Hospitals are caught between pressure from the Affordable Care Act to discharge patients quickly to their homes and the financial penalties they face if patients are readmitted.
To mitigate the risk, hospitals are focusing on patient education as well as ancillary services such as case and discharge managers to help patients assume greater responsibility for their follow-up care, including medications, nutrition and use of medical equipment.
This requires a coordinated, multidisciplinary effort that starts with a patient’s admission to the hospital, said Terri Nichols, director of risk management, PeaceHealth.
“In a culture of safety, we think ahead about the discharge environment. We think about home assessments,” she said. “We think about grip bars in showers. We think about who will help an elderly relative up the stairs. We think about teaching family members how to inject medications.”
Planning for discharging patients is crucial because inadequate information or preparation, or discharge into unsafe environments significantly increases the chances of readmission.
“Proactive discharge plans have reduced readmission rates significantly,” said Dana Welle, chief medical officer, The Risk Authority, Stanford, Calif.
Most U.S. hospitals are projected to receive lower reimbursements from Medicare in fiscal 2016 because too many patients return within 30 days of discharge, according to “Modern Healthcare.”
Fewer than one-quarter (23 percent) of more than 3,400 hospitals subject to the ACA’s Hospital Readmissions Reduction Program (HRRP) performed well enough in 2015 on the Centers for Medicare and Medicaid Services (CMS) 30-day readmission program to escape penalty.
Statistics about hospital readmissions are confusing and contradictory. — Pamela Popp, executive vice president and chief risk officer, Western Litigation
HRRP targets higher-than-average readmissions for heart attacks, heart failure and pneumonia, and it stepped up penalties from 1 percent in 2013 for to 2 percent in 2014 to 3 percent in 2015.
The problem, however, is especially intractable among the homeless, Nichols said.
Seven in 10 homeless individuals who were discharged were readmitted, visited the emergency room or returned for an observation stay, according to the National Center for Biotechnology Information.
Interpreting the Numbers
Statistics about hospital readmissions are confusing and contradictory, said Pamela Popp, executive vice president and chief risk officer, Western Litigation.
While the proportion of hospitals receiving a penalty increased to 78 percent in 2015 — up from 66 percent in 2014, according to The Henry J. Kaiser Family Foundation – penalties remain below 1 percent, although the maximum cap rose in 2015 to 3 percent.
It’s unclear what those numbers say about hospitals’ efforts to control readmission because of some changes in the regulations, said Popp.
CMS added two more diagnoses — chronic obstructive pulmonary disease, and hip and knee replacements — to its performance criteria in 2015, significantly raising the potential universe of tracked readmissions.
And the ACA requires more reporting about readmissions than in the past, forcing hospitals to acknowledge that admissions that wouldn’t have been counted in the past – often for sepsis – are related to a prior admission.
About half of the sepsis infections are preventable, and they accounted for roughly the same percentage of hospital readmissions in California as heart attacks and congestive heart failure in 2015, according to UCLA research.
Preventing avoidable readmissions depends on unbroken communications between patients, care providers and care managers, said Popp.
“Make sure patients and families know what normal healing looks like as opposed to an acute condition,” she said.
Often, she said, patients and caregivers fail to comply with follow-up instructions, either because they don’t understand what is necessary or are not able to.
“They can’t afford their meds, or they can’t afford to stay home from work. Then they put a recovering child back in day care, and the providers miss symptoms until there’s another crisis,” Popp said.
An increasing number of hospitals phone patients immediately after discharge to check on their condition and later to remind them of follow-up visits, Welle said. Some send doctors or nurses within 24 hours of discharge to re-evaluate patients.
Some contract with rehabilitation and home health services to provide follow-up care.
Hospitals will also engage their quality control and risk management departments to monitor and implement the new interventions, she said.
“It’s not enough to simply put interventions in place. There must also be a way to measure if they’re helping,” she said.
