the post-hospital discharge period?

Limited success

With the advent of various value-based payment initiatives, hospitals are increasingly financially accountable for patients through the 90-day post-hospital discharge period. Hospitals have responded to these alternative payment models by implementing various methods to track patients after discharge. These efforts have been met with limited success, however. Preventing and tracking avoidable readmissions is a tremendous challenge because so many factors outside of the hospital’s and provider’s direct control contribute to the problem, and many factors confound the index hospital’s awareness of the readmission event itself.

For example, some reports estimate that up to 65% of patients with complications are readmitted to a hospital other than the discharging hospital (also called the index facility).2 Though the index facility may bear financial risk for that event happening, it may not even be aware of the readmission. Readmissions to hospitals other than the index facility often go unknown to the index facility until CMS reconciliation (if the hospital is in a value-based program) or until billing occurs. Unfortunately, collecting data about readmissions and complications from all payers for all patients in a timely manner is virtually impossible for most hospitals. And by the time the hospital becomes aware of these readmissions, the event may be so far downstream, that it’s usually too late to initiate a timely quality improvement effort.

So, how can hospitals gather more timely feedback about readmissions and overall healthcare utilization for recently discharged patients? One solution is to bring the patient into the feedback loop.

Patients as participants in quality assurance and improvement

When a patient experiences a complication or a readmission, arguably, only two parties are aware of the event: the payer and the patient him or herself. Imagine if patients could be reliably engaged to share with a hospital their healthcare utilization, as well as complications or readmissions through 30, 60, and 90 days via automated digital check-ins? 

With GetWell Loop, we’ve seen the power of engaging patients in their care. When our customers use an automated digital patient engagement solution that combines remote monitoring and guidance, they have reported relative decreases in 30-day readmission rates ranging between 16% and 70%. Equally important, with remote monitoring, leakage of patients to other facilities can be mitigated because care teams are made aware of emerging clinical problems often before the patient has presented to the index or to a second facility.

Building on our success in meaningful patient engagement, GetWell Loop has recently launched a new utilization dashboard for our hospital clients. The dashboard illustrates in near-real time, discharged patients’ self-reported complications and healthcare utilization, including readmissions, emergency department visits, skilled nursing facility stays, home health use, physical therapy sessions and resumption of driving/return to work. 

The report provides timely feedback to hospitals about overall readmission rate, percentage of patients that leaked to other facilities and the names of those hospitals where they were readmitted. Hospitals can use the data, for example, to gain greater insight into opportunities for post-discharge improvement, to benchmark skilled nursing facilities or physical therapy agencies in order to find the highest-performers relative to utilization or to identify outliers that may cut into slim margins for hospitals under bundles. Perhaps the most compelling aspect of the unifying dashboard is that these utilization data flow back to our hospital customers in near-real-time.

When information flows seamlessly between patients and care teams, in a manner that is convenient and workflow-compatible, healthcare providers can understand patients better, and healthcare administrators can iterate, learn and improve more rapidly.

As payment transitions from volume to value, ensuring high-quality care and excellent outcomes after discharge is increasingly important. Implementing new ways to identify and improve weak links in the delivery system, especially in the last mile of the healthcare journey, are welcome advances towards a hospital discharge quality guarantee.

[1]Jencks SF, Williams MV, Coleman EA. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine 2009;360(14):1418–28.

[2]Greenbaum JN, Bornstein LJ, Lyman S, Alexiades MM, Westrich GH. The validity of self-report as a technique for measuring short-term complications after total hip arthroplasty in a joint replacement registry. J Arthroplasty 2012;27(7):1310–5.