Readmission Penalties: RNs to the Rescue

As the Affordable Care Act continues rolling out, preventable readmissions will cost hospitals even more. Medicare currently imposes a 2 percent penalty if patients go back into the hospital within 30 days of discharge. Hospitals wanting to avoid ever-steeper penalties may not have to look beyond nursing stations for a solution.

In addition to jeopardizing the health of patients, readmissions cost Medicare more than $17 billion a year, according to a 2013 analysis of Medicare data by the Robert Wood Johnson Foundation. Hospitals have implemented a number of measures to prevent readmissions, such as starting the discharge process immediately upon first admission, patient education and better organization of the discharge process. But studies also have found higher nurse staffing may help lower the odds of readmissions and increase the likelihood of improved patient outcomes.

Investigators led by Matthew McHugh, PhD, JD, MPH, RN, of the University of Pennsylvania in Philadelphia, used data from the Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program to determine readmission penalties for fiscal year 2013. They found that hospitals with a more favorable nurse-to-patient ratio were 25 percent less likely to incur readmission penalties than comparable hospitals with lower nurse staffing (Health Affairs 2013; 32[10]:1740-1747).

Earlier in the year, McHugh and Chenjuan Ma, PhD, RN, also of the University of Pennsylvania, determined the relationship between certain aspects of hospital nursing (staffing, education and work environment) and 30-day readmissions for Medicare patients with heart failure, heart attacks and pneumonia by analyzing both discharge data and nurse surveys asking about staffing, education and work environment (Medical Care 2013:51[1]:52-59).

Risk of understaffing

Their analysis revealed that nearly 25 percent of heart failure patients, 19.1 percent of heart attack admissions and 17.8 percent of pneumonia admissions were readmitted within 30 days. The odds for readmission for all patients were higher in hospitals with higher nurse-to-patient ratios and in hospitals with poorer work environments.

“Environments where nurses are understaffed and under-resourced and where there is poor support of nurses are linked to poor outcomes and processes of care that we know are associated with bad outcomes,” McHugh says. “Nurses are less able to do the kinds of things that evidence suggests are more likely to promote better outcomes, such as patient education, discharge planning, care coordination and advocating for patients on the post-discharge care they should be getting.”

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At the Heart Failure Society of America scientific meeting in September, Therese Prentice, CRNP, formerly the heart failure coordinator for Capital Health System in Mercer County, N.J., and colleagues presented a study that compared readmission rates from before a hospital relocation to the rates after the relocation. Prior to relocation, the newly instituted heart failure program saw a 47 percent reduction in readmission rates over the previous year. However, the investigators found that readmission rates after relocation jumped back up again due to the temporary increase in heart failure patients per nurse.

Once staffing returned to a 1:4 nurse-to-patient ratio, readmissions returned to pre-relocation rates.

Donald Haas, MD, senior author of the research and director for mechanical circulatory support at Abington Memorial Hospital in Abington, Pa., says the research, which is not yet published, highlights the need for adequate nursing staff for heart failure patients. These patients are critically ill and need proper education in order to avoid coming back to the hospital.

“It’s also probably more important to educate the caregivers,” he says. “The average age of heart failure patients is about 72, so they’re getting a lot of support from their children or others who care for them.”

Making an investment

McHugh and Haas say the financial incentives offered by reducing readmissions could offset the cost of hiring more nurses. According to a report by CareerBuilder and EMSI, registered nurses earn an average of $32.04 per hour.

“Investing in nurse staffing benefits all patients because not only would there be gains in readmission reductions, but also in hospital-acquired infections and fewer complications,” McHugh says. “Any one of those wouldn’t pay for itself, but the good thing about focusing on a broad, system-level intervention is that every patient population gains regardless of the individual components.”

Additionally, more nurses would lead to more satisfied patients, which also can translate into financial incentives.

Haas explains that while hospitals are under financial pressure to reduce readmissions, each hospital has to consider its own staffing needs and there’s no one-size-fits-all solution. Hospitals’ readmission penalties are based on comparisons to other hospitals, and those numbers may change every year.

“Staffing has to be made on a case-by-case basis,” Haas says. “But people are more willing to make investments in anything that could potentially lower the readmission rates than they were five years ago.”

In addition to fiscal barriers that may affect hiring, outside factors such as the nationwide nursing shortage may impede efforts to beef up nurse staffing. McHugh says the shortages tend to be cyclical, so the impact may not be felt all the time. The bigger challenge may be appropriate skills and education.

“Even if you throw more bodies into the mix, [that] doesn’t guarantee you will reap all the benefits. You need to look at everything in combination,” he explains. “You need to make sure the workforce is educated to the highest possible level and also focus on the work environment for nurses.”

Specialized nurses

The Institute of Medicine and the Robert Wood Johnson Foundation issued a joint statement in 2010 on the future of nursing that called for 80 percent of nurses to hold bachelor of science in nursing (BSN) degrees by 2020. In 2008, only 36 percent of nursing school graduates held BSNs while 60 percent had associate’s degrees and 3 percent diplomas.

But according to Haas, there is a different type of nursing shortage. He argues that there are not enough nurses specially trained to care for patients with heart failure.

Currently, treatment for heart failure often focuses on relieving the most serious symptoms and patients are then sent home; however, specialized nurses are able to recognize how to potentially alter the progression of the disease to improve long-term outcomes.

“Being a heart failure nurse is a unique skill set. You need educated staff who are going to understand the nuances of a very complex patient population and who can appreciate the natural history of the disease,” Haas says

As a former bedside nurse himself, McHugh has worked in settings where staffing and resources have ranged from adequate to poor. “Nurses are good at figuring out how to make things work even in the worst circumstances and most nurses experience that when they’re stretched thin, everything is intensified and everything is more difficult,” McHugh says.

But the stakes are getting higher. As healthcare expands and people get older and live longer with more complex conditions like heart failure, nurses will feel even more patient care pressure.

“We tend to look at nurses as the primary surveillance system of the institution,” McHugh says. “Someone has to be there to interpret all the technology and provide the bulk of patient care. Nurses will have to provide more of these services, so we need to make sure the workforce is keeping pace with the demands of care.”