To prevent misallocation of time, attention and resources, it’s important for the risk management community to understand that “most of the factors leading to a readmission have nothing to do with the quality of clinical care,” Popp said.
“It’s a communications issue.”
Readmissions should be reported all the way up to the board of directors, Welle said, because senior-level involvement may increase funding for external resources such as additional discharge nurses or contracts with rehabilitation and home health services.
The insurance industry also can play a role in reducing readmissions, Popp said, by ensuring that hospitals track and learn from readmissions.
Investigation into its readmission rate should be part of the underwriting process, she said, especially for those related to sepsis.
“Look for adequate discharge instructions and follow-through,” she said.
New Role for Insurers
Emerging technologies may plausibly disrupt the insurance industry as we know it.
Futurists and insurance experts predict the industry will see changes, from product design, pricing, underwriting and adjusting claims to the skill-sets sought in employees and boards of directors.
Four issues will lead change in the industry, said John Cusano, senior managing director, global insurance, Accenture:
- Cyber risk.
- Things and people equipped with networked sensors.
- Data harvested from networked sensors.
- The cloud, which “PC Magazine” defines as “a datacenter full of servers that is connected to the internet.”
The last three items on that list, which collectively constitute the Internet of Things, will provide a much more accurate picture of the exposures, hazards and risks of insured assets than is possible now, said Donald Light, director, North America property/casualty insurance practice, Celent.
Equipped with this broader and deeper understanding of clients’ risk, the insurance industry’s role will shift from insuring risk to protecting it, he said.
“Many insurance brokers and carriers already provide risk assessment and loss control services in the limited form of one-time or periodic assessments,” Light said.
“With the new technologies, carriers will have the ability to continuously monitor risks and ask policyholders to take actions to prevent losses.”
Changing Role for Insurers
“Some insurers will get very connected and play a meaningful role in monitoring, deploying and incenting use of technologies,” said Cusano. “They’ll still help with financial backing if something goes wrong, but their real purpose will be to help clients have less risk.”
For example, he said, modern ships are equipped with thousands of sensors. In case of a leak or flood, the broker or carrier could help correct it and prevent damage to the vessel or its inventory. In bad weather, the carrier could divert the route and manage arrival expectations with the factory or retailer at the destination dock.
“The whole world of goods and factories and retail could be transformed by real-time data on the state of transportation,” Cusano said.
“Every little asset can be sensor- and wireless communication-enabled,” said Anand Rao, partner at PwC analytics and global co-lead for Future of Insurance 2020.
In a manufacturing setting, sensors on pipes, boilers, generators or other equipment could measure pressure, temperature or humidity, for example, and transmit the information to a data collector, which builds predictive models from aggregated data collected from many similar assets.
If, say, the pressure in a machine reaches unsafe levels, the data triggers preventive maintenance.
“That data has implications for insurers and brokers because it enables them to move from writing claims from an event to preventing the event,” Rao said.
“If carriers take on that role,” said Rao, “will they partner with tech companies? If brokers do it, will they partner with carriers?”
By taking a hands-on role in monitoring sensors, Cusano said, carriers would know the sensors are working from the date of installation, not just that they’re installed.
For example, a carrier might offer a discount on premiums to incent an insured restaurant to install sensors to monitor for flood, fire, air conditioning and other risks, and then preserve the discount as use of the sensors continues.
Uses for network-enabled sensors cross industry lines, with applications including intelligent highway infrastructures, intelligent connected buildings, and fleet operations with driverless trucks and road trains connected through a variety of technologies.
User adoption is another unknown, said Rao. “Just because they have a cool new gadget, clients won’t necessarily use it.”
If only 1 percent or 2 percent of clients adopt, insurance companies won’t invest in the technology. But if 15 percent do, “they’ll start getting into the game,” partnering with vendors that offer the desirable technology, testing the waters with pilot programs and then working with brokers to see how their clients can use it.
Carriers that retain the more traditional role of pure financial insurance will “take a more niche or secondary position,” Cusano said.
