Einstein dramatically reduces readmission rate

Fred Henson was waiting to be discharged after gallbladder surgery when yet another hospital staffer came to his room bearing pills.

The visitor, a pharmacist at Einstein Medical Center, discussed in detail the contents of each of the four vials. She gave him a compartmentalized pillbox and a matching sheet of paper with photos of each pill accompanied by descriptions of what it does and when and how to take it. And then she sent him home with well over 100 pills - a month's supply - so there'd be no need to take new scripts to a pharmacy and deal with insurance hassles.

"Now I know what to expect, what not to expect," said Henson, 68, who keeps the paper in his bureau at home in Oak Lane.

These simple yet revolutionary changes in handling drugs when high-risk patients are discharged are at the core of a program that has cut its readmissions within 30 days of discharge by 50 percent, according to internal studies at Einstein.

Hospitals across the country have been reducing readmissions, although not as dramatically in most cases, in response to financial penalties built into the federal health-care overhaul to save money and improve outcomes.

Medicare traditionally pays a set fee for each admission, regardless of length of stay, and it pays again if a patient is readmitted. Hospitals make money by discharging patients as soon as possible, and have long earned more if they return.

Nearly 20 percent of Medicare patients are readmitted within 30 days, costing taxpayers more than $17 billion a year.

Starting in October, however, the government began penalizing hospitals whose readmission rates for three conditions - heart attack, heart failure, and pneumonia - were higher than medical models predict they should be. The penalties are based on past rates and applied to future reimbursements, and they are painful: up to 1 percent of total Medicare payments for all patients this year, rising to 2 percent next year and up to 3 percent after that.

More than two-thirds of U.S. hospitals are being penalized this year. (Einstein's hit will be 0.56 percent, significantly worse than average.)

"Having some money behind these programs has really spurred a lot of activity," said Karen Joynt, a cardiologist and health policy researcher at Harvard University. "The interesting thing to me," she said, is that health systems are "recognizing that this is not just about the hospital." Rural hospitals, for example, now have an interest in arranging transportation so patients don't miss follow-up appointments with physicians far away.

Joynt has criticized the government policy as a "blunt instrument" that punishes hospitals for things they could not control even if they wanted to. Safety-net hospitals that care for poor patients often have higher rates of readmissions, as do the teaching hospitals that take the most complicated cases.

Only 13 percent of Einstein's patients, drawn mainly from North Philadelphia, are privately insured. The rest are on Medicare or Medicaid or have no coverage.

"When someone leaves our hospital, they frequently don't have the support systems in place that those in other hospitals do," said Cindy McGlone, an Einstein vice president.

A few years ago, McGlone mentioned the coming readmission penalties to Deborah Hauser, a hospital pharmacy director.

"I had never in a million years even thought about this," Hauser said. The more she researched, the more obvious the problem became. For someone with a heart condition or diabetes or asthma, not taking prescribed drugs can land you in the emergency room quickly.

"It's one of the top three reasons why people come back. It kind of boils down to, they don't have access to their medications, maybe they don't have insurance coverage," Hauser said, or "they don't understand how to take them properly. . . . Another reason is they are afraid of side effects."

But the hospital wouldn't know any of that until a patient returned, and often not even then. Hauser wondered: "Wouldn't it be great if they talked to a pharmacist before they left?"

Aided by two small grants and, eventually, two new hires, she developed a program called REACH.

"R" stands for reconciliation: comparing a patient's prescriptions at arrival and departure, verifying dosages and checking to see if anything is missing - or duplicated. Several months on, a tally showed the new pharmacist had made 59 interventions for 47 patients - more than one fix apiece.

"E" is for education. Meeting with patients in their rooms, Mariel Sjeime, the new pharmacist, reviews each pill and offers a sheet of paper with photos and instructions. She probes.

"When you have high blood pressure, high cholesterol, you feel fine until something happens," she said. When she explains that the drug is intended to prevent problems, she said, "I've had them say, 'Oh, I'm going to start taking it now.' "

"A" is access. A retail pharmacy won't fill a prescription without payment. Einstein sends patients home with a month's supply and bills them later. Sjeime sets up payment plans, pursues overrides when insurers reject a script, and finds pharmacies that make home deliveries.

"C" stands for counseling: a follow-up phone call within three days and again toward the end of a month. Patients often are overwhelmed when they are being discharged; questions arise later.

And "H"? "I'm into acronyms," Hauser said. Doing all the above leads to a healthy patient at home.

In a controlled comparison of two groups of high-risk heart patients - adults with at least five prescriptions, two or more chronic conditions, and at least 48 hours in the hospital - 10.6 percent of those who had experienced the REACH program were readmitted within 30 days vs. 21.4 percent of those who had not. It was expanded after a year to more high-risk patients, with similar results.

The initiative was named one of eight hospital "best practices" by pharmacists nationally.

Efforts to cut readmissions are part of a broader movement, from "medical homes" to Accountable Care Organizations to hospitals' buying up physician practices, that is edging away from the "silos" typical of the U.S. health system and toward shared responsibilities that consider the whole patient all the time, said Joynt, the Harvard cardiologist.

She is surprised at how quickly hospitals, given incentives to cut readmissions, have begun to innovate in areas that arguably have little to do with the inpatient experience.

"It makes me wonder," Joynt said, "what else could we be doing?"