The primary goal of this project was to understand readmission factors germane to the Indian Health Service (IHS) and how these factors intersect with Centers of Medicare and Medicaid Services (CMS) regulatory requirements. National readmissions best practices were identified and adapted for potential to improve care transitions in this marginalized population. The secondary goal of this project was to observe the early stages of national health policy translation into frontline practice within the IHS.
IHS hospitals generally have fewer than 50 beds and provide essential services in their communities. Many of the diagnoses targeted by CMS in their readmissions reduction effort (heart attacks, heart failure) are not a significant component of IHS hospital case mix. There is concern that the CMS risk adjustment model does not capture the factors that drive readmissions for IHS patients. The IHS functions as a quasi-closed, predominantly indigent care health system. Distance from specialty care, underfunding, and support service limitations directly impact health outcomes in Native communities.
The IHS Hospital Consortium is comprised of the 28 hospitals. Interagency agreements between the Department of Health and Human Services (HHS) and the Center for Medicare and Medicaid Innovation (CMMI) within CMS have allowed IHS to participate in the Partnerships for Patients initiatives around hospital medicine. The IHS readmissions arm captures readmissions data in three domains: for each facility; transfers from facility emergency departments; and admissions to hospitals outside the IHS system.
A structured review of medical and health policy literature was performed and national best practices around readmissions identified. The literature review directed key informant interviews with frontline staff as well as experts in hospital quality improvement to determine the applicability of various readmissions reduction strategies to the IHS context. Strategies to strengthen relationships with referral facilities were included since IHS facilities are often a conduit for readmission and may be the only focal point of contact for a multiply-admitted patient. Learning tools to evaluate readmission patterns and incorporate tribal and patient perspectives were included.
National policy formation to reduce readmissions has applied hospital-specific risk-standardized readmission rates across vastly different hospital systems to benchmark rates to a national standard. Hospitals have assigned significant resources to address the issue but may have limited ability to influence the drivers of readmission, including local issues of provider access, limited support service availability, and patient engagement.
Hospital readmission is not a “one-size-fits-all” metric. It is hoped that healthcare quality will increase and hospital utilization decrease as frontline hospitals implement strategies to improve communication with patients and primary care providers. Future studies are needed to develop a more nuanced understanding of the intersection between hospital, community, and primary care in the health outcomes of individual patients.
David Civic, MD, Director of Quality Management, Phoenix Indian Medical Center
Ty Reidhead, MD, CMO, Phoenix Indian Medical Center