Linking Readmission, Reimbursement Exposes Complex Needs of Diabetes Patients

Few elements of the Affordable Care Act (ACA) have forced health systems to rethink their role in patients’ lives like the penalties Medicare charges if they fare poorly on 30-day readmission rates.

While the Hospital Readmission Reduction Program has sparked debate since it started in 2012, it has forced healthcare staff to reach into the community, to ask why some patients land back in the hospital and others don’t. With the earliest 30-day measures measuring how many returned after heart attacks, heart failure, and pneumonia, patients with diabetes quickly captured health systems’ attention since they were likely candidates for readmission.

What hospitals are learning, according to a speaker at the American Association of Diabetes Educators annual meeting in Indianapolis, Indiana, is that a patient’s diabetes may not be first on the list of health problems. That makes successful interventions complicated, and it often means that solutions must be customized to a patient’s unique needs.

Virginia Peragallo-Dittko, RN, CDE, BC-ADM, FAADE, executive director of the Diabetes and Obesity Institute of NYU Winthrop Hospital and professor of Medicine at Stony Brook School of Medicine, told educators gathered Saturday that the right model for reducing readmissions “doesn’t have the hospital at the top—it has the community at the top.”

“Transitions are going to look different,” she said. While the ACA has forced changes and things have improved, there’s still a long way to go. The challenges start even before the patient leaves the hospital, Peragallo-Dittko said. If a patient is diagnosed with diabetes in the hospital, it can take up to 2 weeks for a meter to arrive by mail order, and if a prescription for insulin is called in, the abandonment rates are extremely high.

If a patient returns home to the same diet and lack of family support, “who do you think is likely to be readmitted?” she asked.

Patients with diabetes account for more than their share of hospitalizations; a study in California found that people with diabetes over age 35 made up 31% of hospitalizations in that state in 2011. But, she asked, “What do we know about inpatient or outpatient transitions of care?”

When it comes to diabetes, these transitions are understudied, she said. What is known is that many problems start before discharge or relate to the discharge process itself, including:

• Patients want to go home and don’t listen to discharge instructions
• Patients don’t ask questions
• The family caregiver is not present, or there is no caregiver
• The patient is overwhelmed by the information

Peragallo-Dittko said many patients with diabetes have chaotic home lives and not only have no help, but their health is undermined. If diabetes is not the main cause of hospitalization, the disease may take a back seat. “Our patients are very sick coming into the hospital. Many are poor and have limited resources,” she said.

One study of 400 patients with diabetes who were discharged found that within 3 weeks, 19% had an adverse event, of which 66% were related to a problem with prescription drugs.

Diabetes care remains very fractured, and hospitalists and primary care physicians do not always coordinate despite the calls for more patient-centered care. A senior citizen who is instructed to follow up with a surgeon and a doctor about his diabetes will make the surgeon the priority, Peragallo-Dittko said. “He’ll say, ‘I’m not going to ask my daughter-in-law to take another day off to take me to the hospital.’ “

Telehealth could solve some of these issues. But telehealth reimbursement is not permitted in suburban and urban areas, she said. So, diabetes educators find themselves in the middle, trying to resolve transportation issues and psychosocial problems that keep people with diabetes from seeking care. Educators who spoke during the question period told of helping patients find funds to deal with a lack of functioning bathrooms or bedbugs. Getting an insulin prescription filled isn’t on that person’s radar, they said.

Peragallo-Dittko reviewed a series of successful intervention projects. “Most interventions are complex,” she said. “The successful ones use home visits, although we frequently see patients refuse home visits.” Why would a patient do this? “We hear, ‘I haven’t cleaned.’”

For diabetes educators, the challenge is figuring out “who needs us the most,” and helping physicians with items like prior authorization, getting meters to patients as quickly as possible, and overcoming problems like lack of testing supplies. One successful intervention worked because the diabetes educators were willing to take phone calls 7 days a week, reasoning this was better than dealing with a readmission.

Peragallo-Dittko encouraged the educators to use metrics to gauge their success, and to realize that not all steps will work with every patient. While diabetes educators are passionate about what they do, no one person can do it alone. “At some point, you’re going to need a village,” she said.