Continuing coverage
Springfield News-Sun reporter Tom Stafford has followed quality of patient care at Springfield Regional Medical Center for months.
Medicare will withhold more than $120,000 in reimbursements from Springfield Regional Medical Center for the second straight year because the hospital readmitted more patients after initial treatment than Medicare says it should.
The penalty is authorized by the Affordable Care Act, which many call Obamacare. It represents about half a penny (0.56 cents) on the dollar of the money Medicare reimburses the hospital for care of Medicare patients.
A Springfield News-Sun comparison among eight hospitals in the region showed Springfield Regional’s penalty rate was second highest to Dayton’s Good Samaritan Hospital.
In an official statement about the penalty, the hospital called its readmission rate “an issue we’ve already been addressing the past few years and are obviously improving. We have made a significant investment in resources to ensure the most vulnerable patients get the help they need to remain healthy and avoid hospital readmission.”
A nudge to hospitals to improve their care, the program empowered Medicare to withhold up to one percent of its reimbursements to hospitals with readmission problems last year, two percent for the coming year and three percent beginning in October 2014.
Medicare reported Springfield Regional’s biggest readmissions problems involved cases of pneumonia, which were about 13.8 percent above what it says are expected for a hospital of Springfield’s patient profile.
Medicare said the hospital’s readmission rate for heart failure patients was 5.4 percent worse than its peers, while the rate of readmission for heart attack victims was 2 percent better than others.
The period Medicare used to calculate the penalty rates for this year and next was a difficult one for the hospital, a time after Community Hospital and Mercy Medical Center merged, and while the current facility, which opened Nov. 13, 2011, was being built.
During that same time, the hospital’s patient satisfaction scores plunged but have been slowly recovering.
Premier Inc., which collects data from Springfield Regional for Medicare, indicates the hospital has made progress on its readmission problem more recently.
The reporting group said the readmission rate for all causes here fell from 14.8 percent in 2011 (slightly above the Medicare benchmark) to 13.46 percent in 2012 (slightly below the benchmark). So far in 2013, Premier reports the readmission rate at 13.83 percent, which it said is “exactly at” the benchmark expectation.
The rate of the penalty, which takes effect in October for the next fiscal year, is identical to the one Medicare imposed on the hospital this year.
Springfield Regional reported that the 2014 penalty will be about $121,000, $3,000 less than than the current year’s penalty.
The Medicare penalty program has itself had some setbacks. In 2013, it made two changes to the penalties imposed on hospitals after its initial announcement.
Critics of the Readmissions Reduction Program — including those who advocated for its creation — have said that it unfairly penalizes hospitals serving poorer patients, those who are at higher risk for readmission because they lack alternatives to hospitals for places to get health care.
Springfield Regional staff say their work on the readmissions issue is also moving not only the hospital but the wider community in the direction being shaped by the Affordable Care Act.
“I think electronic medical records have helped a lot,” said Susan Moeller, manager of quality and case management at Springfield Regional.
One benefit is that the hospital, doctor’s offices and some extended care facilities are working off the same electronic records, lessening the chance for error when care is shifted from one to the other. At those times, patients in vulnerable health are at risk for more problems if their medications and treatment orders are jumbled.
Simply having printed rather than hand-written notes “we’ve seen a decrease in errors,” said Karen Gorby, administrator/chief nursing officer at Mercy Memorial Hospital in Urbana, a part of Community Mercy Health Partners.
The hospital also has tried to decrease readmission rates by improving the information it gives patients on how to care for themselves after discharge.
“That’s a huge piece in our readmissions effort,” Gorby said.
In addition to aiming the written material to the 6th grade reading level so more can understand it, Springfield Regional has started a “Teach Back” program in which patients repeat their understanding of what care they need to nurses as a check on their understanding.
Another part of the program is a so-called stoplight model that teaches patients how to know whether their recovery is going as expected (green light), when something is going on they should discuss with a doctor or nurse (yellow light), when they should return to the hospital for immediate treatment (red light).
As part of this effort, the hospital has put together standard information packets for patients going home after treatment for heart attack, congestive heart failure, stroke, pneumonia, diabetes and chronic obstructive pulmonary disease (COPD).
“The other piece we look at is the circle of care” for patients after discharge, Gorby said, whether the patient goes home or to an extended care facility.
Eventually, the goal is to tie the facilities in to Springfield Regional’s electronics record system to bypass issues that arrive when information is faxed.
The hospital also is trying to develop closer relationships with the extended care facilities. One reason is to make it easier to arrange places for patients to be cared for who no longer need to be in the hospital but can’t care for themselves at home.
Another is that if those facilities err in their care, the patient often ends up being readmitted to the hospital. The relationship also is likely to prepare long-term care facilities for future Medicare requirements.
Said Moeller, “Coming down the pike, the physician and the long-term care facilities are going to be held to the same standards we’re being held to as a facility.”
Springfield Regional has started holding a series of monthly workshops at extended care facilities targeting issues related to readmission, including infections and sepsis.
Often patients readmitted from nursing homes because of such problems “don’t do well,” said Moeller, so poorly “they usually die within 48 hours.”
Springfield Regional has also created “The Conversation Project,” encouraging extended care facilities to discuss end-of-life care issues with patients for whom continued hospitalization may not extend their lives and for whom hospice and palliative care at home or in an extended care facility might be more appropriate and less expensive.
The hospital is also trying to troubleshoot for readmissions at two internal locales.
One is the Emergency Department. The hospital created an emergency department case manager to work with staff, patients and physicians to line up outpatient resources, financial or other things needed to get patients the care they need and avoid situations where the choices end up either admitting a patient or sending the patient home when neither is the right thing to do.
The second location is the patient’s bedside, where nurses are identifying patients at higher risk of readmission before they’re discharged. The goal is to determine whether supporting them outside the hospital with other services might prevent a readmission.
Moeller said higher-risk groups include the elderly, “especially if they’re living at home and don’t have a good support system,” and those who have been hospitalized for heart attack, congestive heart failure, stroke, pneumonia, diabetes and COPD.
The hospital said higher readmissions rates also are experienced by patients who lack money, transportation and family to help with follow-up care; who fear having people come to their home to provide the required help; and who choose not to follow advice about taking steps to improve their health.
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