The Senate Health Education, Labor & Pensions (HELP) Committee released its piece of the comprehensive health care reform bill on June 9. Despite being 615 pages long, several key provisions of any health care reform legislation are not in the HELP Committee bill because they are issues that fall under the jurisdiction of the Finance Committee. Most of the issues related to Medicare, Medicaid, other public options, and taxes (basically how to pay for expanded coverage) will be proposed in the Finance bill, likely coming out next week.

But HELP is first to the table, and may start marking up this bill as early Tuesday, June 16. So it’s worth looking at the bill and asking: What key features of it facilitate more patient-centered health care delivery?

Perhaps most importantly, the provisions of the Wyden-Gregg “Empowering Medicare Patient Choices Act” (see here for overview) that fall under the jurisdiction of HELP are included in Sec. 217, Program to Facilitate Shared Decision-Making (pp. 301-311). Much of the meat of this bill (Medicare carrots and sticks) comes under the jurisdiction of the Finance Committee, but this is a critically important start.

Sec. 212. Grants to Establish Community Health Teams to Support a Medical Home Model provides several opportunities for driving patient-centered care delivery and the provision of information therapy (Ix), though much will depend on how it is implemented. Opportunities include emphasis on “payment that recognizes added value to patient in a patient-centered care; [sic]” (a few typos aren’t surprising when those Hill staffers are working round-the-clock these days). There is also a recognition that support should be provided to PCPs to “provide quality-driven, cost-effective, culturally appropriate, and patient- and family-centered health care” and “promote effective strategies for treatment planning…sharing information, treatment decision support…”

The role of Ix in patient-centered discharge planning and reducing readmissions is highlighted in both the medical home section and in Sec. 216. Reducing and Reporting Hospital Readmissions (see here for discussion of Ix role in this area). Ix and patient-centered HIT are also an important part of the solution for Sec. 213. Grants to Implement Medication Management Services in Treatment of Chronic Disease.

Admittedly, I haven’t finished all 615 pages, so I’ll probably find more in here over the weekend. If you think I’ve missed answers to my question (What key features of it facilitate more patient-centered health care delivery?), please add in the Comments section.

What are the best strategies for ensuring that health care reform achieves our multiple goals of universal coverage, cost control, and improved quality? I certainly don’t have all the answers, but it’s worth starting with a few, and have all of you build on them.

To be more specific, my primary question here (I recognize there are other ways of framing the discussion for finding answers to the first question) is: What are practical reforms we could make to the delivery system that create better, more patient-centered care delivery at the same time as reducing (or slowing the rate of growth of) costs that free up money to cover un-/under-insured people?

To start with, we can gradually build an expectation of prescribed patient decision aids into the care delivery process. I described a practical model for implementing this model of shared decision making (SDM) here last week in describing new legislation introduced by Senator Ron Wyden (D-OR) and co-sponsored by Senator Judd Gregg (R-NH). The basic idea is to begin with pilots and the development of standards and measures that lay the groundwork for ubiquitous SDM embedded into future care delivery a few years down the road.

We can also take a different approach to how we deal with costly preventable hospital readmissions.  The opportunity here is enormous, which is probably why legislators are seriously considering revamping Medicare payment policy in this area. An Agency for Healthcare Research and Quality (AHRQ) report estimated that hospitals spent almost $31 billion on over 4 million unnecessary readmissions in 2006.  Almost 20% of Medicare beneficiaries are re-hospitalized within the first 30 days of hospital discharge. For heart failure, that figure rises to 27% and in half of those readmissions, there was no outpatient visit billed to Medicare in the month following discharge.

Thankfully, not only is the financial opportunity huge, but the solutions (comparatively speaking) do not require extraordinary measures. During a recent IxAction Alliance webinar, Mark Stewart from the American College of Cardiology (ACC) described the Hospital to Home (H2H) project ACC has developed in collaboration with Don Berwick’s Institute for Healthcare Improvement (IHI). This summer, 1,500 hospitals will engage in the H2H project (as CMS publicly releases hospital readmission rates for the first time) and implement solutions with information therapy (Ix) components such as:

• Pre-discharge education/assessment
• Medication reconciliation
• Follow-up within specific time frames
• Home health involving patient/family education

Success of H2H interventions will be judged primarily by how well patients and their families:

• Understand when & where to seek medical attention
• Can access and are familiar with their medications
• Can schedule and get to their follow-up appointments

ACC and IHI are just a couple of examples of leaders in this area. Content developers such as Krames, Healthwise and Emmi Solutions have created specific Ix interventions focused on reducing hospital readmissions as well.