And hesitation to enter new roles can be perilous, said Jim Carroll, a futurist who speaks and writes frequently on financial and business matters.
“Speed of innovation and change will decide the winners and losers as the insurance industry shifts to Silicon Valley,” he said.
“Who is developing driverless cars? Apple. Google. The tech companies aren’t just tech companies. They’re financial institutions and entertainment companies and transportation companies.”
This shape-shifting of tech companies into unrelated industries makes it hard to assess future risk, Carroll said, but the companies that do it faster will have the advantage, and those that don’t do it at all risk obsolescence.
“The real risk is new competitors who think and do differently.”
To thrive, Carroll advises insurance companies to become like the companies that are upsetting the business model.
“Go out there and hire people you don’t like, people who aren’t like you,” he said.
Hire the Elon Musks, people untrammeled by “caution and conservatism,” although he conceded such individuals are more likely to start their own companies than become employees of an existing one.
“Speed of innovation and change will decide the winners and losers as the insurance industry shifts to Silicon Valley.” — Jim Carroll, a business futurist.
Paul Kovacs, executive director, Institute for Catastrophic Loss Reduction in Toronto, and president and CEO of the Property and Casualty Insurance Compensation Corp., isn’t quite so quick to ring the death knell on traditional insurance companies.
“The insurance industry copes with rapid change well,” he said.
Although individual companies will struggle with rapid behavior change, there will still be a need for risk pooling and risk management. “Risks aren’t getting smaller. The industry as a whole will do well.”
As torrents of data from network sensors flood insurance companies — and they become more tempting targets to hackers seeking to steal sensitive information or disrupt operations — they will hire more mathematically minded people, said Mark Moitoso, analytics practice leader, Lockton.
“Companies will invest more resources in analytics. They’ll hire more statisticians and data scientists to translate large quantities of data into actionable insights, and then company leaders and underwriters can use that information to make more informed decisions about transactions,” Moitoso said.
That future has been here for a while, said his colleague, Justin VanOpdorp, chief analytics officer, Lockton, but current analytics pale in comparison to the future “volume, variety and velocity of information that’s coming. We’ll have opportunities to get at more and better information faster than in the past.”
Data security when it’s collected, transmitted and stored is the biggest issue facing companies that depend on the Internet of Things, said Alan Dayley, research director, Gartner, who covers information governance, archiving, and storage management software.
Unencrypted data from Internet of Things devices are vulnerable to interception as they travel across wireless communications networks from devices to data stores, Dayley said.
The Internet of Things still lacks standard protocols around how data should be encrypted and transmitted, said PwC’s Rao, and the industry should expect more regulation as the technology catches on.
“The Internet of Things is more risky than laptops and mainframes just because of the volume. We’re looking at a large number of devices communicating huge amounts of data.”
Although this risk is substantial for those using connected devices, it’s an opportunity for insurers to monitor and manage the risk.
But make sure your client company fully grasps its cyber risk, said Carroll, the futurist. Cyber risk and cyber security are governance issues, he said, both for insurance companies and the organizations whose risks they insure.
“If I were the CEO of an insurance company, I wouldn’t insure an organization that didn’t have a well-qualified member on its board of directors who understands the scope and depth of cyber security.”
Rx for Violence
Law enforcement responded to Brigham and Women’s Hospital in Boston on Jan. 20, 2015, where a cardiologist was killed.
Dr. Jeffrey Ho treats patients in a busy Level 1 trauma center at the Hennepin County Medical Center in Minneapolis, and he teaches emergency medicine at the University of Minnesota Medical School. He’s also a sworn deputy sheriff in neighboring Meeker County.
The combination of medical practice and law enforcement is not the contradiction it might seem.
It led to his belief that the most effective strategy for preventing violence was not necessarily more deterrence in the form of weapons and armed security, but more and better training in violence recognition and pre-emption for people who dedicate themselves to the helping professions: doctors, nurses, technicians, administrators and therapists, as well as support staff such as receptionists and maintenance crews.
