Guest entry: Taking a stand for patient safety with the Hospital Readmissions Reduction Program

A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share.  The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics.  

This information in the form of a narrative blog post is provided courtesy of a graduate student who is interested in promoting increased awareness of impacts of the Hospital Readmissions Reduction Program.  Because the author only has fieldwork experience and the facility or patient could be possibly identified, with the student's permission I have conducted my standard 'ABC Therapeutics mash-up' of details and narrative so that the intent of the experience could be expressed while maintaining confidentiality. 

In school occupational therapists learn all about diagnostic conditions.  They also learn about ways that people might have difficulties with their occupations.  Occupational therapists also learn how to assess and treat those people so that their conditions will not limit them in the future.

Occupational therapists also learn that some conditions are acute, that some are chronic, and that some are progressive.  None of that really matters though because the best thing about occupational therapy is that knowledge about disability can be matched to the patient’s need, no matter where they are in this process.

That is how it is supposed to work.

These skills that I learned in occupational therapy school did not prepare me well to respond to the needs of one of my patients on my Level II fieldwork.  I completed my fieldwork at a large hospital and I saw people with common diagnoses including heart and lung diseases, joint replacements, and similar acute conditions.  Unfortunately, I learned that a person's care is not always determined by what I think is most appropriate as a professional.

The pace of work at the hospital was fast and the evaluations were simple, but functional.  One aspect of my experience that I did not expect was my work in the hospital’s emergency department.  When a patient entered the ED, the doctor would write an order for an occupational therapy evaluation. The occupational therapist would ask the patient about their home setup and prior level of function as well as have the patient complete simple ADL tasks and transfers. Throughout the evaluation, the occupational therapist would assess the patient’s cognition and safety awareness as well.  Was the patient able to safely complete essential ADL tasks? If not, the occupational therapist is responsible to document that the patient is functionally unable or unsafe to return home and must document appropriate discharge recommendations.

I learned that in October 2012, Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act, which established the Hospital Readmissions Reduction Program. This program was established with the purpose to reduce hospital readmissions – which is defined as an admission to the same or another subsection hospital within thirty days of an initial hospitalization.

The purpose of the program is to improve quality of care and to  reduce Medicare spending. Under this program, Medicare payments to many hospitals across the United States are deducted three percent to hospitals with ‘excess’ readmissions.  The program specifically looks at the kinds of diagnostic categories that I saw on my Level II Fieldwork, namely heart failure, myocardial infarction, pneumonia, COPD, THA/TKA, and CABG.

During my Level II Fieldwork, I evaluated many people; however, there is one person who literally and figuratively 'stands' out.

Mary came to the emergency department with complaints of severe pain in her hip after a recent hospitalization for a total hip arthroplasty. Mary is an active and healthy 66-year-old woman who had a big personality and even bigger life responsibilities.  She is a caregiver for her disabled spouse, watches her grandchildren during the week, volunteers at the local library, and enjoys socializing with her friends. She had a small physique, but her personality was oversized! She was very friendly!

"I have to be independent," Mary told me during the evaluation.  "My husband had a stroke and he needs me - and what would my babies do if I didn't watch them?"   I loved how she called them her babies, even though she was the grandmother!

During the evaluation, she had difficulty with simple dressing tasks using adaptive equipment.  She was also unable to transfer to or from the toilet. In fact, when asked to demonstrate, she unsteadily stood facing the toilet with her hands on the wall as if she was getting arrested and her legs apart straddling the toilet as if she was aiming at a target.

My immediate thought was, "How is this safe?  And if she is this unsteady, how is she able to do all of these other tasks safely?"

In fact it was not safe. I became very anxious thinking of all the things that could go wrong in this situation. Does the walker fit over her toilet at home? If not, does she rely on the wall for support? Where is the toilet paper located? How does she reach the toilet paper if it’s behind her? How does she keep her pants from falling to her ankles? If her pants fall, how does she reach them without breaking her hip precautions or losing her balance?  How is she caring for her husband or her grandchildren when she could not even safely care for herself?

Because of this, I recommended that she receive skilled services at the hospital and then transfer to another facility (SNF) for additional skilled services to maximize functional return and safety.  I based my recommendation on other patients that I saw who were in in the rehab program.  I thought that perhaps Mary just wasn't ready to be home, especially if she was supposed to be the primary caregiver for other people.

However, the hospital disapproved of my recommendation and this caused a lot of tension between the rehabilitation director and my supervisor.  That is not generally a situation that you feel comfortable creating when you are a Level II student!

The rehabilitation director, my supervisor, and myself all met to discuss the issue. It was apparent that the rehabilitation director was using this meeting as a ‘teaching opportunity’ since I was a student, as she stated, “this is the part of healthcare you don’t learn in college.”

This made me feel discouraged and defeated.

Despite my attempts to defend my recommendations, the hospital discharged Mary with a script for more pain medications and outpatient therapy services.

I believe that the hospital's decision to avoid readmission was influenced by the threat of reduced Medicare payments. During the meeting with the rehabilitation director regarding this issue, I was told, “it is cheaper for the patient to receive outpatient services.” I left the conversation feeling frustrated.

Whose needs were met in this situation - the patient or the hospital?

Instead of focusing on the patient and her needs, which we are taught to do in school, the hospital is focused on financial incentives or penalties. This not only affects the patient as it puts her at a higher risk for falls at home or other serious injuries, but this also affects the occupational therapist who is held accountable for discharge recommendations.

Overall, I understand the importance of reducing excessive and preventable healthcare spending, which is the primary goal of the Hospital Readmissions Reduction Program.  However, I believe that hospitals should not solely focus on the financial penalties imposed by the Centers for Medicare and Medicaid Services (CMS) nor that occupational therapists decisions should be influenced by this policy.

Instead, both hospitals and occupational therapists should focus on providing appropriate, quality care to patients in need of skilled services.  Patients like Mary rely on our ability to make decisions and recommendations that are in their best interest, and not that are influenced by the bottom line of some hospital's balance sheet.

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