Tag Archives: readmission rates

Survey says….

When Advanced Inpatient Medicine started at our Wilkes-Barre site in October of 2013, I saw a very dysfunctional facility that was essentially run by specialists and the primary care docs that consulted them frequently. There was no thought to the changing landscape from a fee for service mentality to a pay for performance one. Right before we started there, I met with the CEO & warned that if we did our job right, he would have many consultants beating down his door to complain about us. In fact, that is exactly what happened. We didn’t consult a pulmonologist for every simple pneumonia or cardiologist for every chest pain, so, as our service grew, some specialists got upset and considered us a threat to their livelihood. One went so far as to try to get us thrown out with literally fabricated stories about our performance. On the 2014 physician satisfaction survey, my fellow medical staff, especially the medical specialists, crucified us. They were very critical and talked about a lack of communication and expressed concerns about clinical quality of care. After all, as one cardiologist put it, “You can’t possibly take care of CHF without a cardiologist.” Yes, it was that bad. We had to work with the CMO & other staff to create a dashboard to show that our quality was better than the general primary care doctors, with a markedly lower length of stay with no corresponding increase in admission rates.
Fast forward a year later to the newly released annual physician satisfaction survey this week. Our group has had a tremendously large increase in our scores across the board. No longer does the medical staff seem suspicious that everything we do is part of some conspiracy to affect their livelihood. (Yes, there is always one who just won’t give up that idea!) We received much higher marks in the perception of quality of care, communication, etc. The bottom line is that we have now generally become accepted as a part of the medical staff that provides a quality role at that hospital. That is a very gratifying survey to read because it means that things are progressing right on schedule. Taking care of hospitalized patients is the easy part, and not a whole lot different from place to place. Changing a culture requires patience & the ability to communicate openly & realize that this is a gradual process. Bad habits have been allowed to fester for a generation. Yet, we are slowly putting in system & process improvements that are starting to create fundamental change. The resistant few are beginning to realize that pay for performance is coming whether they like it or not. Those that refuse to embrace it will be left without a hospital to work at. Truthfully, that’s fine with me because I believe that our hospitalist team will be able to provide excellent care of those patients.
AIM continues to grow by hiring staff that embrace the two pronged challenge of patient care and improving the system. Are you one of those looking to truly make a difference? We have added several more sites and are looking for some talented providers that have that same mindset. Time to jump on board!

A Singular Honor

Happy New Year! Today, I found out that I would be the 4th ever recipient of the Certified Leader in Hospitalist Medicine designation. To be recognized as such, one has to complete three Leadership courses and a research project. The Leadership courses that are offered through the Society of Hospitalist Medicine (SHM) have had an enormous impact on my ability to lead my program. Courses cover leadership, finance, hospital finances, conflict resolution, negotiation, and many, many more. If anyone is interested in taking a leadership role in hospitalist medicine, these courses are a must. The research project must be approved by a review board and it is a very detailed process.
My project was to show that we can perform several interventions in a rural setting to decrease readmissions for four key diagnoses: CHF, MI, COPD exacerbations, and pneumonia. I chose this for our rural site at Wayne Memorial Hospital because I couldn’t find a single study regarding readmissions that was performed in a rural site, and thought that perhaps there would be other factors that affect readmission rates here versus an urban setting. As it turns out, we used four interventions: hiring four discharge coordinators to do bedside teaching & arrange follow-ups, etc., having the pharmacist perform medication reconciliation at the bedside prior to discharge, a home health visit on the 3rd day after discharge for everyone, and follow-up phone calls from both a pharmacist & discharge coordinator. The results were better than anticipated. Readmission rates fell over 34% over the one year study period, with CHF being the main diagnosis showing the statistical significance. As it turns out, being on ten or more meds at discharge was significant, and the home health intervention was also significant. No other variable turned out to make a difference, although I suspect having the coordinators make the follow-up appointments and phone calls had a large contribution to the decrease, although it couldn’t be shown statistically. As a result, we changed our approach to discharges and continued and expanded the coordinator role long-term. The bottom line is that we showed that research studies like this can be performed in a rural setting successfully, and I am very proud of this accomplishment. For the full details & discussion, look for the report soon on the SHM web site & eventually in the hospitalist literature where we hope to publish the entire project.
Having achieved this honor solidifies my place, and, more importantly, my program’s place as a leader in hospitalist medicine. When I started this company in 2006, I approached this with the idea that we can do things differently. I wanted to make a difference and become a leader for change. I wanted to make hospitals more efficient, safer, and of higher quality. Many hospitalist programs and companies are interested in profit margins and growth. I am as interested in profit as anyone, but that is not my focus at all. I fit well with the SHM because their goals mirror my own and they don’t provide just lip service. Their goal is to train the leaders of tomorrow who will help us transition from a fee-for-service mentality to a pay for performance model. I am proud to be a part of that change and perhaps a leader of this change by my example. Advanced Inpatient Medicine has adopted this goal which reflects my philosophy. If you are interested in making a difference & not just ‘working’ as a hospitalist, then come on and jump on board and be a part of something special. We are growing & can use the help.

Reducing readmissions…oops!

     On April 15th, AIM just wrapped up one of its many QI projects, this one looking at decreasing readmission rates for four major diagnoses (MI, CHF, COPD, & pneumonia) through 4 specific interventions. It was a great project, involving many people over multiple disciplines. We added staff to provide more in depth discharge planning at the bedside. The pharmacists were involved making phone calls after discharge to go over med issues & also did med rec prior to discharge. Home health visits for every patient enrolled in the project also took place. So far, it looks like we will have reduced the rates of readmissions for CHF, MI, pneumonia, & COPD by about 25-30%!

    Here’s the rub: we didn’t do our hospital any favors & in fact, cost them revenue. The ‘problem’ was that our baseline readmission rates were not excessive, around the national average of 18% or so. We were never going to be hit with readmission penalties. What we did, basically, is cost our hospital business. So, was it the right thing to do? I don’t think there is anyone who wouldn’t agree that this project & these interventions were very good things to be doing. This is a prime example of just how difficult the transition from fee-for-service to pay-for-performance will be. Hospitals are not going to embrace these changes if it hurts the bottom line, no matter how much better it is for patient care. ACO’s & other programs are looking at improving the overall health of the population. In all of these models, the hospital is the cost center and the area to take the biggest hits. As a hospitalist, I have been thinking about the somewhat sad realization that if we succeed in these endeavors, then the need for hospitalists will diminish considerably. All for the greater good? Maybe. Then again, we are talking about government programs here. At the rate our government moves, I will be long retired before health care ever becomes that efficient. I hope we get there, though….eventually.