This is a transcript of my recent podcast interview with Anne Weiss of the Robert Wood Johnson Foundation.
David E. Williams: This is David Williams, author of the Health Business Blog.
I’m speaking today with Anne Weiss. She is Quality/Equality Health Care Team Director and Senior Program Officer at the Robert Wood Johnson Foundation.
The Foundation recently released a report called The Revolving Door: A Report on US Hospital Readmissions, which uses data from the Dartmouth Atlas Project to show that many Medicare patients are readmitted to the hospital after being discharged. The report also includes results from interviews with patients and providers to provide insights into how to reduce avoidable readmissions.
Anne, thanks for joining me today.
Anne Weiss: Thanks for having me.
Williams: Anne, consistent with other Dartmouth Atlas Reports I’ve seen, there’s a lot of emphasis in this one on regional variation. So, my question to you is how significant is this regional variation for readmissions and to what extent do the outliers actually represent best and worst practices that should be emulated or avoided?
Weiss: We do see pretty significant variation in the rates of readmission for Medicare patients who go home after identical surgeries or identical medical problems. There are very different experiences around the country. This is 2010 data and we saw readmission rates for surgical patients ranging from 18% in the Bronx to 8% in Bend, Oregon. For medical readmission, again, 18% in the Bronx down to 11% in Ogden, Utah.
So it’s significant variation. This study is not designed to tell us about the practice patterns in these areas. We looked strictly at admissions and post-acute care. We do know that there are a lot of different reasons behind this kind of variation. You could see differences in the underlying health status of the patients. You can see differences in the quality of hospital care including discharge planning. You can see best and worst practices in care coordination. And this is really important; you can see a lot of differences in the availability of primary care locally and the availability of hospital beds.
We know that the Dartmouth Atlas has already demonstrated that the local supply of hospital beds drives practice patterns. So other things equal, I think we can assume that when there are more hospital beds, patients are more likely to be admitted and readmitted to the hospital.
So, the short answer is we don’t learn a lot about what the best and worst practices are from looking at the Dartmouth data. But it does tells us it’s a local problem; and our emphasis is on helping people at the local level look at their market circumstances and talk about solutions that will work for them.
Williams: It looks from the report that there’s been only limited progress on reducing readmissions, even though readmissions are something that people have at least been looking at for awhile. And it also seems like some of the efforts that looked promising initially have not proven to be sustainable. I realize it’s 2010 data, so maybe things have changed from there. I’m wondering whether there are examples of programs or approaches that had been shown to work well over extended periods of time.
Weiss: When we released the report, we featured a couple of models that do seem to have been picked up widely enough that I think it gives us hope that they can sustain their progress.
One is the Care Transitions Intervention, widely associated with Eric Coleman, a physician at the University of Colorado. It’s a four-week program with a transition coach who helps patients with complex conditions manage their medications and helps them know what to do when their condition gets worse. This has been picked up by about 750 organizations, including 34 who are a part of a major Medicare initiative, the Care Transitions Program. I have not seen specific data, and obviously, it hasn’t been years since this is in place. but the degree to which it has been picked up is pretty promising.
The other program that we featured is the Transitional Care Model developed by Mary Naylor (a nurse at the University of Pennsylvania) along with her colleagues. They provide very comprehensive training in the hospital and then follow up at home for chronically ill high-risk older patients. They use transitional care nurses. They have the skills of a nurse and the care manager and also a patient advocate. I know they’ve had a lot of very promising conversations with health plans and others. So again, I think that’s a sign that they are poised for the kind of sustainability you’re asking about.
I do want to make one other point about some of the programs that we’ve seen developed in communities that are involved in the Foundation’s signature initiative, Aligning Forces For Quality. This is the Robert Wood Johnson Foundation’s major effort to improve quality and reduce cost in 16 targeted markets around the country. And we’ve seen initiatives in places like Cleveland, Memphis, Maine and Oregon that haven’t been in place for a long time. We don’t have data that say that they’re sustainable, but the fact that they’re embedded in a larger community effort where there’s a great deal of transparency is promising. In many of these communities, there is a publicly available report online that compares hospital readmission rates.
They’re in communities that are working on payment reform, unbundled payments. They’re in communities that are working hard to build quality improvement infrastructure and to engage patients and families in demanding better care. I think that offers a lot of potential to sustain a good care transitions effort, although I can’t say today that we know that all these efforts will sustain themselves.
Williams: What can you say about individual patients and their families or caregivers who are perhaps in a region of the country that has above average readmissions, whether they’re in the Bronx or somewhere not quite as much of an outlier? Is there anything that an individual patient can do even in places where such programs are not in existence? And is there any evidence or do you have a sense of whether there are certain patients, perhaps those with higher levels of education or income, that are in a better position to make an impact on whether they are re-admitted?
Weiss: I don’t know from this study. We don’t know a lot about the specific characteristics of the patients. However, I think with rates that are this high, it’s not a problem that’s confined to patients who have low literacy or low incomes. I think if we talk about some of the things that patients and families can do, which I’ll mention in a moment, it suggests that these are things that can be done in a variety of socio-economic circumstances. So I don’t think it’s wholly dependent on family income or education level, although that helps.
The single most important thing we tell people to do is to ask questions, not to be afraid to bother the doctors and nurses and pharmacists, to keep asking until you understand the answer, and when you do get an answer to say it back, to repeat the answer to make sure you’ve understood it.