Beyond patient decision aids/SDM and Ix to reduce hospital readmissions, what other strategies should be integrated into whatever comes out of Congress to reform the health care delivery system? Share your thoughts in the comments below.

A good study appeared in the October 30, 2008 New England Journal of Medicine related to the first public release of HCAHPS data. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a “standardized survey of the experiences of adult inpatients with hospital care and services.” This study is based on July 2006-June 2007 voluntary reporting, but Medicare (CMS) is requiring hospital reporting going forward.

Overall experience data are not surprising: Reasonably satisfied but plenty of room for improvement. Although 89% of patients rated their overall experience 7 or better (10 being the best), only 63% rated it a 9 or 10.

What was most informative was where the data suggested were the greatest areas for improvement:

• Provision of clear discharge instructions
• Communication about medications
• Nursing care
• Pain control

I could make an argument that good information therapy (Ix) that was integrated into systems of care would improve performance in all four of these areas. Clearly, though, the first two areas for improvement are obvious targets for Ix interventions.

Hospitals that want to score better in how they provide discharge instructions and communicate about medications should be working hard now to embed Ix strategies into their core care delivery practices. With public reporting of HCAHPS data just around the corner, this could become an important strategic initiative for hospitals in competitive markets.

Research continues to show that patients do not remember - or understand - everything they are told when they are discharged from medical facilities.  An earlier Ix Blog post on health literacy and patient recall discussed findings such as 14% of patients being unaware of the fact that their physician had prescribed a new medication for them.

A more recent article in the Annals of Emergency Medicine found a strong tendency for patients to overestimate their understanding of emergency department (ED) care and discharge instructions.  Patients had more difficulty understanding post-ED discharge care instructions than information about the diagnosis and cause of their illness, ED care, or return instructions.

This research finding suggests that asking patients whether or not they understand medical instructions is not an adequate way to measure comprehension.  Although handwritten or printed discharge instructions are considered a best practice, this should not be the only method of communicating discharge instructions to patients.  Asking patients to explain information or instructions in their own words may be a better strategy for assessing patient understanding and providing clues about where to focus further discussion and explanation.

A recent University of California study reports a striking increase in fatal medication errors (FMEs) over the last 22 years.  The study examined accidental deaths occurring at home, but also included deaths occurring away from home.  The deaths were further categorized into those involving alcohol and/or street drugs and those not involving alcohol and/or street drugs.

The most striking increase in FMEs was with those that occurred at home, especially those involving alcohol and/or street drugs (a 3,196% increase).  FMEs at home, not involving alcohol and/or street drugs increased by 564%.   FMEs that occurred away from home involving alcohol and/or street drugs increased by 555%.  Finally, FMEs away from home, but not involving alcohol and/or street drugs increased by 5%.

Shifts in health care have resulted in reduced professional oversight and increased patient responsibility for monitoring medication use.  Information therapy prescriptions can play a critical role in complementing medication prescriptions.  If consumers are expected to manage increasingly complex - and potentially dangerous - drug regimes, they need access to tailored information to help them do so safely.

This month’s issue of Mayo Clinic Proceedings has two interesting studies and an insightful editorial (”Medication Literacy Is a 2-Way Street”) that highlight why information therapy (Ix) is so valuable at the end of a hospital stay.

Kripalani et al found that, for patients with limited literacy skills discharged for acute coronary syndrome, 22% had not filled their prescriptions and 21% had difficulty understanding the purpose of the drugs prescribed to them. Maniaci et al studied well-educated patients discharged from an internal medicine hospital ward with at least one new medication prescribed. This study found that, 1-2 weeks post-discharge, 14% were unaware of being given a new medicine. Much worse were the percentages of patients that could recall the name (64%), dosage (56%) or purpose (64%) of the drugs.

It’s clear that providers are not doing an adequate job of ensuring that patients are leaving the hospital with the information they need to manage their recovery effectively. But it’s largely not due clinician error; rather, it’s that little has been done to integrate that information transfer into the care delivery process–especially at critical moments in care such as the discharge process.

That’s why Ix is so critical to ensuring that discharged patients can recover to better health and reduce the chances of being readmitted. Innovative Ix leaders from around the country will be sharing best practices on how to change care delivery to meet patients’ information needs at the 7th Annual Conference. Please join us June 12-13 in Washington, DC to get engaged in this critical element of patient-centered care delivery redesign.