Feature There's No Place Like Home: Reducing Hospital Readmission Rates PTs are playing an important role in reducing patient readmissions to hospitals. They could play an even a bigger one. Here's how. By Eric Ries | November 2015 In the pages of Physical Therapy last November,1 a physical therapist (PT) and a clinical psychiatrist asked the question, "Physical Therapy Information: Could It Reduce Hospital 30-Day Readmissions?" Their response was an emphatic "yes." "Physical therapy provides a unique information-bearing relationship in the hospital setting," observed Jennifer Kreppein, PT, and Thomas Stewart, MD. "It involves hands-on, personal treatment often delivered by the same individual or team, which is an increasingly rare component in fragmented, technology-driven health care delivery." In addition to providing such relevant information as mobility and balance observations, "Of paramount importance," Kreppein and Stewart wrote, is that patients tend to share with PTs pertinent personal details "that could inform discharge planning and re-admission risk." "Who knows their risk," the authors observed, "better than the patients themselves?" Such self-assessment "is not big data," they acknowledged, "but it is personal and actionable information." Physical therapy, Kreppein and Stewart noted, "contributes to patient education and discharge planning, and can contribute to reducing readmission risk through narrative [information], plus quantitative data such as mobility and balance." In a response letter to Physical Therapy this February,2 Jim Smith, PT, DPT, MA, and Anita Bemis-Dougherty, PT, DPT, MAS, endorsed Kreppein and Stewart's view. They wrote that the role of PTs in reducing hospital readmissions is "timely and important," given the existence since 2013 of the federal Hospital Readmissions Reduction Program. That program imposes payment reductions on hospitals considered to have excessive readmission rates for Medicare patients. The program was created in response to the fact that, as noted on APTA's Hospital Readmissions webpage (www.apta.org/HospitalReadmissions/), nearly 1 in 5 Medicare patients—2.6 million senior citizens—discharged from hospitals are readmitted within 30 days, at a cost of more than $26 billion annually.3 Smith, a past president of APTA's Acute Care Section, and Bemis-Dougherty, the association's vice president of practice, cited as a "strong endorsement" of their views a 2011 acute care study4 that concluded, "Holding all other variables constant, a patient was more likely to be readmitted when the therapist discharge recommendation was not implemented and services were lacking," compared with instances in which PT-recommended steps were taken. In their letter, Smith and Bemis-Dougherty expressed concern that "the voice of the physical therapist too often is missing in the discharge planning process"—for reasons that may include staffing reductions that decrease physical therapist services among some inpatient populations and instances in which PTs' discharge plan recommendations are not accepted or followed by other members of the health care team. (One recent study of discharge orders at a large academic hospital5 strongly suggests that such concern is valid.) "Our personal recommendation," Smith and Bemis-Dougherty wrote, "is that advocacy by physical therapists practicing in hospitals is needed to raise the therapist's profile in the discharge planning process." In fact, in a variety of care settings across the United States, PTs are answering that call to action—ensuring that their voices are heard and that physical therapy plays a key role in decreasing the personal and economic costs of preventable rehospitalization. Joint Initiatives Pauline Flesch, PT, MPS, is the executive director for rehabilitation services at Indiana University Health. A couple of years ago, there was "kind of an 'aha moment,'" she says, when the health care system's wound care-specialist PTs and wound ostomy nurses realized that a flaw in the physician referral mechanism was causing needless delays, with negative implications for optimal patient care. "What we discovered on the inpatient side of patient care was that we were duplicating some efforts and delaying service because physicians weren't always sure who was the right provider at the right time when it came to these 2 groups," Flesch recounts. "So, for example, if a referral went to the wound ostomy team but the patient didn't have an ostomy or fistula but, rather, a type of wound that should have gone to our PT wound team, the referral might not make it to the PTs until 24 or 48 hours later." When the 2 groups sat down together, "everyone recognized the benefit to the patient of working in unison to triage all wound referrals," Flesch says. "Now, all patients requiring wound care come to 1 place. We've decreased duplication by at least 25%, and we also know quickly which patients need the services of both teams. This collaboration has had a great impact." For patients and PTs, that impact has extended beyond inpatient care, Flesch notes, with significant implications for decreased readmissions. "It absolutely has heightened