Who needs to buy a risk assessment tool when me and my fellow case managers and nurses can tell you who all of the high-risk patients are before they arrive?!?
If you work in the hospital readmission prevention space, you have likely heard this before. And there is a lot of truth to it.
Risk assessment is just one of the tactics a hospital can use to reduce avoidable hospitalizations
. In the 2015 book Readmission Prevention: Solutions Across the Provider Continuum, I broke the prevention tactics up into three categories.
- Prevention Planning Phase One (PPP1): Before discharge
- Prevention Planning Phase Two (PPP2): After discharge
- Prevention Planning Phase Three (PPP3): The patient returns to the emergency room.
Separating the many tactics operators can use to prevent readmissions into three planning categories provides an efficient platform for acute and post-acute providers to focus on individual tactics that may be worth considering.
But first, a disclaimer…
Most tactics have not worked. That’s because of a lack of commitment from the top. The acute hospital industry is rife with investing all resources in the “problem of the month,” and then abandoning that effort just 60 days later to focus on the new problem.
And the new problem is almost always more of a priority than preventing readmissions. Why? The bottom line. Even with a 3% (of overall Medicare spend) penalty, the amount is just a ripple in the overall revenue of the hospital.
Prevention Planning Phase One (PPP1): Before discharge, focuses on all of the information that can be gathered while the patient is still in the hospital and it also includes tactics the hospital and care team can deploy before the patient is discharged from the initial hospital stay.
The initial hospital stay is referred to as the index stay. The readmission penalties implemented by CMS apply to Medicare Fee For Service patients (within the five disease categories) who readmit to any short-term acute hospital for any reason within 30 days of being discharged from a hospital. In short, the discharging hospital is penalized when a patient readmits to another hospital within 30 days of the discharge date of the index stay.
During the index day, the hospital has the opportunity to capture a significant amount of information about the patient. As electronic medical records become more mature in the healthcare setting, the hospitals must make it a point to consider this in gathering as much data as possible about the patient to prevent unnecessary readmissions. The most common form of data-gathering during the initial index stay is risk assessment. However, there is a tremendous opportunity to capture significant data about that patient well beyond just risk-stratifying them to more accurately predict each patient’s likelihood to readmit based on their overall health and care plan.
For example, family members often provide critical data that would never appear in a medical record. Pertinent patient input and information is often not documented or even appropriate to be included in the medical record. While risk-stratification might be the most commonly implemented tactic used to combat readmissions before discharge on the index stay, those hospitals that are truly taking this issue seriously are going to great lengths to educate the patient (and family) and capture as much data as possible about the patient while they have them in-house.
Make Risk Assessment a part of your structural DNA
I used to joke that every emergency room should have a siren that goes off every time a patient that is a readmission candidate presents (shows up at the emergency department). While the point was made, having a notification system when a high-risk patient presents remains critical – but this should be automated in your electronic medical record system.
The most important thing hospitals can do to address the readmission penalty is capture as much data as possible about the patient at each patient encounter. This is becoming much easier with the integration of electronic medical records both in the hospital and the physician’s office.
Once collected, the hospital then uses a risk assessment tool to interpret the data. Hospitals across the country have turned to different solutions to conduct risk assessments. While many hospitals conduct a risk assessment by hand or with nurses and other employees, there have been many software packages that have (more recently) proven to effectively and efficiently risk-stratify patients, and these software packages will likely become the norm in the near future as hospitals begin to prioritize and set aside funds for population management efforts.
Regardless of the method that a hospital or health system chooses to conduct a risk assessment, it is critical that patients who are at a high risk to return to the hospital be identified as soon as possible.
When Risk Assessments Work
Assuming these assessments become a part of the structured in-take process they work when:
- It’s automated and does not rely on human
- both quantitative and qualitative (input from family, clinicians, doctors, and caregivers) input are included
- the health system or insurer separates high-risk candidates and assigns them to a different case manager or social worker
Many health plans are now creating separate pods for high-risk patients that reimburse more and provide additional resources as well. Interestingly, it is often the mid-to-high risk patients that sneak up on a hospital and cost them more than the high risk as many health systems do not employ resources or a plan for the mid-to-high risk. Thus, have a plan for both categories.
Risk-stratification will become an almost completely automated process and is one of the key components all hospitals should use in identifying those patients who are high-risk to readmit.
When Risk Assessments Do NOT Work
When a hospital or health system relies on humans to do the risk assessment. Why? Human nature. Prioritization. It’s the last thing a nurse or social worker wants to do each day as it is laborious and has no immediate benefit in many cases.
If you choose to utilize risk assessments:
- Have a plan
- Automate the assessment into your EMR
- Include quantitative and Qualitative date
- Have specific categories for each based on their score
- Flag their charts so the EMR and ED staff are alerted anytime they are in the hospital or at the doctor’s office
- Allocate resources and at least one staffer whose full-time job is case managing those patients
- Routine check-ins with the patient, at a minimum weekly phone call or text
- Commit to the plan, which means committing budget and resources