Hospital Readmission Roullette

Hospital Readmission Roulette
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc. (HHI)
Presented by:
Diane Buckley, BSN,RN RAC-CT
Director of Quality & Performance Improvement

Harmony Healthcare International, Inc. 3
Speaker Bio
Director of Quality and Performance Improvement for
Harmony Healthcare International, Inc.
Over 25 years in the healthcare industry
Nurse Manager
Director of Admissions
Director Case Management
Manager of Quality & Risk Management
Training and development of training modules for
Critical Care
Home Care
LTCH
Acute Care
Long-Term Care and Case Management
Copyright © 2013 All Rights Reserved

Disclosure: The planners and presenters of this
educational activity have no relationship with commercial
entities or conflicts of interest to disclose:
Planners:
Elisa Bovee, MS, OTR/L
Diane Buckley, BSN, RN, RAC-CT
Beckie Dow, RN, RAC-MT
Keri Hart, MS CCC, SLP, RAC-CT,
Kristen Mastrangelo, OTR/L, MBA, MHA
Christine Twombly, RNC, RAC-MT, LHRM
Presenter:

Disclosure
Speaker:
The speaker has no relevant financial
relationships to disclose
The speaker has no relevant nonfinancial
relationships to disclose
Copyright © 2013 All Rights Reserved 5

Criteria for Successful Completion
Complete Sign-in and Sign-Out on
Attendance Form
Attendance for entire session
Completion and submission of
speaker evaluation form
Copyright © 2013 All Rights Reserved 6

Objectives:
The learner will be able to summarize the CMS
quality initiative for healthcare reform related
to hospital readmissions
The learner will be able to identify underlying
causes and barriers related to readmissions
The learner will be able to state current CMS
research projects and pilot programs
The learner will be able to identify hospital and
SNF strategies for collaboration
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7

Reducing Re-hospitalizations among
Medicare beneficiaries has become a high
priority for policymakers and the Center
for Medicare & Medicaid Services (CMS)

Hospital Readmissions are seen as an
important indicator of care quality and
account for billions of dollars in annual
Medicare spending (MedPac, 2007)

Harmony Healthcare International, Inc. 10Copyright © 2013 All Rights Reserved
Hospitalizations and Rehospitalizations
are symptomatic of multi process defect in
the health care system due to lack of:
Timely or equitable access to care
Effective handoffs and coordination of care
Safe care
Patient centered and appropriate end of life
care

Five most common Medical condition
for Readmission:
Heart Failure
Pneumonia
COPD
Psychoses
GI problems

Five most common surgical procedures:
Cardiac stent placement
Major hip or knee surgery
Vascular surgery
Major bowel surgery
Other hip or femur surgery

Hospitalization of Nursing Home Residents
Common
Expensive
Often Traumatic to resident and family
Tense with many complications
Delirium
Polypharmacy
Falls
Incontinence and catheter use
Hospital acquired infections
Immobility, De-conditioning, and Pressure Ulcers
Reducing Potentially Avoidable
Hospitalization

Reducing Potentially Avoidable
Hospitalization
Some Hospitalizations of NH Residents
are Avoidable
As many as 45% of admissions of nursing
home residents to acute hospitals may be
inappropriate (Salibaet al, J AmerGeriatrSoc 48:154-163, 2000)
In 2004 in NY, Medicare spent close to $200
million on hospitalization of long-stay NH
residents for “ambulatory care sensitive
diagnosis”
Grabowski et al, Health Affairs 26: 1753-1761, 2007

Why do Re-admissions happen?

Discharge from Hospital is critical and
requires adequate planning and
preparations to avoid
Medication errors
Poor discharge planning
Inadequate arrangements
Poor communication
Adverse events

Medication Errors: The patient is discharged
without prescriptions for the proper mix and
doses of medication, or lacks instructions for
taking them, or new prescriptions may interfere
with existing medications.
Poor Discharge Planning: There is little or no
effort to plan follow up care, including
scheduling necessary doctor’s appointments.

In half of all Medicare 30-day
readmissions, patients had not seen
their regular medical doctor or any
health provider following discharge.
Inadequate arrangements: Family
members and other caregivers lack
information or are unable to care for the
patient after discharge.

Poor Communication:
Providers delay providing discharge instructions, or
fail to provide them at all.
Lack of discharge summaries to community physicians
and post-acute care providers.
Too many cases of community providers that have no
reports, test results, or other history when seeing the
patient at first post discharge visit.
Patients may not have received information on how to
have a successful recovery.
such as alerting them about symptoms that may need medical
attention in an outpatient setting.

