20% of admissions to internal medicine departments in Israel are readmissions within a month.
When a patient is discharged from hospital, they are handed a discharge summary and instructions for continued care.
Arranging an appointment with the right physician, and getting the information from the hospital to the treating physician at the HMO (Israeli health fund), remain the responsibility of the insured member.
How many patients actually know the bureaucracy, or what the correct process even is? It falls to the member to convert the hospital’s instructions into the appropriate referrals and funding approvals at the HMO; to explain to the HMO physician what treatment was given and on what basis the decisions were made; to obtain the right medications through the HMO; and to arrange their own follow-up at the frequency and urgency the hospital defined – blood tests, imaging and so on, which are not available at the HMOs within the intervals those instructions require.
It is clear that today most of the responsibility for a clean discharge into the community rests on the patient’s shoulders, and that may well be why 1 in 5 patients admitted to an internal medicine department were there in the month before the new admission.
Research shows this is not inevitable: changing processes and infrastructure, in the community and in the hospitals alike, can improve outcomes for patients and for the public at large.
Israel and the rest of the world are both grappling with readmissions. Data published by the Ministry of Health in 2013 show that –
- Roughly 20% of all admissions to internal medicine departments are readmissions within a month, and 8% are readmissions within a week. The figure has held steady for years, with no discernible trend.
- The readmission rate rises with age: at 75, 25% of admissions are readmissions within a month. The longer the index (first) admission, the higher the likelihood of returning to an internal medicine department.
- Widen the measurement window and the picture is starker: patients admitted to an internal medicine department today are 2.42 times more likely to be admitted again within the next six months than people with no prior admission.
- Patients with certain conditions – malignancies, renal failure, chronic obstructive pulmonary disease and heart failure in particular – sit in a markedly higher risk group for readmission (1). That raises the question of whether there is genuine potential to reduce readmissions, or whether they are simply the natural course of disease progression.
- No correlation was found between the number of beds in a hospital and its readmission rate
There is no doubt this is a phenomenon that carries a heavy price – from the health and wellbeing of the patient through to measures of public and economic efficiency. Many health systems are preoccupied with readmissions and with how to prevent them.
Estimates in the literature put the share of readmissions that could be avoided at between 9% and 50%, with a median of 30% (2,3), and most prevention approaches address the infrastructure and processes behind optimal continuity of care across acute and community providers.
Who owns continuity of care?
Continuity of care is the process by which a patient moves between inpatient institutions and the community, and back again.
Patients who have completed the acute phase of an illness often need an orderly handover to the community – one party or more who knows how to build and execute the appropriate follow-on intervention plan. It is well established that better continuity of care delivers better medicine, reduces costs and raises satisfaction among patients and clinicians alike (10). Without real continuity, the risk of readmission, of complications and of rising expenditure all climb.
The quality of continuity of care depends, among other things, on the working relationship between the organizations involved in the process – the hospitals and the community providers.
The HMOs and the hospitals are two large organizations within the health system that run a supplier-customer relationship between them: the HMOs pay the hospitals for the services their members receive. Spending on inpatient days accounts for a substantial share of HMO budgets – 41% of HMO community-sector operating expenditure goes on hospitalization (4).
The Ministry of Health has a strong interest in securing continuity of care, both clinically and in public and economic terms, and it is indeed the regulator on the subject.
At the same time, the Ministry owns 11 public hospitals in Israel – so it sets policy on one hand and carries operational responsibility on the other. That dual role weighs heavily on the relationship between the HMOs and the hospitals, with the Ministry sitting at the heart of the conflict, holding both ends of the stick.
Between 2011 and 2013 the Ministry of Health ran a support scheme for the HMOs designed to push them to reduce readmissions, with a target of moving from 20% to 17% (worth ₪300-400 million a year).
To that end the Ministry allocated ₪40 million to be shared among the HMOs that managed to cut readmissions by 10% in 2012 and by 20% in 2013 (5). At the end of the period, however, the Ministry determined that no HMO had met the target.
In the United States, by contrast, where there is no public health system of the kind Israel operates, a mechanism of fines on hospitals tied to readmissions was introduced in 2010. A study tracking the effects covered 48 million admissions and showed a significant fall in the readmission rate, around 15% on average. (6)
Return to Israel and examine how a patient moves from acute inpatient institutions to continued care in the community, and it becomes clear that most of the responsibility for coordinating, implementing and securing continuity of care sits with the patient.
