What happens after a patient is discharged from the emergency room? A decade ago, hospitals had no idea. But under the Affordable Care Act, also known as Obamacare, hospitals are now responsible for patient health beyond their four walls – and they can be penalized with lower Medicare and Medicaid reimbursements depending on the outcome. To achieve lower readmission rates and good quality patient follow-through, hospitals must integrate their systems with patients’ primary doctors and skilled nursing facilities, rehabilitation centers and other places patients go after a hospital visit. Oakland-based Kaiser Permanente Inc., which has medical centers in Panorama City and Woodland Hills as well as several locations throughout the greater Valley region, has had less issues with integration as their hospitals, doctors’ offices, pharmacies and other facilities are all under the Kaiser umbrella. “We’re aligning the goals of all our departments and services and are not having one group work on readmissions,” said Dr. Dan Huynh, regional assistant medical director for Kaiser’s Southern California medical group. “It’s care coordination at every level – everyone does their share.” Other Valley hospitals are also working on implementing similar coordinated services and record keeping across care providers. But in these cases, they have to develop partnerships with other health organizations, playing catch-up to compete with the Kaiser model. In addition, with President-elect Donald Trump about to take office, the rules of health care are expected to change. Yet, many hospitals are taking a wait-and-see approach until more information is available. “We are in an unpredictable time,” said Erik Wexler, chief executive of Providence St. Joseph Health’s Southern California market. “With a lack of predictability, it’s hard to make the proper preparations. So we are keeping a close eye on what we hear not only from the Trump administration but from other elected officials, whether Democrat or Republican, but in particular from Congress.” Care continuum Before Obamacare, hospitals were not responsible for patient outcomes after discharge; it was the patient’s responsibility how he or she received care thereafter. Yet, the Affordable Care Act aimed to align hospital incentives with the incentives of post-acute care providers, like home health agencies, rehabilitation centers and long-term care hospitals. The purpose was to improve how patients fare after discharge, so they don’t have a return visit to the most expensive place to receive care – a hospital. The U.S. Centers for Medicare and Medicaid Services implemented two initiatives to accomplish this – the Bundled Payments for Care Improvement Initiative and the Hospital Readmissions Reduction Program. The bundled payments model establishes a financial relationship between the hospital and the after-discharge provider that puts the hospital in the “payer” position for the post-acute services. This forces the hospital to be financially responsible for related services a patient receives following a visit. The readmissions penalty is imposed on hospitals when a patient is readmitted within 30 days for certain conditions. For all Medicare admissions, reimbursements were 3 percent lower in 2015 compared to a 1 percent penalty reduction in 2013, according to a health policy report by New York-based financial advisor Deloitte’s Center for Health Solutions and Center for Regulatory Strategies. In Kaiser’s case, when a patient who has a high-risk of readmission is discharged from a hospital, a follow-up appointment is scheduled with his or her primary doctor within five days. In addition, the Kaiser member receives a call within 72 hours to address any medical concerns. If the patient has any questions after that initial call, Kaiser also provides a hotline number to handle additional concerns, which can be escalated to an on-call physician if need be. “We have seen our readmit drop 20 percent or more over the last couple of years,” Huynh said. Other hospital systems – such as nonprofits Adventist Health of Roseville and Providence St. Joseph of Renton, Wash. – are executing new programs to track patients with the aim of avoiding returns, lowering costs and improving patient outcomes. Adventist Health operates two Valley hospitals, Glendale Adventist Medical Center and Simi Valley Hospital. Glendale Adventist has joined a state pilot program where it sends out paramedics in cooperation with the city of Glendale to residences of discharged heart-failure patients to do home, safety and medication assessments. During the assessments, an aide will remove expired or nonrelevant medications as well as educate the patient. Adventist Health administers this program in cooperation with UCLA for its Southern California market and University of California – San Francisco in Northern California. “It has been about a year (since starting the program), and we are about to close out soon for results,” said Dr. Arby Nahapetian, chief medical officer for Adventist Health Southern California. “We’ve also taken some dollars and invested them into recreating this not just for heart failure but for other diagnoses through case workers and EMTs (emergency medical technicians), who work to do very similar things.” Furthermore, Glendale Adventist has added infrastructure to help patients get an appointment within ideally two to five days of discharge to decrease readmissions. However, if the patient cannot get an appointment within that timeframe, the hospital will refer him or her to one of its four urgent care clinics included in its system