Research Recommendations:
Interventions at time of Discharge
Reliable & prompt follow-up care by
primary care physicians
Aggressive Management of chronicle
illness

Some Readmission to the hospital are
planned
Other are avoidable and the result of
Poor quality of care/ uncoordinated care
Variation in readmission rates by hospitals
and geographical regions
Readmissions rates can be reduced with
application of evidenced based guidelines
and enhanced care coordination

Medicare readmission rates
for Skilled Nursing Facilities
to hospitals increased 30%
from 2000 to 2006

1 in 4 patients admitted to a SNF are
re-admitted to the hospital within 30
days at a cost of $4.3 billion

~ 10% - 25% of long stay NH residents are admitted to
an acute hospital over a 5-month period

June 2007 & 2008 Medicare Payment
Advisory Commission (MedPAC) Report to
Congress highlighted avoidable
Rehospitalizations as an area of high cost and
low quality
Prompted leaders of healthcare systems across
the country to focus on avoidable
Rehospitalizations in anticipations of potential
changes in the market

2009 Re-Admissions emerged as a Major
Quality Initiative of Healthcare Reform.
Reducing Re-hospitalization is an
important element of President Obama’s
February 2009 proposal for financing
Health Care Reform.

12 million fee-for-service Medicare
beneficiaries were analyzed per New
England Journal of Medicine
20% who had been discharged were Re-
hospitalized within 30 days ( 1 in 5 discharges)
34% were Re-hospitalized within 90 days
51% within 1 year
13% of the readmissions - $12 billion worth –
were “potentially avoidable,” (IPPS rule).

90% Re-hospitalizations within 30 days are
unplanned
75% of Readmissions preventable equating to
$12 Billion a year to Medicare spending
68.9% of patients discharged with a medical
condition, were re-hospitalized or died within
one year of discharge
53% re-hospitalization of Discharges after a
surgical procedure

.
50% of re-admissions within 30 days had
no bill for a physician visit
70% surgical patients were admitted for a
medical condition such as pneumonia and
UTI
19% of Medicare discharges are followed
by an adverse advent with 30 days:
2/3 Drug Events that are preventable

Payers & Policymakers are targeting
Readmissions to reduce healthcare
expenditures & improve quality of
care and patient outcomes
Rehospitalization has become a focus
for Medicare, other payers, and quality
care organizations do to its Clinical
and Financial impact.

The Affordable Care Act
From a Policy perspective performance
variation indicated lack of reliable
attention to executing successful
transition out of the hospital and into the
next care setting
Several provisions regarding improving
Care Transition, Care Coordination and
Reducing readmissions

HEALTHCARE POLICY PRIORITY
Affordable Care Act
Accountable Care Organizations (ACO)
Bundled Payments
Strategic Partnership
Clinical & Financial Performance Data

Healthcare Policy Priority
Besides the penalties, the Obama administration is
ramping up other efforts to reduce readmissions.
Giving out $500 million to help hospitals and other health-
care providers improve the transitions of patients out of
hospitals
And the administration has approved 154
“Accountable Care Organizations,” which are
collaborations of hospitals, doctors and other health-
care providers that receive financial incentives for
preventing costly episodes such as readmissions

CMS actively working to change
payments to hospitals to incentivize
readmission reduction
Hospitals with high rates of
preventable readmission will have
payments reduced

CMS has undertaken several initiatives
to reduce readmissions among the
Medicare fee- for- service (FFS)
population

Initiatives:
Reporting hospital readmission rates
through Hospital Compare
Funding hospital level improvements
through partnership program
Changing Payment Policies through the
Hospital Readmission Reduction Program
Various Shared Savings Initiatives

Section 3025 of The Affordable Care Act added
section 1886(q) to the Social Security Act
establishing the Readmission Reduction Program,
which requires CMS to reduce payments to IPPS
hospitals with excess readmissions, effective for
discharges beginning on October 1, 2012

FY 2013 IPPS Final Rule finalized the following
policies
Which hospitals are subject to the Hospital Readmission
Reduction Program
The Methodology to calculate the hospital readmission
payment adjustment factor
What portion of the IPPS payment is used to calculate the
readmission payment adjustment amount
A process for hospitals to review their readmission
information and submit correction to the information before
the readmission rates are to be made public

