Moving the needle
Relatively high readmissions rates are also a big reason why none of Northwell's hospitals received more than three stars out of five in the 2017 CMS overall hospital quality ratings. News media and consumers give the Hospital Star Ratings Program a lot of attention.
"Our performance has been poor and the numbers are a wake-up call. But the good news is that we're committed to improving," Dr. Smith said. "And once Northwell decides to do something, we tend to be able to move the needle."
In fact, an increased focus on care management during the transition from hospital to home is already producing good results. Transitional care management programs swing into action for patients undergoing hip or knee replacement, heart surgery or who are admitted for heart failure, heart attack, stroke or chronic obstructive pulmonary disease (COPD).
"We're seeing really powerful outcomes," said Zenobia Brown, MD, Health Solution's medical director for transitional care. "For joint surgery and heart surgery, we had a 25 percent decrease in readmissions in just one year."
A simple concept is at the heart of Northwell's transitional care management: Build a relationship with the patient and check in often in order to avoid or fix potential problems before they get out of control. So before a planned hospitalization (or during an unplanned one), a care manager meets with the patient. They review what to expect and discuss issues that might make recovery difficult. There are more meetings and more conversations during the discharge planning process.
Once the patient is home, the care manager calls within 24 hours to make sure that everything is going smoothly. For instance, has a home care agency made contact? Are all the medications the doctor prescribed on-hand? Is there pain, fever or swelling? If the patient is at high risk of returning to the hospital, the care manager will make a home visit to check vitals and trouble-shoot. The care manager will stay in close touch for 30 to 90 days, depending on the reason for the hospital stay.
Trust is key to making the process work, Dr. Brown said.
"We had one patient who had returned home but hadn't filled any of his prescriptions," Dr. Brown said. "English was his second language and he had an intense distrust of the medical system, but he finally agreed to let a care manager come to his home. It turned out he couldn't afford his medications.
"Once we knew that, we were able to get him on Medicaid. We got his meds in blister packs, which are easier to deal with, and put other interventions in place. Now, for the first time in a year, the patient is taking his medications regularly."
Northwell first began transitional care management four years ago. It covered about 300 patients as part of Medicare's original bundled payment program. Now, more than 15,000 Northwell patients annually benefit from transitional care.
A key element in cutting readmissions is to make sure patients get linked back in with their ambulatory care providers. So ultimately, the health system's readmission reduction work has to extend beyond the hospitals, Dr. Smith said. "Readmissions are not a Health Solutions problem, not a hospital problem and not an ambulatory network problem," Dr. Smith said. "They're everyone's problem, because everyone owns a piece of it."
The benefits will be measured in dollars and cents, ratings and grateful comments from patients and their families, said Joseph Lamantia, executive director of Health Solutions and vice president of population health. CMS ratings are based on a three-year, rolling average of hospital metrics, so it will take a few cycles for improvements to register, but the health system is in it for the long haul.
"Readmission rates will be a major focus for Northwell until we get it where it needs to be. It's ultimately a quality-of-care issue and a patient-experience issue," Mr. Lamantia said. "We do a great job of caring for our patients in the hospital. Now we're applying that same mindset to what happens when our patients leave."