Readmission impossible

A dedicated team strives to keep a complex patient out of the hospital.


Dr. Phillips' pager beeps. When he calls in, the voice on the line says, “Good morning, your mission is to discharge the patient in room 892 and not have him return within 30 days.” With that, his pager begins to smoke, and Dr. Phillips tosses it into the garbage. He gathers his team—the Student, the Resident, and the Case Manager.

Dr. Phillips briefs his team: Mr. Wyrzutowa was admitted yesterday with acute on chronic systolic heart failure, permanent atrial fibrillation, and chronic kidney disease stage IV. This is his second admission this year. He has been assigned to the IDF (Impossible Discharge Force) for management.

Illustration by David Rosenman
Illustration by David Rosenman.

The team discusses a discharge plan for Mr. Wyrzutowa. The medical student is handling research and data. She tells the team that the patient's 30-day readmission risk is 35%, according to the EMR risk calculator. However, she notes that most EMR-based risk calculators perform poorly in accurately predicting readmission risk for patients who have not already been admitted twice within the past year.

The resident asks who the patient's primary care physician is. Nobody (including the patient) knows the answer. The medical student is assigned to track this down (including a fax number, in case the outpatient physician is among the 7% who do not use electronic medical records). In her quick survey of the topic, she is shocked to learn that 27.5% of primary care physicians do not have a discharge summary in hand when they see a patient in follow-up, increasing the risk of adverse events such as readmissions. That isn't going to happen in this case; the IDF always gets it done.

Another resident who had treated the patient meant to document his CHA2DS2-VASc score of 6 and defer anticoagulation discussion to outpatient follow-up, but he was distracted by a septic patient on the service. His omission increases Mr. Wyrzutowas' risk of readmission or death (26.5% of primary clinicians also note that the summary infrequently contains all desired information, the med student notes). But the IDF catches this error and corrects it.

The patient's bedside nurse (an IDF contractor) assures the team that she has completed teach-back education about following a low-sodium diet, and the patient answered 90% of his follow-up questions correctly. The charge nurse, just back from a conference, cites evidence that correctly answered teach-back questions are not associated with reductions in 30-day readmission rates for heart failure patients. However, another nurse says she read a different study in which patients described being discharged too soon, feeling weak at discharge, having limited help at home managing chronic illnesses, and receiving insufficient discharge instructions as the primary reasons for readmission.

The case manager locates and contacts the patient's primary care team in Montana. An outpatient nurse will call him within 24 hours of his arrival at home and review symptoms, medications, and follow-up planning. Mr. Wyrzutowa has a new oxygen requirement, and after much effort the case manager is able to arrange portable oxygen for his long drive home.

On hospital day three, the patient is ready for discharge. His discharge summary is fresh off the printer. Prescriptions wait at the hospital pharmacy. His new oxygen concentrator sits next to him on the bed. The bedside nurse completes the discharge education. The social worker provides him with charity meal vouchers so he doesn't have to eat gas-station pizza all the way home. The patient feels he is ready to be discharged and feels he has the support at home from his wife to be able to manage his chronic illness and get home safely.

But Mr. Wyrzutowa's 2 p.m. discharge time comes and there's no sign of his wife. The team calls her cell phone and it is answered by a nurse in the emergency department. Mrs. Wyrzutowa presented this morning with angina and will be staying in the observation unit overnight.

The IDF huddles and considers discharge to a hotel room. Without his wife, Mr. Wyrzutowa would be highly likely to fall and cannot get his outpatient medications. One readmission avoided, at least for 24 hours. After his wife is released from observation, he is discharged.

Three weeks later, the IDF attends a department-wide meeting with the hospital's newly hired quality specialist, who reviews their hospital's performance on two of the CMS value-based performance programs: the Hospital Value-Based Purchasing Program (VBP) and the Hospital Readmissions Reduction Program (HRRP). The specialist explains that in fiscal year 2018, CMS will withhold up to 2% of Medicare revenue under the VBP and up to an additional 3% of revenue under the HRRP.

In 2017, the hospital had a base operating Medicare revenue of $33 million. Because they performed marginally on both the VBP and the HRRP, the hospital lost $825,000 in CMS revenue (a composite reduction of 2.5%).

The quality specialist reviews the domains that contribute to the hospital's total performance score under the VBP: 1) safety, 2) clinical care, 3) efficiency and cost reduction, and 4) patient- and caregiver-centered experience of care/care coordination. Tthe HCAHPS survey factors in performance on the fourth domain with measures like nurse communication, doctor communication, communication about medicines, and discharge information.

Thinking of all the work she has, the resident is actually relieved when her pager goes off and gives her an excuse to leave. That is, until she sees the message. It's Mr. Wyrzutowa, back in the ED.