Health care delivery is changing, whether we like it or not. The-fee-for-service environment where quantity, not quality, is rewarded is not sustainable and contributes to fragmented care. In essence, patients are really the only ones accountable for their own care.

But this doesn’t work for a variety of reasons: lack of knowledge, access to care, or being in a state of denial about medical issues means care delivery can be delayed. If everyone was doing a great job educating patients about the dangers of poor health, obesity would be less of a risk and no one would smoke.

How to pay for care?

The rising cost of health care is not sustainable and major changes need to occur. The Department of Health and Human Services has adopted a set of three aims for health care: improve care for populations; improve care for individuals, and decrease the cost. This is also consistent with the National Quality Strategy.

Two of the most important changes from the Affordable Care Act included the expansion of health care coverage to many more people, primarily the working poor, and obtaining funding through the Center for Medicare and Medicaid Innovation. Sylvia Burwell, Secretary of the Department of Health and Human Services, recently developed significant goals and an aggressive timeline to change the reimbursement system to one that rewards quality of care and is consistent with the three aims. The goal is to have 30% of payment for traditional Medicare tied to alternative payment models by 2016 (the program is now at 20%). These alternative models can include Accountable Care Organizations and bundled payment systems. HHS wants to see that goal increase to 50% by the end of 2018. By end of 2016, HHS wants 85% of Medicare’s hospital payments made through programs such as Value-Based Purchasing and Hospital Readmissions Reduction and to increase it to 90% by 2018. 1

Readmissions becomes a target

Hospitals are in their fourth year of readmissions reduction, which denies Medicare payment for patients readmitted regardless of whether it was the same medical condition they previously received care. Last year penalties totaled $402 million. More than half of all hospitals, 2,592, will receive lower payments starting in October 2015. While the number of readmissions has dropped since the program began, about one of every five patients still gets readmitted within 30 days post discharge. The average payment reduction is 0.61% for all Medicare admissions for the next year with 38 hospitals receiving the maximum 3% reduction; 506 will lose 1% or more. 2

Hospital readmission now an ESRD QIP measure

Medicare’s Quality Incentive Program for dialysis care now includes review of hospital readmissions in 2015. With the cost of a dialysis patient exceeding $85,000 per year (see Fig. 1), which is about 10 times the yearly cost of an average Medicare patient, prevention of hospital admissions and readmissions is a top priority.

The costs of ESRD care

In 2012, 35.2% of dialysis patients in the US were readmitted within 30 days. This is higher than the rate for other chronic diseases, with 25% for congestive heart failure and 18% for chronic obstructive pulmonary disease. 3

The renal community, through various channels, has told the Centers for Medicare & Medicaid Services that the QIP metric to calculate ESRD readmissions is flawed. 3

Reducing hospital admissions and readmissions is feasible but it is a complex process because financial incentives for hospitals and dialysis providers are not necessarily aligned.

  • Hospitals’ livelihood and profits depend on admissions. Dialysis facilities don’t want patients admitted because they can’t bill for a missed treatment and the cost of an open station is expensive. The staff is already present; if the machine was set up then the supplies are wasted and there is no contribution to overhead.
  • Nephrologists earn professional fees when patients are admitted and readmitted and this reimbursement can be in addition to their monthly capitated payment rate. So there is no incentive for them to reduce hospitalizations. As a result of legislation approved this past year that ended the scorned sustainable growth rate — which threatened a more than 20% cut in physician pay annually — physicians will gradually see their payment tied to specific quality outcomes. That could provide incentives to reduce hospitalizations, but that program doesn’t begin until 2019. Physicians included in an alternative payment model will be eligible for 5% bonus payments from 2019 through 2024.

Regardless of these barriers, dialysis facilities are being held accountable by CMS to reduce hospital readmissions, and will face financial penalties if they don’t meet the QIP requirements. The role of the nephrologist is essential as is the dialysis interdisciplinary care team. But how can you make changes in a time-sensitive environment?

The CDC experience

Three years ago our Cleveland-based Centers for Dialysis Care (CDC) was contacted by one of the large academic medical centers (AMC) to work collaboratively on reducing congestive heart failure readmissions. The hospital had numerous care paths in place to manage CHF admissions, but dialysis patients were at the top of the readmission list. For a variety of reasons (short stays and/or not on a cardiology service), the ESRD patients were not included in the care paths. Due to the complexity of this highly vulnerable patient population and the transition of care issues, new processes were piloted in order to reduce the readmissions.