awareness throughout IU Health of the important role of wound management PTs," she says. "The long-term goal now is to achieve the same standard of care throughout all our facilities by modeling similar collaboration between our CWS [certified wound specialist] PTs and WOCNs [wound ostomy certified nurses]. This collaboration started with the inpatient population, and we recently integrated a WOCN into the physical therapy outpatient clinic to treat appropriate patients." In fact, in what Flesch calls "recognition of the great work being done by physical therapists who are certified wound specialists," IU Health spent about $1 million to double the size of the outpatient physical therapy wound program. "We've carved out a space and time during the week in 1 of our clinic rooms where ostomy nurses can join our outpatient team and assist patients who will benefit from their services," she noted. The result, Flesch says, is that, "If a patient still has a complicated wound upon discharge from the hospital, we're staying on top of that." The data bear that out. "We're keeping track of patients who we believe have avoided hospital readmission as a result of these outpatient efforts," she says, "One recent month, the outpatient wound team performed 56 new patient evaluations. We determined that 35 of those patients might have been rehospitalized or required an emergency room visit if not for the efforts of the outpatient wound team." At Providence Health Systems in Oregon, meanwhile, a number of steps are taken to ensure that PTs are optimally engaged in ensuring patient safety and guarding against unnecessary hospitalization, says Cathy Zarosinski, PT, MS, the health care provider's director of regional rehab operations. These steps begin at the hospital and continue through transitional settings and home care. She cites as an example Providence patients who have undergone total knee replacements. "We were finding that the overall readmission rates for those individuals was rising slightly, with a number of patients being readmitted about 2 weeks after discharge," Zarosinski says. "We looked into it, and we found that the primary reason people were being readmitted was that they were falling at home." Providence accordingly stepped up efforts to get patients who've undergone total knee replacements into outpatient therapy after discharge, "to improve their range of motion and make sure their balance is where it needs to be." Some physicians may be reluctant to order post-discharge physical therapy, Zarosinski acknowledges, but both hospital and home care PTs educate patients and families on the risks, "empowering them to insist on outpatient physical therapy—particularly if the person who's had the knee replacement is at all fearful of falling. Because," she says, "the patient who is scared of falling will fall. It's inevitable." This complements other, longstanding initiatives at Providence to limit falls risk. "We have built into our medical record a question that's asked of every patient on every physical therapy evaluation: 'Have you had any falls in the past year?' A 'yes' response triggers a complete falls-risk assessment," Zarosinski notes. PTs meet before discharge with all patients who've had joint replacements. "We train the patient and the caregiver on all aspects of safety—safe transfer, safe and proper use of assistive devices," Zarosinski says. "We work hard to instill in patients confidence that they can do everything we need them to do. It's paramount that we make sure the patient and the caregiver understand the exercises we're prescribing. We demonstrate proper transfer and ambulation techniques to caregivers to make certain those are understood, as well." Those things happen at the hospital. Providence is equally committed to ensuring that no nuance is lost in the patient's transition from hospital to home. "Our home care therapy department gets the notes from the patient's treatment sessions with the PT at the hospital, and the PT's contact information," Zarosinski says. "So, the home care PT is aware from the start of any particular concerns." Home-health PTs, furthermore, conduct a safety check to guard against potential hazards, such as throw rugs or ill-placed furniture. They also "reinforce how frequently patients should be getting up, show patients how to use shower benches, ensure that the tub is set up properly, and can call in an occupational therapist for help with a particular matter, if needed," Zarosinski says. "It's all about reducing falls risk—keeping patients safe and out of the hospital." Domestic Pursuits Theresa Gates, PT, COS-C, emphatically stated her position on the role of home-health PTs in reducing hospital readmissions when she named her presentation at APTA's 2014 Combined Sections Meeting (CSM) "We CAN Keep Our Patients At Home!" Gates is the chief executive officer of Beyond Home Health Care Services, based in Jacksonville, Florida. At CSM, she cited the importance of seamless handoff communication between and within care settings (see the link to APTA's position on that on the Hospital Readmissions webpage), incorporating disease-process teaching into interventions