FY 2014 IPPS Final Rule finalized changes to the methodology to
calculate the hospital readmission adjustment factor.
Readmission Adjustment Factor:
FY 2013, the higher of the Ratio or 0.99 (1% reduction)
FY 2014, the higher of the Ratio or 0.98 (2% reduction)
Penalties will increase to a maximum of 2 percent for FY 2014
& 3% for FY 2015
CMS considering similar payment reduction based on high
readmission rates after joint replacement, stenting, heart
bypass and stroke

As of October 1, 2012 a substantial number
of hospitals began receiving reduced
payments from Medicare due to high
readmission rates within 30 days of
discharge
Approximately 2,200 hospitals (2/3 of all
hospitals) received a reduction in
reimbursement for fiscal year 2013
(ranging up to the maximum 1%)

Significant number of hospitals have
been working on innovative programs
using a wide variety of approaches
based on the Hospital Reduction
Program

Major Points are emerging from current
initiatives:
The reason for admissions aren't what people
generally assume
Clear communication during transition is key
Hospital and health systems are forming
collaborations with nursing homes and home
care agencies, including monthly council
meetings to look at problem cases together
and explore the story behind the story

initiatives (continued):
Hospitals are developing innovative services to
offer needed support to patients without
necessarily admitting them
Hospitals and health systems are revamping
transfer forms and educational materials to
support smooth transitions and consistency
between different settings

initiatives (continued):
Hospitalists in the post-acute setting play a
valuable role in reducing readmissions
Hospital and health systems boards need to
develop a consistent strategy for post acute
care

Post Acute Hospitalist Are Practicing In:
Skilled Nursing Facilities
Post Acute Rehabilitation
Post Acute Psychiatric facilities
Custodial nursing care
Assisted Living
Inpatient Hospice facilities

IPC The Hospitalist Company in CA is
larger single-specialty group practice
with over 1,200 full time Hospitalist
nationwide and several hundred part
time.
5 years ago accounted for 5% in post acute
Today increased to 20% of post acute

Barrier Faced by Hospitalist
Major barrier to information flow between
settings is a lack of compatibility between
electronic records, even if the software is from
the same company
The standard hospital discharge form is
designed as a succinct record of care the
patient received while hospitalized, but is not
designed as a road map for care the patient
needs to receive after discharge

Barrier Faced by Hospitalist (continued)
Privacy issues add another layer of
complexity. Communication is horrible from
hospital to the post acute care setting
initiating let to dedicated post acute
hospitalist practices. Patient are in the same
practice and they meet weekly providing an
effective handoff.

Hospital and other organizations have
implemented additional strategies:
Enhanced patient education
Increased post-discharge follow up care
Increased coordination with outpatient
providers (Bradley et. al., 2012)

Seven Principles key to Reducing Readmissions
Seven Principles key to reducing
readmissions from SNF with using
“SNF-ist” of “Hospitalist” were
developed by a Hospitalist Kevin
Sundbye, MD from Stormont-Vail
Healthcare in Topeka, KS

Fax needed medication to the pharmacy
the day before discharge so medication
are on hand when patient arrives
Provide written prescription for pain
medication before the patient leaves the
hospital
Have the doctor at the hospital contact the
nursing home doctor who will be
responsible for the patient.

Continued:
Attempt to let the nursing home doctor know ahead
of time that the patient is being discharged.
Do not allow late-afternoon transfers. If you can’t
have the patient at the nursing home by 4 pm, don’t
send them.
Anybody involved in the transfer process (doctor,
nurses, social worker) can and should stop the
discharge if they detect a problem
Use a checklist to confirm that everything is ready
and going to according to plan.
(GovernanceInstitute.com; BoardRoom Press Dec 2012)

The Department of Health and Human Services
(HHS) has included recommendations from the
Medicare Payment Advisory Commission
(MedPAC) to have skilled nursing facilities
(SNFs) join hospitals in accountability for
avoidable 30-day hospital readmissions.
As part of the 2014 budget proposal, SNFs with
high rates of Medicare rehospitalizations would
have payments reduced by 3 percent beginning
in 2017

The MedPAC analysis showed that
approximately 14 percent of Medicare patients
discharged to SNFs were rehospitalized. To
avoid penalties and ensure quality care, this
budget proposal challenges SNFs to provide
Better care so residents are physically ready for
discharge,
Provide better family education on subjects such a
medication management and
Form partnerships with high-quality community
services.

Also on the table is MedPAC’s
recommendation that bundled
payment for post-acute care providers
be implemented in 2018, including
Long-Term Care Hospitals
SNFs
Inpatient Rehabilitation Facilities
Home Health Providers.

