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November 15, 2012

Reducing Readmissions

According to new data published by the Institute of Medicine in 2011, of all Medicare hospital admissions, approximately 19 percent of patients are readmitted to a hospital within 30 days, and, according to the New England Journal of Medicine, preventable readmissions are estimated to cost $17 billion annually to the Medicare program.

With numbers like these, healthcare organizations must be aware of the lack of care coordination and what they can do to enhance the patient experience and reduce readmissions.  In this offering of Off the Shelf we present you with important resources to help your facility avoid penalties and stay on track to efficiently reduce readmissions and improve patient care.

Hospital Readmissions Reduction Program

Recently, the Centers for Medicare and Medicaid Services (CMS) have begun implementation of the Hospital Readmissions Reduction Program as part of Section 3025 of the Affordable Care Act.  Hospital payments are being adjusted based on 3 years of claims data (July 2008 – June 2011) which showed excess readmissions after acute myocardial infarction, heart failure, and pneumonia hospitalizations.

Currently, 2,217 hospitals have been fined penalties ranging from 0.01 to 1 percent of FY 2013 Medicare revenue.  The penalties will increase to 2 percent in FY 2014 and 3 percent in FY 2015.  With the penalties looming, CMS does not prescribe specific actions for hospitals to take to reduce high readmission rates.

Care Coordination

While some readmissions are unavoidable, care coordination could have a substantial impact on making a successful transition from the hospital to home or skilled nursing facility.  Care coordination is vital for Medicare populations with multiple acute and chronic conditions, but, in fee-for-service Medicare there is a lack of coordination of care among a multitude of providers and settings.  Many Medicare patients have a number of health events each year and this population may have challenges that hamper communication with multiple providers about their condition.

The June 2012 Medicare Payment Advisory Commission (MedPAC) report on Medicare and the Health Delivery System outlined three reasons for poor care coordination.

  1. No single entity is responsible for care coordination. Many providers, settings, and clinical and nonclinical staff are involved with each patient’s episode of illness.
  2. Fee for service payments do not usually pay for non-face-to-face activities such as communication between providers to coordinate a patient’s care.  Lacking the ability to bill for these services leaves little incentive to spend time coordinating care.
  3. There is no easy way to communicate information across providers and settings.

The MedPAC report also describes a variety of models to improve care coordination that have been developed to maximize the experience for people who can most benefit from improving the delivery of coordinated care.  The models vary in design and attempt to coordinate care by:

  • Transforming primary care practices that can better manage patients with a heavy chronic disease burden (chronic care model or medical home)
  • Utilizing a care manager role, either inside or outside the physician’s office (nurse case managers embedded in physician practices)
  • Managing transitions between settings, targeting hospital patients who are discharged to other settings (transition coaches, advanced practice nurses, community health teams, or disease management organizations)
Quality Improvement Efforts & Resources

Established by CMS, QualityNet provides healthcare quality improvement news, resources, and data reporting tools and applications to hospitals, quality improvement organizations (QIOs), nursing homes, physician offices, and data vendors.  Through this CMS-approved resource, QualityNet has identified a series of initiatives to reduce readmissions and improve care:

Other CMS-approved initiatives include:

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