With the implementation of Section 3025 of the Affordable Care Act of 2010 (ACA), hospitals are intently focused on identifying their populations at risk for readmission and on designing and testing new approaches to reduce hospital readmissions. The ACA established a Hospital Readmission Reduction Program focused on driving meaningful reductions in readmissions by imposing payment penalties on hospitals with high risk-adjusted readmission rates for certain conditions.1 In October 2012, the Center for Medicare and Medicaid Services (CMS) began reducing Medicare payments to hospitals with higher than expected readmission rates among patients with 3 targeted diagnoses. It is anticipated that the penalty will increase annually, with a 3% penalty expected by 2015.2

This focus on readmissions is significant because the costs associated with readmissions consume nearly one-third of the nation's total health expenditures.3 Nationally, it is estimated that 20% of patients are readmitted within 30 days after discharge.4 Of the $17.5 billion in Medicare spending on readmissions,5 it is projected that $12 billion is potentially preventable.6 The CMS National Strategy for Quality Improvement in Health Care contains a goal to reduce readmission rates by 20% by 2013, potentially preventing 1.6 million hospitalizations.7

A review of the readmission literature8 suggests that the programs that are most successful in reducing readmissions involve enhancing patient-centered discharge processes, with a special focus on medication reconciliation, improving coordination with community-based providers, and effective patient self-management of their disease and treatment. These strategies have decreased readmissions in many populations and settings, and hospitals across the country are incorporating these elements into their discharge processes.

The diagnoses currently being targeted for reengineered discharge approaches are congestive heart failure (CHF), acute myocardial infarction (AMI), and pneumonia. Evidence suggests that nearly 1 in 4 patients hospitalized with CHF and 1 in 5 patients hospitalized with AMI are readmitted within 30 days of discharge.9 Hence, the focus on these diagnoses is critically important to the financial well-being of hospitals as well as the clinical well-being of these patient populations. By 2015, the range of targeted diagnoses is expected to include readmissions for chronic obstructive pulmonary disease (COPD), coronary artery bypass graph, percutaneous coronary interventions, and other vascular procedures.10

Within these broad diagnostic categories, a subset believed to be especially high risk for hospital readmission includes patients with low health literacy. Low literacy is linked to poor health outcomes, decreased use of preventive health screenings, and increased hospitalization and emergency department (ED) use. In addition, patients with limited health literacy are more vulnerable to medication discrepancies and discontinuities at care transitions that are linked to increased hospitalizations and readmission rates.11

This article examines best practices for reducing 30-day readmissions and synthesizes those with best practices for delivering patient centered care to the approximately 30% of the population with low health literacy. The purposes were to raise awareness of the impact of low health literacy on the issue of readmissions and to present effective, lower-cost interventions to improve patients' ability to manage their care after discharge.

Readmissions

Each year, approximately 35 million patients, excluding newborns, are discharged from our nonfederal hospitals,12 and of that number, nearly 2 million Medicare beneficiaries are readmitted within 30 days of their discharge, frequently for reasons directly associated with the initial hospitalization.5 This cycle of readmission costs Medicare approximately $17.5 billion annually.5

There are many reasons for high readmission rates. They are primarily related to the demographic, disease, and acuity profile of hospitalized patients; lack of organizational integration between community-based and hospital-based providers; and the reimbursement environment that incentivizes shorter lengths of stay (LOSs) and does not reward well-coordinated care across several care delivery/provider settings. In the past 30 years, the average LOS for each admission has fallen from 11.7 days in 1980 to 4.9 days in 2011.13,14 For patients admitted with an AMI, the LOS declined by nearly one-third over 10 years, from 7.2 days in 1995 to 5 days in 2005.15

Numerous studies have described the population at risk for readmission. Patients who are 75 years or older, male, African American, hospitalized with a medical diagnosis, and without insurance other than Medicare have been demonstrated to be at risk for readmission.16 Patients with cardiovascular disease, chronic lung disease, renal failure, cancer, or diabetes have also been documented to be at high risk for readmission.17 In addition, the socioeconomic status of patients contributes to the complexity and challenges of arranging posthospital care, thus increasing the probability of readmissions.