Health care workers are injured through violent acts at more than four times the national rate, according to the U.S. Bureau of Labor Statistics. FBI statistics show the incidence of active shooter incidents in health care settings rose from 6.4 per year between 2000 and 2006, to 16.4 per year between 2007 and 2013.
Those numbers are a gross underestimate, Ho said, because the health care culture doesn’t yet take assaults seriously, other than the deadly ones. OSHA doesn’t break out violence in its statistics on injuries to workers, although it breaks out other sources of injury. And workers themselves don’t consider minor incidents worth reporting.
When he consults with other hospitals on beefing up security — another of his jobs, along with his role as medical director for TASER International — Ho asks caregivers, “Has a patient ever threatened you or has anybody ever touched you?”
“Every hand goes up,” he said. Then he asks how many times they’ve reported it. “Nobody raises a hand,” he said.
A Big Problem, But How Big?
When an accurate registry of incidents exposes the pervasiveness and severity of the problem, Ho said, hospital administrations, the insurance industry, the government and general public will be shocked into corrective action.
However, obstacles to accurate reporting are nearly as pervasive as the violence itself.
The main reason violent incidents are under-reported, said Barry Weiner, managing director, health care practice leader, Aon, is that there is no mandate for facilities to report all events.
For those that report anyway, there is no universal definition of a reportable (or recordable) injury, said Jane Lipscomb, professor at the University of Maryland Schools of Nursing and Medicine, and author of “Not Part of the Job: How to Take a Stand Against Violence in the Work Setting.”
OSHA has one set of requirements, workers’ compensation carriers may have another and facilities may have their own.
“What’s an ‘event’?” asked Weiner. “Every emergency department sees a half-dozen on a good night, but won’t report all of them. Where is the threshold for reportable incidents?”
“We had to get staff to understand that behaviors that would be criminal in other settings are not OK just because they happen in a hospital.” — Dr. Jeffrey Ho, Hennepin County Medical Center
Many victims, particularly nurses, don’t report staff-on-staff incidents for fear of retaliation, said Lori Severson, health care loss control consultant, Lockton Cos.
An Institute for Safe Medication Practices study finds a virtual epidemic of violence, intimidation and passive aggression by health care workers, who may be stressed out by accountability for life-and-death procedures.
A dysfunctional team, said Lipscomb, is more apt to make errors, which may expose the organization to litigation. “Increasingly, organizations recognize that staff safety and patient safety are closely linked.”
Obstacles to Reporting
Electronic medical records, mandated by the Affordable Care Act for patient records, may contribute to the problem, said Weiner, as hospitals may have a disincentive to record incidents.
“Discoverability can be an issue,” he said. “An electronic record is permanent and discoverable. Both sides can use it in a courtroom.”
Not infrequently, Severson said, a repeat offender cycles through a facility again and again. “Health care workers may then feel workplace violence reporting isn’t a solution but an empty motion. Why report the same person multiple times?” she asked.
Veterans Affairs facilities electronically flag the file of patients who have acted out violently against staff in the past two years, and security personnel escort them whenever they’re in a facility for treatment, according to published reports.
The financial ramifications of violence combined with the need to protect employees create an urgent problem. A broker’s role, said Weiner, is to work with clients to scope out the problem.
“Some of the solution lives with us. We deliver training, promote best practices and engage leadership in meaningful discussion about reducing violence.”
Responsibility for the so-far nonexistent registry of assaults, Ho said, doesn’t belong with a government agency, but with a professional risk association.
The American Society for Healthcare Risk Management was unavailable for comment.
But a professional association faces the same obstacles as OSHA, the Department of Labor, the Crime Victimization Survey and the “other organizations out there trying to make good estimates,” said Lipscomb. “Staff don’t report if they work in an environment where they think violence is part of their job, where reporting is risky, and where it won’t produce results anyway.”