and goals, being attentive to medication reconciliation, taking advantage of evidence-based care-transition toolkits (see Resources box on page 20), and changing the culture of home health agencies to help reduce readmissions. In an interview with PT in Motion, she elaborates on those themes. "When a patient comes home, there needs to be a paradigm shift in the PT's mind," Gates says. "The goal no longer is to 'ambulate 200 feet with min assist of rolling walker.' The goal now is to keep that individual out of the hospital. We must start with that end in mind. What is the goal of health care reform? To provide quality care at reduced cost. How do we do that? By keeping people at home and avoiding unnecessary rehospitalizations." "If you start with that goal," Gates continues, "sure, as a PT you're still focused on helping patients ambulate functionally and safely in the home. But what are the other factors involved in reducing the risk of hospitalization? Studies have shown that medication errors are a leading cause of rehospitalization. Well, every clinician is responsible for medication reconciliation. Read the hospital discharge instructions and education materials the patient has been given. Ask nurses questions related to adverse events. Read the materials on drug-to-drug interactions that are available on most electronic medical records. And then, if you see that individual eating a high-sodium meal when you know that person has been placed on a low-sodium diet, speak up and intervene. Coach the patient on how proper nutrition can reduce the risk of rehospitalization." Home health PTs also must be able to determine the causes of nonadherence to medications that ultimately affect a patient's functional status, Gates says. "For example, why might a person with diabetes have difficulty managing his or her own medication? The reason may be functional—gross- or fine-motor ability—or cognitive, or both. Our occupational therapists conduct cognitive assessments to help determine the patient's learning mode for self-managing medications. PTs or OTs can work with patients on motor skills." "Or, take a patient with COPD [chronic obstructive pulmonary disease]," Gates says. "The PT needs to be knowledgeable about such things as oxygen saturation rates, lung sounds, and intermittent claudication with resting pain at a level of higher than 4 out of 10. Your goal as a home care PT for a person who has COPD may not be 'walk 50 feet with min assist of the rolling walker.' The role of home care PTs is to coach patients to maintain or increase functional mobility without increasing signs and symptoms of an acute exacerbation. So, in the example of the patient with COPD, it would be more effective to progress him or her with ambulation while monitoring and managing breath sounds, oxygen saturation rates, and pain-scale levels before, during, and after activity—gradually increasing activity tolerance while managing the biomedical aspects of his or her care." At Beyond Home Health Care Services, the expectation that PTs will recognize and address readmission risks is conveyed from the get-go, during the interview process. "Part of our interview process is to ask the clinician, 'How many of your patients were readmitted to the hospital in the past week?' Because we need to hold all clinicians accountable for their role in reducing and avoiding readmissions," Gates says. "Not only should home care PTs know which of their patients were readmitted, but they should know the reasons why, and whether the readmission was potentially avoidable." Readmissions accountability starts with leadership, she says—with expectations outlined and needed resources and tools provided. "Reducing readmissions is a team approach, and constant, consistent, interdisciplinary communication is essential," Gates emphasizes. "The expectation should be that all clinicians are discussing the biomedical and psychosocial aspects of the patient's care and are working together at all times to anticipate and appropriately respond to any adverse changes." PTs' expected role in helping to reduce rehospitalizations literally is written into their Beyond Home Health Care Services job description—as is a requirement that every PT participate in case studies that look at why selected patients were rehospitalized. "Every PT has to be able to identify which rehospitalizations were preventable and which were not," Gates says. "It's a culture of continuous quality improvement that our referring hospitals expect. When a hospital sends us a letter asking why 3 of the 8 patients it sent us last month went back to the hospital, I need to be able to respond, "You're right, Mr CEO. We sent 3 patients back. Two of those readmissions were unpreventable. Both patients had strokes. But the other readmission was avoidable. The patient had a urinary tract infection. There were signs and symptoms our team should have caught and acted upon. Here's what we did about it, and here's our improvement process." Although the home care setting is not currently subject to penalties under the Hospital Readmissions Reduction Program, such sanctions surely are coming, Gates says. She