Every HMO has set up an internal unit intended to safeguard continuity of care, yet many patients still run into difficulty in the transitions between hospital and community. Those difficulties come down to missing processes and infrastructure for receiving the patient back into the community, and they can push the patient to choose the emergency room again the moment a problem surfaces.
The challenges in the move to the community may be bureaucratic – the time it takes to convert a prescription into medication, or a referral into an available community appointment – or purely clinical, in understanding the instructions the hospital gave and applying them.
Meaningful continuity of care, built on infrastructure, processes, measurement and incentives in the hospitals and in community institutions alike, can deliver the change required to prevent readmissions.
Rolling out tools to predict readmission and to identify the population at preventable risk will let the HMOs focus their processes and infrastructure on the patients whose readmission can actually be prevented, rather than on the edges.
- Information sharing between hospital and community, and back the other way. Israel has come a long way technologically here, and a substantial share of the information is now visible on both sides. Even so, there is a long road left before every citizen has a single medical record. A complete file that travels with us between HMOs and, of course, between the acute stages and community care. That is what would allow genuine continuity of diagnosis, medication and the design of an appropriate intervention plan.
- Discharge planning in the hospital, covering: assessment of the patient’s needs for discharge home, with a focus on functional needs; guidance for patients and, where required, for family members or carers; review of the medications the patient takes and updating them as needed; transfer of information to the next treating party in the hospital, or coordination of care with community providers; and follow-up audit through home visits and/or telephone calls after discharge from hospital.
Building intervention processes to bridge hospital and community. Every HMO has a body that acts as the patient’s bridge between hospital and community. It is responsible for coordinating continuity of care in practice.
These bodies need to implement processes and working tools that reduce and prevent readmissions – among them rapid conversion of prescriptions and referrals (ideally before the discharge itself), booking specialist appointments and bringing them forward where necessary, and a full handover to the next party in the community, the one who will manage continued care. - Timely follow up – the ideal timing for a follow-up appointment with the community physician after discharge is not known. Many studies have examined the relationship between the timing of the first community follow-up and readmission, and most show a fall in readmission rates among patients given an appointment on discharge (7). It is also known that 50% of patients who require readmission within 30 days of discharge had not yet been seen by a community physician (8). That said, a large retrospective study of close to 5,000 discharges from Mayo Clinic hospitals found no relationship between the timing of the post-discharge follow-up appointment and readmission (9).
Processes and infrastructure in the community
As noted, the question of who is responsible for securing continuity of care is fundamental to preventing readmissions, and the HMOs need to implement processes and working tools in the community too if they are to prevent the next admission. Untangling bureaucracy, availability of specialist appointments, conversion of prescriptions and referrals – all of these have to keep running after the coordinating body has left the picture.
Once the working processes are in place, they need to be backed by targets, measurement and incentives for everyone involved:
- Measuring effectiveness through process metrics – for example, the share of discharged patients contacted proactively within a week; assessment of readmission risk by a community nurse or physician; the share of discharged patients in the risk group whose follow-on care recommendations were actually carried out (prescriptions filled, referrals and tests completed, and so on)
- Performance metrics – actual readmissions within the intervention group. Intervention by multidisciplinary units for complex patients, such as the home hospitalization units the HMOs run today. Those same units can also run a month-long prevention program until the patient is stabilized (usually a patient carrying a heavy disease burden), before responsibility passes to the home clinic.
- Monitoring at-risk patients (COPD, CHF) – a process already in place at several HMOs.
- And last, though important and not yet studied at scale, is educating the patient and building their own ability to prevent readmission. This matters a great deal in chronic patients, and particularly in heart failure and chronic obstructive pulmonary disease patients, who carry an especially high risk of readmission. The estimate is that in these cases educational intervention can cut the number of readmissions by as much as 40% (10).
In summary, as the population ages, readmission rates will place a growing load on health systems in Israel and worldwide. Cutting them by even a few percentage points would deliver meaningful savings in money, time and morbidity, and would materially improve the quality of care.
The question of who is responsible for coordinating and implementing continuity of care in the community is the question now facing the HMOs and the Ministry of Health. Placing responsibility for part of the solution on the community and the hospitals rather than on the patient, changing processes at the transition points, and proactive HMO intervention that starts at the discharge stage, could all prove key to preventing the next readmission.
