Hospitals have little or no control over some factors related to their readmission rates, such as poor access to community health facilities outside of the hospital in socioeconomically disadvantaged areas. Nonetheless, hospitals in underserved communities are penalised when high readmission rates trigger reductions in Medicare reimbursements. Community-focused efforts could help to reduce hospital readmissions by improving access to quality care beyond the hospital setting.
An editorial written by Teryl K. Nuckols and published in Health Services Research addresses variation in readmission rates at the local level, largely based on the findings of a 2014 study by Herrin et al. entitled “Community Factors and Hospital Readmission Rates”. According to that research, readmission rates for individual hospitals frequently reflect variables within the community that are beyond the control of the hospitals, such as citizens’ access to outpatient care.
Hospital Readmissions Reduction Program
In recent years, the Hospital Readmissions Reduction Program (HRRP) was introduced in the US in response to concerns that between 15 and 20 percent of older adults who are discharged from hospitals are readmitted soon thereafter. These readmissions and their associated expenses may be avoidable through improved care and discretionary criteria.
HRRP was implemented by the Centers for Medicare and Medicaid Services (CMS) at the end of 2012 for fiscal year 2013. The program penalises hospitals for exceeding expected 30-day risk-adjusted readmission rates for older adults (aged 65+). 70 percent of hospitals incurred a penalty in the first year. Medicare payments were subsequently reduced by 0.31 percent, which is considerable since Medicare patients represent 40 percent of hospital discharges.
More Than Half of Variation Explained By Location
Despite readmission rates of Medicare patients falling since the implementation of HRRP, Herrin et al. noted that most of the differences in readmission rates among individual hospitals is tied to factors beyond the control of the hospitals. Specifically, a hospital’s county explained 58 percent of the variation. Counties vary in outpatient and postacute care quality, and citizens’ access to such care. The availability of nursing homes and primary care physicians within counties have an inverse relationship with hospital readmission rates.
Given those facts, a nationwide reduction in readmission rates would necessitate widening the focus from individual hospitals to incorporate local health systems where patients can seek and receive care both before and after hospitalisation. The CMS is currently experimenting with a pilot project called Community-based Care Transitions Program, running from 2011 to 2016; as of May 2014, there were over 100 participating sites. The program is part of Partnership for Patients, which seeks to reduce preventable medical errors and hospital readmissions.
The 2014 study by Herrin et al. also reported higher rates of readmission in hospitals which have a relatively greater number of beds per capita. The relationship between bed availability and hospital admissions suggests that discretionary readmissions may be more common at hospitals which have the capacity to take in more patients. Thus, differences in the clinical criteria that providers use to readmit patients may further explain some of the variation in readmission rates by geographic area.
Striving For Equity
Other ways for hospitals to curtail high readmission rates may be negatively associated with operational success. For example, readmission rates would fall for an individual hospital if the hospital avoided the admission of high risk patients, delayed readmission until after 30 days, or kept patients under observation instead of admitting them. However, such choices would conflict with the intentions of HRRP to reduce readmissions and costs through improved care within communities.
Ensuring equitable care for vulnerable populations is another goal. Notably, Medicare beneficiaries are often more likely to require continued care because of medical comorbidities, lack of self-management abilities and lower socioeconomic status. Due to their advanced age, they may be more likely to live alone or have a lower functional status. Previous research has tied higher readmission rates with higher numbers of Medicare beneficiaries per capita, which could make it especially difficult for facilities in low-income areas to reduce the rates of hospital readmissions.
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