Healthcare News & Insights

Functional impairments in Medicare patients linked to readmissions

ThinkstockPhotos-122552779You’re probably sick and tired of hearing about hospitals having to reduce readmission rates or be financially penalized. After all, your facility is doing everything it can, right? 

Maybe there is something else hospitals can do.

A new study from JAMA Internal Medicine found functional impairment is associated with increased risk of 30-day readmission in Medicare beneficiaries, especially in those admitted for heart failure, myocardial infarction or pneumonia.

Makes sense. Of course acute illnesses can have negative effects on elderly patients’ functional status, which can send their health into a downward spiral.

Medicare requirements

Medicare realizes this too because it requires functional assessments for reimbursement in acute rehabilitation and nursing-home settings, but it doesn’t require it for hospitals and skilled-nursing facilities. And given Medicare’s current policy on reducing readmissions by penalizing hospitals with high readmission rates, it would seem to be a logical step.

But until this study, few have analyzed the role of functional impairment on readmissions.

Over a 10-year period, the study analyzed 7,854 community-dwelling seniors with 22,289 Medicare hospitalizations. The primary outcome was 30-day readmission assessed by Medicare claims, and the main predictor was functional impairment determined from interviews preceding hospitalization.

The researchers broke down functional impairment into five levels:

  • no functional impairments
  • difficulty with one or more instrumental activities of daily living (IADL)
  •  difficulty with one or more activities of daily living (ADL)
  • dependency (need for help) in one to two ADLs, and
  • dependency in three or more ADLs.

Adjustments were made for health and demographic factors shown to effect 30-day readmission in prior studies. And follow-up surveys were given to all participants every two years.

Study results

Overall, 48.3% of the Medicare participants had functional impairments associated with higher readmission rates. And as the risk of admission increased, so did the severity of the impairment. In fact, patients with the most functional impairments were 42% more likely to be readmitted compared with those with no impairments.

The breakdown was:

  • 13.5% had no functional impairment
  • 14.3% had difficulty with one or more IADL
  • 14.4% had difficulty with one or more ADL
  • 16.5% had a dependency in one to two ADLs, and
  • 18.2% had a dependency in three or more ADLs.

In the subanalysis, which was restricted to patients admitted with conditions targeted by Medicare (i.e., heart failure, myocardial infarction and pneumonia), this trend became even more prominent for the most impaired:

  • 16.9% had no functional impairment
  • 16.5% had difficulty with one or more IADL
  • 18.8% had difficulty with one or more ADL
  • 18.4% had a dependency in one to two ADLs, and
  • 25.7% had a dependency in three or more ADLs.

Overall for this group, 19.2% of admissions were associated with a 30-day readmission.

“Functional status matters and Greysen et al deserve credit for drawing attention to this important outcome,” wrote Dr. Laura Burke and Dr. Ashish Jha, in an accompanying editorial. “Indeed, their findings should encourage medical centers to focus on patients with disabilities and to intervene in ways that reduce readmissions.”

Financial implications

The study authors pointed out how the link between functional status and readmission risk also has important financial implications for hospitals. “The difference in readmission rates we demonstrate, while modest in absolute terms (10% difference between unimpaired and the most impaired), can translate to substantial penalties for individual hospitals under the new CMS [Centers for Medicare & Medicaid Services] readmission reduction program.”

So if you can improve the functional status of patients, hospitals can reduce their readmission rates and risk of being penalized.

Another positive: Assessing IADL and ADL impairments doesn’t take special equipment or training. While there are several scales available, a series of simple questions asked of the patient or caregiver is all it takes, as long as providers consistently use the same measure.

 

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