Disrupting the vicious cycle of under-reporting and perpetuation of violence, Lipscomb said, usually depends on a facility’s enlightened leadership, without whose commitment of time, resources and adequate staffing to meet patients’ needs, culture change is “nearly impossible.”
The organizations she visited to identify best practices, she said, have many things in common, such as morning huddles every day, when CEOs and unit heads get together to talk about what happened in last 24 hours. “They ask, ‘What do we need to do to make sure it doesn’t happen again?’ ”
“Staff don’t report if they work in an environment where they think violence is part of their job, where reporting is risky, and where it won’t produce results anyway.” — Jane Lipscomb, professor, University of Maryland Schools of Nursing and Medicine
This is already common practice with patient care. Taking their cue from aviation and other safety-essential industries, they have adopted a culture where errors and near misses are considered opportunities to improve the facility’s practice.
“That’s how you get people to report,” Lipscomb said. “Then you can do something about the problem.”
Ho’s facility has done “a good job” controlling violence, thanks to senior management’s follow-up on recommendations from a violence prevention task force formed in 2007. The task force’s recommendations start with a carrot (de-escalation) and end with a stick (force). The longest journey, he said, was training staff members to consider their own safety.
Having been taught for years that verbal abuse and getting punched in the face by a distraught patient or family member is simply an occupational hazard, the forgivable by-product of grief or pain, “we had to get staff to understand that behaviors that would be criminal in other settings are not OK just because they happen in a hospital.”
In fact, several states have passed legislation making any attack on a health care worker a felony. Although there is no federal standard for workplace violence protections, according to the American Nurses Association, some states require employer-run workplace violence programs. Washington is the only state to require reporting of incidents.
Among the Hennepin County Medical Center task force’s recommendations: Signage around the facility stating appropriate behavior.
The Joint Commission, a national certifying organization, now requires its accredited hospitals to have a code of conduct that identifies appropriate behaviors and how inappropriate behavior should be managed.
Training helps staff recognize risks, such as frustration with long ER wait times, intoxication and drug-seeking behavior, according to experts.
It teaches empathetic listening, the most basic de-escalation technique, which means the distraught person has no need to act out in violent ways to be heard, said Elizabeth Moreland, senior risk engineering consultant, Zurich Insurance.
Emergency rooms and mental health settings are particularly high-risk areas, experts said, but “everyone who has patient contact should get basic crisis prevention awareness training,” said Moreland.
Some organizations, such as the Crisis Prevention Institute (CPI), provide training specific to health care facilities. Typically, a facility sends one or two staff members for training, and they return to spread the gospel.
The National Institute for Occupational Safety and Health, the Centers for Disease Control and Prevention, and some trade associations offer free programs and best practices to help manage health care violence.
Training typically includes rehearsing non-judgmental and non-provocative responses to a distraught person’s demands. Body language can also diffuse emotions, Moreland said. For example, standing to a person’s side is a less confrontational posture than standing nose to nose.
For most people, these techniques require practice, she said. “In-service role-playing is very effective. Don’t depend on once-a-year training sessions.”
People, Not Livestock
Batsheva Katz, vice president of Windsor Healthcare Communities, which runs elder care, skilled nursing and rehabilitation facilities in New Jersey, takes pains to provide “a happy environment” as the most effective prevention against violence.
Biting, hitting, pushing and scratching are typical assaults in residential facilities, where emotions run high among residents and their families as they face the fear of mortality and the discomforts and humiliations of aging.
“Happiness” in those circumstances is a systematic, top-down effort to treat residents “as someone’s mother or father,” rather than as bodies that need to be fed and washed, Katz said.
“That means talking to them if they want to talk, addressing them by name, knowing their tastes and preferences.” It also means teaching care partners to approach residents slowly and speak softly but audibly. Care partners explain what they’re doing, such as, “I’m going to put your socks on now.”