throughout the Burbank and Glendale area. Much like Kaiser has standardized record keeping throughout its whole system, Adventist Health has also streamlined and integrated its medical records to readily transfer the information between facilities. Providence St. Joseph, which has three Valley hospitals in Burbank, Mission Hills and Tarzana, has instilled similar follow-up procedures post discharge but has also invested in and strategically partnered with Encino-based Exer More Than Urgent Care. The chain, which currently has four Valley locations, has been expanding quickly, partially due to this collaboration, and just opened a clinic in Redondo Beach. “These centers are being developed in areas close to our hospitals, and we are educating patients and the public about them,” said Providence St. Joseph’s Wexler. The partnership allows both organizations to refer patients to each other, collect data, collaboratively measure readmission rates and jointly identify what’s causing them. Providence St. Joseph refers patients to Exer when an ailment does not require an emergency room visit as well as for follow-up appointments, ultimately reducing readmissions and costs. While receiving that patient traffic which adds business and prompts its ongoing expansion, Exer refers patients to Providence St. Joseph when the illness is serious enough for a hospital admission. “I think everyone is saving – hospitals, payers and patients,” said Wexler. “There are savings in the cost structure when patients don’t have to come back.” Other examples of Valley partnerships with similar aims include Van Nuys-based Valley Presbyterian Hospital’s collaboration with medical clinics Valley Community Healthcare in North Hollywood and Northeast Valley Health Corp. in San Fernando. The hospital received more than $1 million in grant money to implement a pilot program where the three entities integrate medical records and assign case managers to clinic patients at Valley Presbyterian. If a patient checks in for an emergency room visit at Valley Presbyterian, the system will notify the hospital if that patient receives primary care at Valley Community or Northeast Valley Health. From there, a case manager is assigned to the patient to help with all related follow up, including transportation, appointments and whatever else is needed to reduce the chance of readmission. Valley for-profit companies are working to implement similar efficiency processes as well. For example, Agoura Hills-based Casamba Inc., a health care software developer for skilled nursing facilities, just merged with home health software company HealthWyse of Boston and outpatient software provider for physical therapists TherapySource of Birmingham, Ala. The merged company aims to provide comprehensive, integrated software for the entire post-acute care continuum. Casamba believes by integrating all these software programs, the company will be able to track patients through the different phases of care as well as help providers better comply with regulatory requirements. Lagging legislation Prior to the Affordable Care Act, hospitals were not as strongly incentivized to coordinate care. Now, through the Hospital Readmissions Reduction Program as well as the Bundled Payments for Care Improvement Initiative, the U.S. Centers for Medicare and Medicaid Services are rewarding caregivers that follow through with patient care to ensure the patient is not readmitted for further complications. However, complying with these readmission and reimbursement laws have been huge hurdles for hospitals as there are so many variables out of their control. Providers say it’s hard for them to monitor patient habits outside of its facilities. But to receive equitable reimbursements, it’s a necessity that has to be addressed. “It’s a tremendous challenge, so much that there definitely is a link between higher readmission rates and markers of low socio-economic status,” said Jennifer Bayer, vice president of external affairs for the Hospital Association of Southern California. “If people don’t have access to primary care or mental health services, they are very likely to be readmitted. So many of those things are far beyond a hospital’s control. It’s an incredibly frustrating scenario.” In addition, analyzing patient data and assessing care and readmissions take time –sometimes years – until the hospital knows if it must pay a penalty or not. “From a penalties perspective, there is a huge disconnect,” said Adventist Health’s Nahapetian. “There is usually a two to three-year lag, but Medicare is working on shortening the timeframe.” With such long lag times, this begs the question, will the Trump administration transform health care right as hospitals are working to comply with current law? The Hospital Association’s Bayer believes hospitals will continue along this path as they are deeply vested in their communities and that any changes to Obamacare are going to take time. “To make some fierce assumptions that everything is going away tomorrow is not realistic,” she said. “The details will tell us which way we are going to fight and work together.” Meanwhile, hospitals continue to explore how to improve patient care outside of their facilities. Providence St. Joseph is providing $100 million in grant funding to improve access to mental health services, while Adventist Health and Kaiser are working on improving home health care. “Home is the new frontier,” said Kaiser’s Huynh. “You are going to see a lot of care that revolves around the home. Members are asking for that. So, how do we deliver care outside the boundaries of the hospital?”