Moreover, patients in hospitals today have a far higher level of acuity and care complexity than even 5 years ago. Medicare beneficiaries with multiple chronic conditions accounted for almost all hospital readmissions, and within this group, those with 6 or more chronic conditions had a disproportionate share of readmissions.18 Beneficiaries who were "dual eligible" (receiving Medicaid as well as Medicare) are at especially high risk of readmission. Discharge planning for this population is challenging, and they may leave the hospital with treatment plans for 1 or 2 conditions but have other significant problems also needing to be addressed. Many patients are discharged without understanding their illnesses or treatment plans, and they inadvertently discontinue important medications19 and fail to follow up with referrals and appointments. This population is also the least able to navigate the complex and fragmented healthcare system, yet they are often left on their own to connect and manage the various community-based providers involved in their care.20 It is not surprising, then, that with increased acuity, shorter LOS, and high expectations of patient self-management, more patients are at risk for readmission.

In addition to patient characteristics, systemic flaws mediate against providing sufficient support for successful transitions to postdischarge care. Discharged patients see a myriad of community-based providers and scattered accountability among hospital staff, community providers, and other facilities about who is responsible for what aspects of postdischarge care results in considerable confusion and significant gaps in care. Community providers are generally not organizationally linked to hospitals, and the financial incentives to engage in the resource intensive activities required for coordination of care across settings are inadequate or absent.

Link to Health Literacy

The characteristics of patients at highest risk for readmission parallel those of the population with low health literacy. Defined as the "ability to obtain, communicate, process and understand the basic health information and services needed to make appropriate health decisions,"21 health literacy is an essential skill for self-management after discharge. However, approximately 36% of adults in the United States have limited literacy skills, and an additional 30 million adults have below basic skills.11

The significant health literacy deficit in the United States makes reading even simple instructions very challenging for many people. Moreover, the literacy requirements for successful navigation and management of posthospital care contribute to the high rate of hospital readmission among this population. Discharge instructions are generally jargon-laden documents written at the 8th to 13th grade level, and referral forms not only are confusing but also require an understanding of insurance benefits, network issues, and available providers.

Low health literacy is associated with poorer knowledge of chronic disease and decreased ability to successfully self-manage chronic conditions. Patients with low health literacy have difficulty managing their medication regimens and are less able to interpret labels (eg, medication and nutrition labels) than their counterparts with adequate health literacy. The situation is further complicated because medications are frequently changed at the time of discharge, and seniors with inadequate health literacy are more likely to err because of misunderstanding their discharge instructions and new medication regimens.22-24

Patients with low health literacy are also sicker than their counterparts with adequate health literacy. For example, a recent study of health literacy and CHF outcomes found that patients with low health literacy were more likely to have comorbidities, such as diabetes, hypertension, and chronic pulmonary disease, significantly increasing their risk of mortality.25

In addition to its negative impact on health status, knowledge, and self-care abilities, economic analysis reveals that people with limited health literacy skills use health services inefficiently and generate higher medical costs. Friedland26 suggested that about $73 billion in additional health expenditures nationwide were related to low health literacy. More recent economic analyses place the economic toll of low health literacy in the United States at $1.6 to $3.6 trillion.27 These figures serve to increase the urgency of incorporating evidence-based approaches for caring for these patients, especially as they transition from hospital to home.

Although low health literacy has not been empirically demonstrated to be an independent risk factor for readmission, some studies report an association between literacy and negative outcomes, such as hospital readmission. For example, Denison et al28 reported CHF patients with inadequate health literacy are at increased risk for poor self-care and hospital readmission. In addition, The Case Management Society of America has found that a deficit in health literacy is a contributing factor to medication and treatment nonadherence.29 Finally, because nurses and physicians are likely to overestimate patients' understanding,30 they might be less likely to objectively ascertain patients' comprehension of their discharge instructions, resulting in patients being discharged without an adequate knowledge of how to manage their care at home.