This is a human resources issue, Katz said, requiring adequate staff, time, training and a concerted search for applicants with the friendly, caring personalities that are crucial, but harder to find than résumés boasting relevant but teachable skills.
The practice pays off in “extremely favorable” workers’ compensation premiums, virtually no claims related to violence and very high employee retention, said Ettie Schoor, president, Prism Consultants, Windsor’s hands-on insurance broker.
When new residents are admitted, Windsor’s interdisciplinary care partners and administration undertake a “72-hour meeting” with them and their families to get to know the resident’s tastes, personality, triggers and risk factors, such as dementia or a tendency to wander; if residents wander, their care partners wander with them and bring them back gently, Katz said, to avoid power struggles. Windsor matches residents with care partners they like and trust.
For example, said Katz, staff members noticed one resident’s combativeness eased on weekends, when he had a male certified nursing assistant (CNA). “All he wanted was a male CNA,” said Schoor.
Kendra L. Stea, director of client services, CPI, urges facilities to reconsider inflexible rules, policies and protocols that produce power struggles between patients and staff, which can escalate into violence.
A psychiatric patient’s request for a glass of milk at night led to “a really ugly outcome,” she wrote in a CPI blog, when a caregiver refused, saying it would lead to a stampede of midnight demands for milk.
“We have to be creative and flexible in deciding which of our rules are negotiable, and which are non-negotiable,” she wrote.
Securing the Plant
Ryan Clarke, director of security and transport, Renown Regional Medical Center in Reno, Nev., agreed that education and awareness are the best tools against violence.
After a shooter killed a doctor and wounded two others before killing himself in 2013 at the center, Clarke’s facility introduced more comprehensive staff-wide de-escalation training for handling people who are verbally or physically out of control. And it added armed security guards to its team, mostly as a deterrent to future attacks but also to add a greater level of response.
Much of its re-evaluation of the physical plant’s security addressed access control: Who needs to be where? Who’s coming into the ER? Armed security guards and volunteers, who are trained to perform a visual risk evaluation, greet people as they pass through a door.
“We put access control at main and intermediate doors inside the ER so if we need to lock down an area, we can,” Clarke said.
“If we suspect a visitor problem, we can lock the lobby off from the patient area until we can ensure that it’s safe.”
Clarke looks at furniture. Can it be broken up and weaponized? He also looks at layout. Is there enough space to separate people with a history of hostilities, maybe gang members or fighting domestic partners, who may meet again in the ER?
“In a good layout,” he said, “visitors see a staff member or security officer as soon as they enter. In a poor layout, the entrance is isolated, and nobody is there to identify potential threats.”
Some experts challenge the efficacy of color-coded alert systems — such as Code Gray for personal threat — as unintelligible and unhelpful to non-staff. Emergency codes are not standardized by any state or agency.
After the tragic 2015 shooting at Brigham and Women’s Hospital (BWH) in Boston that left a cardiologist and the shooter dead, police were on the scene within seconds, the 5 million-square-foot facility was cleared within 16 minutes and the violence was contained to the exam room.
That faint silver lining was due, in part, to a 39-word plain-English scripted announcement that identified and located the incident and explained what to do.
An announcement “needs to be plain English so untrained visitors, patients, anybody who is in the building, can hear it and know what’s happening,” Robert Chicarello, director of security at BWH, told “Boston Magazine.”
Pamela Popp, executive vice president and chief risk officer, Western Litigation, recommended that health care facilities cultivate relationships with law enforcement.
Facilities that can’t hire security staff may offer free food or cafeteria discounts to local police, whose presence serves as a visual deterrent.
Ho agreed, with qualifications. Does the cop understand how to work in health care settings? In case there’s a pursuit inside the hospital, is the sterilization area locked? Are there flammable gasses?
“A firearm or Taser is dangerous in those environments,” he said.
A security solution that’s appropriate for one facility won’t necessarily work in another because of endless variables: differences in the community, the layout, the size of the hospital and risk factors in the community.
Study and adapt best practices, advised Clarke.