has 3 words for that inevitability: Bring it on. "We should be held accountable," she reiterates. The feedback she gets from her PTs is that Beyond Home Health Care Services' emphasis on preventing readmissions is making them better "holistic clinicians" in a day and age when "many patients no longer come home medically stable." That postdischarge need for medical management, Gates says, "elevates the physical therapy profession to an extremely important position in readmission-reduction efforts." Rules of Engagement When it comes to the role of PTs in preventing unnecessary patient rehospitalizations, the key words are "activation" and "engagement," says Alice Bell, PT, DPT, GCS, given that a significant component of evidence-based practice is inclusion of the patient's goals and values. Bell is vice president of clinical services and care design for Genesis Rehab Services, which provides physical, occupational, speech, and respiratory therapy, as well as wellness services, to patients in 46 states and the District of Columbia, in settings ranging from skilled nursing and assisted living facilities to home health. "I think PTs largely are teachers and educators. We bring a unique skill set in terms of addressing physical limitations and various pathophysiologies," Bell says. "But our goal is to create a situation in which patients begin to assume greater responsibility, and gain greater control, over their own health and wellness, and management of their own care." Genesis has incorporated the Patient Activation Measure, a commercially available questionnaire that assesses patients' knowledge, skill, and confidence for managing their own health. "All clinicians working with the patient need to understand at the outset exactly how in-control this person feels," Bell says. "The engagement piece, then, involves tapping the talents of each member of the therapy team to positively influence activation. The interventions we use as therapists to address activation include providing information in the ways in which patients and family members will best understand and absorb it, facilitating compensatory strategies, and working to restore function and movement. It's that whole interrelated intervention strategy that is so important." Making sure the care recommendations and observations of PTs and other providers are not lost or overlooked during patient transitions between and within care settings is critical, Bell adds. She says 2 keys to bridging potentially harmful gaps in provider-to-provider communication are leveraging technology and personal relationships. At Genesis, "We share all our data and information electronically among providers, but we also encourage more reaching out by telephone," Bell says. "We bring providers from one setting into another, as well. For example, we include the home health provider as part of the team in the skilled nursing facility when the patient is first admitted, rather than at his or her discharge. The handoff when the patient goes home is more likely to be seamless," Bell notes, "when a relationship already has been established between the home care PT and the patient—as well as between the 2 PTs." Care standards throughout the Genesis system regularly are reviewed by an interprofessional management team that features representatives from rehab, nursing, and medical services, Bell says, and comprehensive assessments are conducted on patients to determine who is at highest risk of adverse events and, potentially, rehospitalization. "We continually modify our risk assessment tool based on the evidence we gather," Bell says. "We've incorporated the Modified Barthel Index of Activities of Daily Living to better understand the degree of caregiver support the patient will need when he or she returns to the community from an interim care setting." Bell is a strong advocate of the use of "meaningful tests and measures" by PTs as tools for achieving optimal patient outcomes and avoiding needless rehospitalizations. "And I'm not just talking about the traditional tests and measures that PTs use," Bell emphasizes. "Again, Genesis integrates the Patient Activation Measure. Our PTs also look at things like the Flacker scale, which gauges factors associated with 1-year mortality. And there are many tests and measures that nurses and physicians use that can yield a lot of useful information for PTs. Look at the Braden or Norton scale, for example, which both measure pressure sore risk." Physical therapy, Bell observes, can "move the needle not only on tests and measurers that are specific to PTs, but also on tests and measures that are more global in terms of their predictive ability around risk. Which is why it's important for us to quantify the impact of the care we are providing." Narrative Nuances Jim Smith, who, with Anita Bemis-Dougherty, signed that letter to Physical Therapy about the value of PTs' discharge recommendations in preventing rehospitalizations, cites in particular the importance of PTs eliciting and conveying to other members of the health care team the patient's complete "narrative." Meaning, the patient's detailed account of the circumstances surrounding his or