Crossroads Hospice and Palliative Care, a privately owned provider, has developed a program to support congestive heart failure patients and their caregivers, improve patient satisfaction, and potentially reduce costly readmissions.
Crossroads provides hospice and palliative care to approximately 1 million patients annually in Georgia, Missouri, Oklahoma, Pennsylvania, Ohio, Tennessee, and Kansas. The organization’s average daily census is 2,400, 74% of which are hospice patients.
The organization launched Heartlink in 2009 to provide support tailored to the specific needs of heart failure patients. The organization runs similar programs focused on patients with other conditions such as renal disorders and dementia.
“Reduced readmissions are an indirect benefit of the program. The goal is to address the concerns of the heart failure patient and empower them with the truth,” Tim Ihrig, MD, chief medical officer for Crossroads, told Hospice News. “We come to the home and educate them about the disease trajectory, symptoms, and systemic effects, as well as how we will address those. When you lead with care, and a proactive care plan, you help the patient overcome fear and misperception.”
Nearly 25 percent of heart failure patients covered by Medicare are readmitted to the hospital within 30 days of discharge, accounting for more readmissions than any other condition, according to the American Heart Association (AHA). Readmissions for all conditions cost Medicare upwards of $17 billion annually, AHA found.
For these reasons, the US Centers for Medicare & Medicaid Services (CMS) has been targeting readmission rates for several years, establishing a Hospital Readmissions Reduction Program that reduces payments to hospitals when a patient is readmitted within 30 days of discharge. Kaiser Health News in 2012 estimated this would lead to $280 million in lost revenue during the program’s first year.
While hospices are not subject to these penalties, readmissions do affect their bottom lines. CMS pays hospices a per diem rate for routine home care. When a patient returns to the hospital, those payments stop.
Effective patient education and communication can help reduce preventable readmissions. A 2016 study in the Journal of the American Medical Association identified a lack of discussion about care goals among patients with serious illness as a significant factor contributing to many 30-day readmissions.
“Generally speaking, our health care system often fails to educate patients and their families. Many are referred to hospice without a full understanding of what that means,” Ihrig explained. “We try to shift the narrative away from dying and come to understand what is most sacred to the patient, not only in terms of their death, but how they want to live their lives—even as they approach the end of life.”
Some readmissions occur simply because a patient is frightened or panicked. They may not understand what they are experiencing, call 911, and are transported to a hospital emergency department. In order for Medicare to cover care the patient receives as a hospital, the patient must revoke his or her participation in the hospice benefit.
Staff participating in Heartlink clarify to patients and caregivers that they can contact the hospice at any time, 24 hours a day, seven days a week, to ask questions or to receive support. Program staff also work with patients to address psychosocial concerns, such as feelings of stigma or guilt related to their condition—that heart “failure” is a physiological process and not a failure on their part.
The causes of readmissions are complex and don’t necessarily stem from deficient care. Some, but not all, are preventable.. As regulators scrutinize readmissions to control costs, hospice providers work to balance regulatory obligations with what is best for patients.
“Hospitalization is not antithetical to hospice care,” Ihrig said. “It is our belief that in the course of care for a hospice patient, sometimes you do have to use that resource. If hospitalization is consistent with the goals of care, I have no problem with it.”
A readmission may occur because a patient’s symptoms may worsen to a degree that necessitates hospitalization. Or the patient may present with conditions unrelated to their terminal diagnosis. If a hospice patient falls and breaks a bone, for example, they will need hospital care.
“We need a conversation at a higher level to bridge that chasm,” Ihrig said. “Regulators have stepped up oversight, and the industry as a whole is getting skittish. Regulators and payers need to sit down with health care providers and look at what happens in that space.”