Medicare 9th Scope of Work
Began investigating 30-day Re-Admissions.
CMS’s Fiscal Intermediaries and state based QIOs
began flagging 30-day readmissions to the same
facility and for same diagnosis.
AMI
Heart Failure
Pneumonia
QIOs contact hospitals and conducted reviews of
discharge plans and other documentation to
identify patterns of preventable readmissions.

CMS will monitor the success of this project
by watching the rates at which patients in
these communities return to the hospital. Re-
admission rates for hospitals have been
tracked by CMS for some time, and will be
available to consumers through the Hospital
Compare Web site at
http://www.hospitalcompare.hhs.gov.

CMS included a Care Transition in its 9th
Statement of work (started in 2008)
Quality Improvement Organizations (QIOs)
in 14 communities are working to coordinate
care and promote seamless transitions across
settings
Specifically focusing on reducing unnecessary
readmissions to the hospital by improved
transitions of care and greater coordination
among providers

IHI (Institute for Healthcare Improvement)
on May 1, 2009 launch the State Action on
Avoidable Rehospitalizations (STAAR)
Initiative
Grant support from the Commonwealth Fund.
Initial phase, Two year Multi state project to
reduce avoidable Rehospitalizations focusing
on two components

STAAR Initiative
One of the First large-scale , multi-
stakeholder effort to reduce
readmissions and an early leader in
encouraging the field to form state-level
and local cross-setting partnership to
address system issues in transitioning
care across settings.

STAAR Initiative
Aims to reduce Rehospitalizations by
working across organizational boundaries
and by engaging:
Payers
Stakeholders at the State, Regional and
National level
Patient and families and caregivers at multiple
care sites and clinical interfaces

STAAR Initiative
IHI partners with STAAR states to
provide
Strategic guidance
Support
Technical assistance
To hospitals and cross-continuum teams
to improve transitions in care and
reduce avoidable rehospitalizations

STAAR Initiative
IHI (Institute for Healthcare Improvement)
Focusing on Two components:
A multi-state learning community to Improve
Transition of Care
Targeted Technical Assistance to address
systemic barriers to reducing avoidable Re-
hospitalizations

STAAR Initiative
1. Improve Transition of Care by cultivating a
cross-continuum learning collaborative
Participants are required to engage partners from
across the continuum of care to problem solve and co-
design improvements in the day to day work of
providers
The initiative supports the process improvement work
in hospitals and cross continuum teams by creating
robust learning community

STAAR Initiative
STAAR provides
Content reviews
Process recommendations
Inventory
Celebration of Best Practices and suggested
measurement strategies

STAAR Initiative
2. Engage State-level leadership to
understand and mitigate systemic barriers
to change
Reducing rehospitalizations in a state or region
requires not only front-line process
improvement, but also identification and
mitigation of barriers to system-wide
improvements, policy & payment reforms that
will reduce fragmentation and encourage
coordination across the continuum of care

STAAR Initiative
Reforms are necessary to address the
shortcomings of the current volume-based
incentives, and to place a premium on the quality
of the patient’s experience across the continuum
Rehospitalization involves new behaviors, norms,
relationships and partnerships to communicate
and coordinate care between disciplines, settings
and organizations
State-level leadership is essential to understand an
act on the barriers that front line teams encounter
in doing this work

STAAR Initiative
STAAR Hospital Teams focus on the
implementation of four key
recommended process level
improvements that require extensive
collaboration between the hospitals and
their community partners to effectively
co-design better processes

STAAR Initiative
Perform an Enhanced Assessment of Post-
Hospital Needs
Provide Effective Teaching and Facilitate
Enhanced Learning
Provide Real-Time Handover-
Communications
Ensure Timely Post-Hospital Care Follow-
Up

STAAR Initiative
Perform an Enhanced Assessment of
Post-Hospital Needs
Involve family caregivers and community
providers as full partners in completing a
needs assessment of patients’ home-going
needs
Reconcile medications upon admission
Create a customized discharge plan based
on the assessment

STAAR Initiative
Provide Effective Teaching and Facilitate
Enhanced Learning
Customize the patient education materials
and processes for patients and caregivers
Identify all learners on admission
Use Teach Back regularly throughout the
hospital stay to assess the patient’s and family
caregivers’ understanding of discharge
instructions and ability to perform self-care.