The second major area is to leave the hospital with a detailed written plan that covers two things — medications and appointments. So, a written list of medications with instructions about when and how to take them and a written list of follow-up appointments. The appointments are very important. If people have trouble making appointments or they don’t have a doctor, a family doctor, or the right specialist to go to, you can ask the hospital for help. And for both of these things, the medications and the appointment, I think it’s really important to involve a family member or a friend to make sure that they understand what could be done and they can help with things like transportation and making sure that you keep those appointments.
The last thing we tell people to do is to know what to do if you don’t feel well. Know the danger signs and know what you’re supposed to do if your symptoms got worse. I think it’s obvious that these things are more challenging for people who have low literacy or low health literacy. But I think all of them are things that any patient and family can try to become more engaged in.
I also want to mention that we have a great many tip sheets and other resources for patients at the website we set up for this initiative, which is called CareAboutYourCare.org. There’s a lot of information there that is really helpful for people from a very broad range of backgrounds and circumstances.
Williams: For a patient or a caregiver who is not currently contemplating a hospital visit, are there things that can be done perhaps structurally, and not just behaviorally, to try to make it less likely that a readmission would be needed? So for example, does it matter if a patient picks a primary care physician who practices as part of an integrated delivery network? Is there a difference in readmissions if the primary care practice uses hospitalists? Does it matter what type of health plan is used?
Weiss: Intuitively, it does seem that being part of an integrated system, your doctor being able to see you in the hospital, that those things should make a difference, but I have not seen data on this.
I will say that we conducted extensive interviews with patients and providers as part of the study and we did hear that the use of hospitalists can lead to more fragmented care, because the doctor isn’t always glued in to what happened in the hospital. That doesn’t mean that hospitalists are bad but it may mean that an intervention has to have an explicit step of getting the information back to the primary care doctor. And watching my parents in the health care system, I can’t think of how many times somebody threw a clipboard on their feet in the ambulance, and that was the extent of the information transfer.
Again, I haven’t seen information that compares the experience as patients in an integrated system or not. That does seem appealing, although we hope anyone who follows the weekly story about the safety implications of electronic health records can tell you that even in a completely integrated system, people miss pieces of information that were answered in one clinical setting and are relevant in another. So I don’t think you can let your guard down just because you’re in an integrated system. But you’re right, it’s promising.
And I know you said you wanted structural answers and not behavioral ones, but in my heart, I don’t think at this point in our health care system that there is a substitute for people understanding their conditions, understanding the behaviors that put them at risk, getting information that was proven to work, talking to the doctors, participating in making informed choices. And I don’t think we have the health care structure in the market yet that allows us to stop behaving that way as patient and consumers.
Williams: Fair enough.
So this sounds to me, Anne, like a problem that’s big, complex, perhaps even intractable. But the bright side of that might be some opportunities for entrepreneurs who are looking at ways to address elements of this readmission challenge. Any thoughts that you have for folks that are contemplating businesses in this area about where they might want to point their compass?
Weiss: A couple of things. I think the study does tell us that this is a local problem. And one thing we heard very strongly during all the public events was that you don’t pick something up in one market and just turn the key and it works in another market. Reinvention — what was it that somebody said — replication is reinvention. So, I think it’s important for entrepreneurs to think about that local market customization. That’s one point.
I think there is room for entrepreneurship across the continuum, whether it’s home care, whether it’s alternatives to the emergency department in the middle of the night, whether it’s new mobile technology. We heard from a patient who had a PDA that allowed him to answer five questions about his breathing condition every day; his nearest kin could monitor his status from afar and see how he was doing. So you could see all kind of mobile apps that could do that.
I think we have a payment system right now in this country where there’s a lot of financial rewards to a lot of people from the admissions. So for an entrepreneurial solution to work, it’s going to have to pay better or differently from readmission. The Medicare policy for readmission will start to rebalance that equation, but I think that’s a challenge.
The last thing I want to say is probably a little provocative to say to your readers. But I will say it anyway. I’ve been interviewed frequently about things like the company that provides care coordination to large employer groups. “If you get cancer, our company will come in and manage all your appointments and help you keep track of all the billing and everything.” And to me, that’s a symptom of what’s wrong with our health care system. And people will hold it out like, “Isn’t this great that we’re helping patients.” And I think that is true. I do think that a lot of the entrepreneurial opportunities have a lot of potential for improved care. But the problem we’re seeing here is a bad problem and my hope would be that we have a health care system that is patient centered enough that we don’t always need entrepreneurship to cure the ills that shouldn’t exist in the first place.
So I have mixed feelings about it but I do think that there are a lot of opportunities in the short run to make things better for patients and family.
Williams: I see on the motto of Children’s Hospital things like, “Until there’s no more childhood illness.” I think the children’s hospitals are busy trying to put themselves out of business. But they have no real fear of that happening in the near term. This may be something similar.
Weiss: Right, I mean it’s sort of like the argument we often have on primary prevention. And yes, we definitely can prevent a lot of chronic illness, but most cases of cancer are not preventable. We don’t know enough about them to prevent them. It’s a lot of things, so we still have a lot of room to make our health care system perform better and meet people’s needs. Some of the best opportunities right now, I think, are coming from innovative entrepreneurs.
So, in the short run, I think there is room for that. I just think it’s important for us to also keep track of the overall impact of the system on patients.
Williams: I’ve been speaking today with Anne Weiss from the Robert Wood Johnson Foundation. We’ve been talking about a new report on hospital readmissions and about RWJ’s Care About Your Care Initiative.
Anne, thank you so much.
Weiss: Thanks for having me.