Health analysts Dr. Foster have conducted research into the impact of government policy which penalises acute trusts whose patients return within 30 days of being treated. The findings will make painful reading for many NHS medical directors and chief executives. It estimates that hospitals could lose up to £1.5bn of NHS funding a year, with some individual trusts facing losses as high as £28.7m. The study reveals that, in 2009, hospitals earned £1.49m for treating patients who were readmitted within 28 days of undergoing surgery, or 6.7% of the total. It warns that they stand to lose some or all of that income under the new regime. 

Health secretary Andrew Lansley claims the aim of the new policy is to make hospitals and mental health establishments work more closely with GPs and community-based healthcare professionals to ensure patients receive more help with their convalescence after discharge, making them less likely to return to hospital.

“It will be in the interests of the hospital for patients to be discharged only when it is ready and safe for them to do so,” says Lansley. “If a patient is readmitted within 30 days, the hospital will not receive payment for the additional treatment. We’re sending a clear message that patient care doesn’t end when they walk out of the hospital door.”

Surveys highlight inadequacies

Little wonder, then, that acute trusts are keen to stem readmission rates which have soared over the last decade, says Dr Steffen Achenbach, Medical Director Europe at Microsoft. “Unplanned readmissions aren’t good for patients or their families, and many readmissions could be avoided. If the patient is deteriorating in a post-acute situation, all sorts of fears are triggered and complications can easily arise. Avoidable readmissions are bad news for taxpayers, too, as the NHS bears the unnecessary cost of care, leading to wastage of resources.”

Nor do the challenges for acute trusts end there. As of April last year, they must also provide a Discharge Summary to the GP within 24 hours of a patient’s release from hospital. Research suggests, however, that many are struggling to achieve this quality level. Indeed, a 2010 survey by the NHS Alliance found that GPs believe the quality of hospital discharge information is deteriorating, with 57% claiming patients are put at risk by poor reporting. Moreover, 70% said discharge information was invariably late, incomplete, or both, while data on medication changes was frequently absent or incomplete.

In addition to poor information about care, an earlier Inpatient Survey by Picker Institute Europe found that the patient experience of the discharge process is also far from ideal: on average, 37% of patients had their discharge delayed, some by up to four hours; 37% were not given any written information about what they should or shouldn’t do after leaving hospital; while 52% didn’t receive a copy of the discharge letter from the hospital to their GP.

The need for better discharge planning

Whilst many studies tend to focus on cost, Dr Achenbach believes trusts need to understand why a patient is readmitted within 28 days. “All too often, Community Services or GPs do not have the information they need to handle an early complication, so often the only option they have is to send the patient back to hospital.

Clinicians then face the challenge of detecting such readmissions and reacting to them correctly. They need to ask the right questions - like ‘what’s gone wrong and why are you here?’ If they don’t document information along the patient journey, that’s when they end up being financially penalised. By getting to the bottom of a patient’s previous medical history, clinicians can often detect unnecessary readmissions in time to put them back more appropriately into the hands of the GP or community services.”

At the same time, Dr Achenbach says hospitals should ensure patients are only released upon satisfactory recovery and with the right support and information. And whilst a thorough hand-over to community services and GPs is necessary for every patient, he says there are many cases where it is absolutely essential. There are a number of things a trust can do proactively to reduce readmissions through more efficient and safer patient discharge planning.

“It is crucial to provide additional checkpoints, follow-up calls, coordination with primary care - but unfortunately, it would be too expensive to do this for every patient,” he says. “Hospitals therefore need to gauge their patients carefully to identify those who would benefit most from these additional steps. This is where good discharge planning comes into play. Once the planned discharge date is set, staff should have a clear picture of what’s needed, and by when, and then coordinate post acute care with the GP or Community Services as appropriate.

“Responsible discharge is about hospitals providing transparency for GPs and community services, so they have a clear picture of what happened to the patient in hospital, what medication they now require, provision of test results and so forth. By providing an automated summary of available data on patients, GPs and community services can understand much better what’s really wrong with them and decide on the best course of action, rather than simply sending them back to the hospital.”

Dr Achenbach concedes, however, that achieving a reliable discharge summary is often hampered by a lack of visibility across the breadth of patient data. “Non-interoperable IT systems within hospitals can make it difficult for clinicians to get a comprehensive view of patient information - they often have to look in several different places to find everything they need. What’s more, those systems frequently have to ‘time out’ after a period for security and privacy reasons, so they have to constantly login, wasting huge amounts of time and causing frustration.”

Consolidating patient data in a single interface

One organisation that recently overcame this problem is Milton Keynes Hospital NHS Foundation Trust, which has expanded its deployment of Microsoft Amalga - Microsoft’s real-time data aggregation system - to minimise patient readmissions. By unlocking and pulling raw data from a wide range of existing core technology systems, the Amalga platform is able to present it through a single interface to authorised members of clinical teams, enabling them to rapidly access consolidated patient information.

Amalga enables Milton Keynes clinicians to take this aggregated information and create reports and dashboards to better analyse patient data that was previously locked in siloed systems. “By bringing data together into a single interface, our staff can provide quicker, more accurate diagnoses - with the ultimate goal of improving patient care and advice,” says Consultant Physician Dr. Vasantha Kumar. “Amalga also helps lower our costs because we don’t have patients returning to us due to mistakes. As well as making us much more agile and flexible clinically, it helps us improve patient care, while also aligning ourselves with the Commissioning for Quality and Innovation (CQUIN) targets and reporting.”

Amalga also offers powerful discharge summary functionality, aggregating data in near real-time to pre-populate electronic forms ready for discharge. These forms and automated alerts:

• flag patients at risk of readmission while still in the hospital
• automate reporting against compliance targets
• can be tailored for particular departments and roles
• incorporate performance dashboards for use by consultants and management.

“By pulling data together from a variety of sources, Amalga enables clinicians to detect those patients who have a higher risk of re-hospitalisation and then coordinate their care with the GP or community services to provide better monitoring and early intervention in the event of deterioration,” says Dr Achenbach. “The platform is also being used by some colleagues to create ‘virtual wards’ and monitor patients following their discharge from hospital. This enables clinicians to call patients up, enquire about their progress and offer advice - rather than waiting for them to show up in A&E and having to treat them without being reimbursed.”

A solution for commissioners and providers alike

The UK is by no means alone in penalising hospitals for preventable readmissions. From October 2012, Medicare in the US will begin imposing financial penalties on hospitals with higher-than-expected readmission rates for certain conditions such as heart failure or pneumonia. “It is clear that hospital admissions and readmissions are becoming a critical parameter worldwide for tracking care delivery from both a financial and quality perspective,” says Dr Achenbach.

“Microsoft Amalga will enable NHS trusts to address this very important business need by helping them identify the root causes of multiple readmissions more easily and by strengthening the discharge process. What’s more, it will benefit GPs by enabling them to maintain more accurate records of medication and treatment, and by helping them to make more informed decisions about healthcare in the community.”

More on Amalga Unified Intelligence System (UIS): http://www.microsoft.com/amalga/default.mspx