Strategies and Approaches to Decrease Readmission Rates

Although the impetus to address 30-day readmissions has intensified over the past few years, most hospitals have quality improvement (QI) projects in place to improve the discharge process, streamline care coordination mechanisms, and encourage patient self-management of chronic diseases. A recent article in the Journal of the American College of Cardiology9 reports on a sample of more than 1000 hospitals enrolled in Hospitals to Home, a campaign sponsored by the American College of Cardiology and the Institute for Healthcare Improvement (IHI), which has a goal of lowering readmission rates by 20%. A synthesis of the data from participating hospitals suggests that the following 10 practices hold the most promise for decreasing readmissions: (1) having at least 1 QI team focused on reducing readmissions, (2) giving pharmacy techs responsibility for the medication history, (3) monitoring 30-day readmissions, (4) arranging outpatient follow-up before the patient leaves the hospital, (5) providing information about medications, (6) alerting the community physician to the patient's discharge within 48 hours, (7) having pharmacists conduct medication reconciliation at discharge, (8) calling patients regularly to provide follow-up and/or further education, (9) providing direct contact information for physicians and/or an emergency plan, and (10) monitoring proportion of discharged patients with follow-up appointments within 7 days.

Many hospitals have developed unique programs tailored to their highest risk patients. For example, Project RED (Reengineered Discharge), located in Boston and serving an inner-city, low-income, ethnically diverse population, has as its central feature a nurse discharge advocate educating patients about their diagnosis and treatment throughout their hospital stay, organizes postdischarge care (ie, appointments, referrals, testing, etc), reconciles all medications, and calls the patient within 2 days of discharge. The program has resulted in a significant reduction in hospital utilization, especially among patients with historically high rates of utilization.31 The Transitional Care Model at the University of Pennsylvania School of Nursing is similarly focused on coordinating care before and after discharge. Their population is primarily at-risk elderly patients, with an advanced practice registered nurse serving as the care coordinator. Features include consistency of provider across episodes, in-hospital assessments, regular home visits, ongoing telephone support, early identification of risk, active engagement of family, and communication across formal and informal providers. They report that their patients are less likely to be rehospitalized, resulting in significant cost savings.32 Project BOOST (Better Outcomes for Older Adults) is a program that provides coaching to hospitals with the goal of reducing 30-day readmissions and improving their hospital consumer assessment of healthcare providers and systems scores. The Care Transition Model22 provides support to patients and caregivers, develops skills among family care providers, and enhances information exchange across settings. Both have reported significant and robust improvements in key variables, such as readmission rates and cost savings.8 In addition, the IHI has embarked on a multistate effort called State Action on Avoidable Rehospitalizations, which seeks to mobilize state-level leadership to improve care transitions.33

Improving Transitions for Patients With Low Health Literacy

In a systematic review, low health literacy was associated with increased healthcare use, inappropriate drug use, low use of preventive services, and overall poorer health.11 Therefore, preparing this population for successful self-management after discharge is imperative. There are some unique challenges in the current environment: resources are limited, hospital stays are abbreviated, and patients are frequently discharged with several comorbid conditions and complex treatment plans. Although not all hospitals have the resources to fully implement the formal care transition models described above, there are evidence-based strategies and approaches that have been demonstrated to be successful in improving comprehension, knowledge, and self-management among the population with low health literacy.

Teach Back

Teach back, also referred to as "show me," confirms comprehension and is a low-cost, evidence-based technique that can be used throughout hospitalization, at discharge, and in follow-up communication after discharge.34,35 In addition to confirming patient understanding, it also reveals "misunderstanding" and confusion35 and provides opportunities to provide additional information.

Although most nursing and medical school curricula teach this technique, there is some evidence to suggest that it is underused in most clinical settings. A recent study of providers' use of this technique suggested that teach back is used more frequently with patients who had the following characteristics: African American race/ethnicity, not native English speakers, less education, and elderly. This study concluded that some physicians seem to be limiting their teach-back efforts to certain patients, including those from demographic groups where lower literacy is perceived to be more common, potentially excluding patients outside those demographic groups who could benefit from teach-back.36

Jargon-Free, Slowed Down Verbal Communication

Many older adults, especially those with low literacy, have difficulty with recall of verbal instructions.37 Poor understanding of instructions is associated with higher mortality.38 The use of highly technical, jargon-laden communication has been repeatedly demonstrated to impede patients' abilities to understand their disease and treatment regimen and negatively impacts their abilities to manage their care independently. Interestingly, physicians were found to use nontechnical language only 12% of the time, even though they believed they were using layman's terms.39 Using jargon-free verbal communication enables patients to both correctly recall and adhere to postdischarge treatment plans, thereby reducing postdischarge complications.