Starts at discharge…

The ACM implemented a new program called RED, which stands for Re-Engineered Discharge processes. The developers utilized the following:

  • Discharge advocate/care coordinators
  • Medication reconciliation
  • Enhanced patient and family education
  • Improved transfer of information to all stakeholders
  • Improved transitional care with CDC

We created and funded a new position called the Transitional Care Coordinator (TCC). For this pilot, the TCC was limited to working out of the largest CDC facility (80 stations and over 300 patients), and provide support on all hospital admissions to the main campus of AMC’s 1,000 bed academic medical center, located less than 1 mile from CDC. Admissions to other hospitals were handled by the facility staff in the tradition manner.

A number of systems were set up for the TCC. She was given access to the AMC’s electronic medical record so that she could read everything in the patient’s hospital chart. To enforce the collaborative approach, access to CDC’s EMR was also given to the nursing staff in the hospital dialysis unit and to the nurse practitioners. All of the nephrologists were already credentialed with CDC and had CDC EMR privileges.

A system was set up for the TCC to be notified whenever a CDC dialysis patient had been admitted to the AMC. The TCC would always notify the patient’s primary nephrologist so that he/she knew of the admission. In the past, the community nephrologists and the AMC nephrologists, who were not on service that month, often didn’t know that their patient was admitted until a call was made by a CDC nurse for return to dialysis discharge orders. CDC utilizes the best practice of never allowing an order “to resume previous dialysis orders.” This creates numerous last minute conflicts, such as when the nephrologist would refuse to give orders since he/she had no knowledge of what occurred during the admission.

Include the patient

The TCC tries to visit the patients in the hospital so that she can explain her role and to develop a relationship with the patient and the family/support system. She provides the patient with her cell phone number and email and encourages the patient and family to contact her with any questions. She also sees the patient on dialysis at least weekly for four weeks following discharge.

The TCC also reviews the CDC EMR to determine if there were any red flags of issues that if addressed could have potentially prevented the admission and/or need to be evaluated during the admission/readmission. The red flags include shortened and skipped treatments, inability to achieve dry weight, large weight gains, catheter usage,infections, and recent hospitalizations.

In addition, the TCC has been able to establish effective working relationships with the various members of the hospital health care teams, including the dialysis facility leadership and staff, nurse practitioners, social workers, and discharge planners on the multiple floors as well as with the nephrologists.

Even though the hospital tries to put most ESRD patients on the same floor, patients always end up in a variety of places. Over time the hospital has been very helpful to allow the TCC to make a presentation to all of the discharge planners and social workers so that they know her role and is a resource whenever CDC dialysis patients are admitted.

The TCC feels that she has been well accepted and is called appropriately. Even though the TCC’s role is really limited to just patients in the one facility, she takes calls about any patient from one of CDC’s 18 facilities. She passes that information internally to the most appropriate CDC person who can address the issue or who needs the information. This practice has worked well for the AMC since they only need to communicate to one person at CDC Discussion

Data in the literature, although limited, supports some of the main reasons why patients are readmitted, which include the following:

  • Patient did not follow discharge plans
  • Patient did not understand dis- charge instructions
  • Patient lacked support to comply with discharge plans
  • Patient had no primary care physician
  • Prescriptions not filled or picked up
  • No coordination between or among care providers

The TCC is able to talk with the hospital staff prior to discharge to improve the transition and address the above issues. In addition they jointly determine if they believe the patient is a high risk for readmission. Criteria they use includes:

  • living in a nursing home
  • having a poor support system at home
  • has a history of frequent hospitalizations
  • frequently skips and/or shortens their dialysis treatments, as well as other subjective information.

Patients are evaluated to determine if they would benefit from a home health visit. Patients are referred to determine if they qualify for reimbursement.

After evaluation of the outcomes for many months, the AMC decided to utilize home health even if the patient didn’t qualify when the team determined the patient to be at high risk for readmission. The data is still being collected and evaluated; however, based on anecdotal evidence, this practice seems to be cost effective.

Other opportunities: medication management

CDC has also been piloting a medication therapy management program. Frequently the pharmacist or the nurse practitioner for the pharmacist works with the CDC, the transition coordinator, and the AMC discharge planners to review the medications. If changes are requested, the pharmacy can either provide the medications prior to discharge or deliver them on the same day.

Other opportunities: primary care for every patient

Based on non-ESRD literature, read- missions were reduced when a patient saw their primary care physician with- in 7 days of discharge from the hospital. During the TCC dialysis pilot it was discovered that many dialysis patients either didn’t have a PCP or no one on the dialysis patient’s care team knew who they were. The AMC is now assigning a PCP prior to discharge to any patient who does not have one. Since most of the nephrologists function as the Principal Care Physician/ Primary Care Nephrologist (PCN), either the AMC’s discharge planner or the TCC attempts to schedule the patient to see their PCN within seven days of discharge. Patients with a PCN in private practice are more likely to get an appointment within that time frame. Due to time constraints, the AMC patients are scheduled to see the nurse practitioner within that time frame. This visit seems to be equally beneficial.