her need for hospitalization in the first place. He gives a couple of examples from his clinical experience. "An older woman had fallen in the assisted living facility where she resided, requiring hospitalization," Smith recounts. "I was determined to get at the root of the precipitating factor—what truly had caused the fall—because the answer to that question might well help prevent a future fall and potential rehospitalization. It turned out," he says, "that she'd experienced urinary urgency and then had slipped on her own urine. It took some effort to get the full story, but by respectfully but insistently asking the necessary questions, a full picture emerged. That led to a referral for urogenital physical therapy interventions that reduced the woman's future falls risk." Another former patient of Smith's was recovering nicely from surgery for a hip fracture but, as the time approached for her to return home, her progress stalled. "She became very tentative," Smith says, "Something was happening that wasn't a physical issue and wasn't readily apparent." He asked a series of questions and learned that the woman, who lived with her daughter, had fallen and fractured her hip when she'd bent over to give leftovers to the family's golden retriever. His patient, Smith learned, was "terrified of needing to get around with a walker with the dog underfoot," but had been loath to communicate that to her daughter. Smith did so for her. The family opted to gate the dog, ensuring that canine and family matriarch would always be separated. "Boom!" Smith recalls with a satisfied laugh. "My patient went home the next day. When I subsequently ran into family members in the community, they told me it had been an easy and perfect solution that made everyone—especially my former patient—feel safer." Smith, an associate professor of physical therapy at Utica College in New York, heard a lot of "frustration" during his tenure as president of the Acute Care Section that the care-transition recommendations of PTs often were being questioned or overridden by other members of the health care team during discharge planning. It is important, he says, that PTs advocate for their patients in 2 key ways to best ensure optimal outcomes and reduced readmission rates. "First, our evaluation of where patients should go upon transition from the hospital, and the supports they'll need to be successful in that environment, is valuable input—it's the product of our evidence-based expertise as PTs," Smith says. "We should, therefore, promote it confidently. And second, we must be prepared to defend our findings, laying out our reasoning and the evidence behind it with a conviction that the care team will respect and that payers will acknowledge." Another important aspect of care transition is having difficult but necessary conversations with patients and family members about what's going to happen when the patient comes home. "It can be frustrating for the patient and his or her family when all they want to focus on is having the patient back home—and not what it's going to take keep him or her there," Smith acknowledges. "But the PT needs to lay all of that out. 'We need to work on getting [the patient] in and out of the car.' 'We need to address hygiene—who's going to assist with toileting?' Those aren't easy discussions to have, but we need to have them so the care transition is safe, and so the patient doesn't bounce back to the hospital because of a problem that should have been addressed and avoided." A Place at the Table "Even 5 years ago, 'readmission' was not a buzzword you heard in the quality-reporting sector for health care," notes Heather Smith, PT, MPH, director of quality at APTA. "It started with the Hospital Readmissions Reduction Program of the Affordable Care Act. That was the beginning of a growing readmissions focus in this country. I do think in the future we'll see measures like these migrate across the payer base. Given their enormous costs, unnecessary readmissions are something payers want to avoid." There are economic costs, of course, but to Anita Bemis-Dougherty, curbing unnecessary readmissions is a matter of eliminating preventable barriers to the health and well-being of patients. It's about practicing patient-centered care and living up to APTA's vision for the physical therapy profession: "Transforming society by optimizing movement to improve the human experience." "The role of physical therapy in avoiding preventable rehospitalizations is huge," she says. "No providers are better suited than are physical therapists to determine where patients should go from acute care, nor to help them be successful in that new setting. We talk about improving the human experience. Part of that, for our patients, is staying healthy at home and avoiding the infection risks and other potential hazards that accompany rehospitalization." "That's why," Bemis-Dougherty continues, "you want PTs to be at the table in any kind of discharge planning—and to be involved in high-level decision-making centered on readmission-prevention at hospitals." Eric Ries is associate editor. He can be reached at firstname.lastname@example.org.