Understandable Written Materials

The Plain Writing Act of 2010 requires all federal government materials to be written in a "clear, concise, well-organized" manner.40 The Joint Commission also mandates that patients receive education at a level appropriate to their degree of understanding. However, much of our written health materials require high reading attainment, are complicated, are poorly organized, and provide nonessential information. These problems with written materials can limit understanding and decrease compliance with medical protocols after discharge.

In addition to using pictures to clarify concepts, written materials should convey just 3 key points at each visit and be jargon-free.34,41 Pictures representing action when combined with verbal directions are shown to enhance recall of spoken medical instructions among literate adults,39 and Yin et al42 found that prescription drug counseling using a plain language, pictogram intervention resulted in fewer medication-dosage errors and greater adherence versus standard medication counseling. In a study of patients with COPD, Roberts et al43 reported that patients participate more fully in their care and in their health management when their healthcare providers impart information in different forms and reinforce spoken word with pictorial images.43 Numerous organizations and associations, including Agency for Healthcare Research and Quality, CMS, Health Resources and Services Administration, and others, have developed teaching materials using "plain language."

Follow-up Telephone Calls With Tailored Messages

The literature on strategies to reduce readmission generally includes follow-up telephone calls, but the effectiveness varies. Although many studies report reduced readmission rates, many others report no change in readmission rate.44-46 Some report using scripted messages, care maps, and standardized algorithms to assess symptoms and self-care behaviors. However, these approaches may not account for the unique characteristics of learners with low literacy.

Using tailored messages that account for patients' literacy levels is 1 approach recommended for this population.47,48 Ideally, tailoring messages for follow-up care should be based on previously assessed understanding using teach back.35 In a study using tailored messaging to patients with CHF, the authors report that tailored instructions with personalized reminders resulted in improved knowledge, correct self-care behaviors, and improved dietary behaviors than the control group.49

Beginning Discharge Planning Early

Top-performing hospitals begin discharge planning on admission,33 with staff assessing the patient's risk factors, needs, resources, knowledge, and family support within 8 hours of admission. This is a highly significant practice for patients with low health literacy, many of whom are elderly and may have cognitive impairment. Their learning is enhanced when educational sessions are brief and highly focused and the main points are repeated and reinforced. In addition, whenever possible, it is recommended to involve family and/or other caregivers, preferably in face-to-face communication.41

Summary

As the nation becomes more focused on identifying areas for potential healthcare savings, addressing opportunities to improve transitions in care and reducing readmissions have become priorities. Clearly, major changes in the ways in which we reimburse care and the creation of incentives to strengthen the alignment between hospital and community providers are necessary. These factors will become even more critical when the individual and employee mandates in the ACA roll out in 2014 and the newly insured Americans begin to seek and use healthcare.

As hospitals focus on improving care during the inpatient stay, at times of transition, and after discharge, the Institute of Medicine has suggested that making the commitment to become a "Health Literate Health Care Organization" will benefit not only the 77 million Americans who have limited health literacy but also any patient who has difficulty accessing, navigating, and effectively using healthcare services.⁵⁰ Lower-cost, evidence-based interventions hold promise of reducing readmissions among patients with low health literacy. It is well documented that patients who have a clear understanding of their postdischarge instructions are 30% less likely to be readmitted or visit the ED than are patients who lack this information.31 Strategies such as teach back, jargon-free communication, tailored messages, and early assessment of postdischarge needs have been demonstrated to be effective in improving patients' understanding of their disease and its treatment and have improved the population's ability to manage their care safely and effectively after discharge. There are many resources available to assist hospitals to develop and implement strategies that are responsive to the needs of the population with low health literacy, and nurse administrators are well positioned to move these value-added approaches into their organizations.

References