In addition the TCC assures that all other follow-up appointments are scheduled. She assures that the discharge summary information is obtained and that the PCN and the dialysis facility are aware of the discharge.

Through the CDC’s EMR system, the TCC sends an alert message to the dialysis RN so that when the nurse sees the patient, he/she is informed that this is the first treatment back following a hospital admission. That also triggers completion of the First Visit Back Assessment. Another alert is sent to the rounding nephrologist to also notify the physician of the recent hospital admission and requests a focused assessment based upon the reason for the admission. The TCC’s notes on the admission are also available in the CDC EMR for everyone.

Communication is key

Since the goal is to prevent read-missions within 30 days following dis-charge, the TCC coordinates weekly care conferences with the dialysis facility care team once a week for four weeks. The TCC usually sees the patients on dialysis at least once a week and reviews the EMR to follow- up on the patient’s progress. The RN’s first assessment following discharge and the rounding physician notes are also reviewed. The TCC and the other care team members meet weekly to discuss progress with the plan and document any changes. The PCN and the pharmacist and/or the pharmacist’s NP and the AMC’s home health staff also try to attend the weekly conferences either on site or via a conference call. While the meeting can be time consuming, all agree that it is valuable. There has also been a learning curve with these and they now tend to go more quickly.

On a monthly basis, the TCC and other CDC staff meet at the AMC with numerous members of their teams to review and discuss all readmissions within the prior month. Both parties evaluate the data from their own perspective prior to the meeting and then they share data to determine what could have been done to prevent the readmission. These meeting have been productive and no one is blamed. The goal is to prevent future readmissions by developing patient centered prevention interventions.

Lessons learned

The combined teams have learned a lot. They have discovered that a multitude of psychosocial problems are often part of frequent re-admissions. In our centers, other reasons can include cocaine-induced chest pain, relapsing chronic conditions (e.g. pancreatitis, ascites), patients with poor attendance at dialysis, and poor adherence to the prescribed dialysis time. Utilization of palliative care for symptom management has also increased.

And the sickest patients tend to lead the pack. The “frequent flyers.” or the most vulnerable patients, account for 13% of our population — and 31% of the readmissions. These MVPs have been the subject of very specific joint care planning conferences. One patient who had numerous readmissions became the case study in a joint care conference with 19 medical professionals, including physicians from the emergency department. They were a critical addition. Once the ED physician was on board with the care plan, the number of readmissions decreased significantly.


Transitional care coordination is a critically important and complex function, but in our view is required in order to help prevent readmissions. It is time consuming and requires collaboration among all parties. Dialysis staff nurses do not have the time required to coordinate all of the functions.

The utilization of a Transitional Care Coordinator is an effective way to keep the multiple stakeholders informed and involved in the process. Technology in our TCC pro- gram was a great resource. Gaining access to the AMC’s EMR was a difficult and time consuming process, but well worth it.

As noted earlier, communication is key in making the TCC position successful. A task list and a report are sent each week prior to the weekly conferences following hospital discharges. These reminders help each member of the team to be well prepared for the weekly care planning meetings. The task list is available on a shared site on the CDC intranet so that all members can see it. The TCC utilizes a Surface Pro-3 tablet to gather and review information. Information from the CDC and AMC’s EMRs is easily accessible on the TCC’s phone, desktop computer and tab- let. The screen from the tablet can be removed and used to provide patient education at the chair side.

There is a high degree of physician, staff, and patient satisfaction with the TCCs. Patients love having “their own nurse.” Care coordination can help to reduce readmissions provided there are enthusiastic, creative, and collaborative stakeholders. The TCC is the critical link to success and needs to be highly motivated, assertive, knowledgeable, personable, flexible, have good communication and computer skills, be highly organized, and can work autonomously in a team environment.

We consider the TCC concept a success, but it seems like the work we have done is just the beginning. There are no quick fixes and there are tremendous opportunities to improve quality and decrease costs. The utilization of a TCC to connect all of the dots is essential and in the future needs to be funded in some manner above the expanded dialysis bundle. CDC, as a not-for-profit organization with over 40 years of service to the northeast Ohio area, has been willing to fund the pilot project for the past three years in preparation for future integrated care opportunities. We think it is a solid investment with many good returns.