STAAR Initiative
Provide Real-Time Handover-
Communications
Reconcile medications at discharge
Provide customized, real time critical information to
next clinical care provider(s)
Give patients and family members a patient-friendly
discharge plan
For high risk patients, a clinician calls the individual
listed as the patient’s emergency contact to discuss the
patient’s status and plan of care

STAAR Initiative
Ensure Timely Post-Hospital Care
Follow-Up
Identify each patient’s risk for readmission
Prior to discharge, schedule timely follow-
up care and initiate clinical and social
services based upon the risk assessment

STAAR Initiative
Measurements of Outcomes and Process
Measures
Outcome Measures: Readmissions
30-Day All-cause Readmissions (% of discharges
with readmission for any cause with 30 days)
Readmission Count (Number of readmissions:
Numerator for 30-day all cause readmissions
measure)

STAAR Initiative
Outcome Measures: Patient Experience
HCAHPS Communication Questions:
“During the hospital stay, how often did nurses explain things
in a way you could understand?”
“How often did doctors explain things in a way you could
understand?”
HCAHPS Discharge Questions:
“Did hospital staff talk with you about whether you would have
the help you needed when you left the hospital?”
“Did you get information in writing about what symptoms or
health problems to look out for after you left the hospital?”

STAAR Initiative
Outcome Measures: Patient Experience
Care Transition Measures: The hospital staff took my
preferences and those of my family or caregiver into
account in deciding what my healthcare needs would
be when I left the hospital.
When I left the hospital, I had a good understanding
of the things I was responsible for in managing my
health.
When I left the hospital, I clearly understood the
purpose for taking each of my medications

STAAR Initiative
Process Measures:
Enhanced Admission Assessment for Post-
Hospital Needs
Percent of admissions where patients and family
caregivers are included in assessing post
discharge needs
Percent of admissions where community
providers (e.g., home care providers, primary care
providers and burses and staff in skilled nursing
facilities) are included in assessing post discharge
needs

STAAR Initiative
Process Measures (continued):
Effective Teaching and Enhanced Learning
Percent of observations of nurses teaching
patient or other identified learner where Teach
Back is used to assess understanding
Percent of observations of doctors teaching
patient or other identified learner where Teach
Back is used to assess understanding

STAAR Initiative
Real-time Patient and Family-Centered
Handoff Communication
Percent of Patients discharged who receive
a customized care plan written in patient
friendly language at the time of discharge
Percent of time critical information is
transmitted at the time of discharge to the
next site of care (e.g., home health, long term
care facility, rehab care, physician office)

STAAR Initiative
Post-Hospital Care Follow Up
Percent of patients discharged who had a follow-
up visit scheduled before being discharged in
accordance with their risk assessment
Balancing Measure
Observation Admits
Number of Admission to observation status in the
month

STAAR Initiative
Five Steps the STAAR initiative found to
be effective:
Know your data
Know your partners-with whom you share patients
Form operational alliances to share data and improve
transition processes. Form a cross continuum team
Perform a review of five recently readmitted patients,
and bring to the cross continuum team meeting
Identify shared process that span the transition from
the hospital to other settings, and work together to
improve those processes

The Affordable Care Act created a formal
Community Based Care Transition Program
(CCTP)
The program was to test models in for improving care
transition and reduce readmissions for high risk
Medicare beneficiaries
CCTP is part of the Partnership for Patients (P4P) a
nationwide partnership aimed to reduce preventable
hospital errors by 40% and reduce hospital
readmissions by 20%
47 organizations are enrolled and budgeted to $500
million

Partnership For Patients (P4P)

INTERACT(Interventions to Reduce Acute Care Transfers)
Joseph Ouslander, MD, Director of
Boca Institute for Quality Aging at
Boca Raton Community Hospital,
created a program aimed at reducing
the number of hospital admission
from nursing homes

INTERACT
INTERACT was initially designed as
“Toolkit” in 2007
Evolved into a full Quality Improvement
Program that will assist nursing homes in
meeting the federal requirement for
QAPI program

INTERACT
Designed to improve the early identification,
evaluation, management documentation and
communication about acute changes in
condition of residents in nursing homes
The goal is to improve care by reducing the
frequency of potentially preventable transfers
to the acute care hospital and related
complications leading to increase health care
expenditure

INTERACT
Program includes
Evidenced Based and Expert
recommended Tools
Strategies to implement them
Related educational resources
The tools are to be integrated into
everyday care and be incorporated into
your facility’s quality improvement
program

INTERACT
Tools:
Quality Improvement Tools
Communication Tools
Decision Support Tools
Advance Care Planning Tools

INTERACT
Implementation Elements
Advance Care Planning should begin at the
time of or shortly after admission and
continued through out the resident stay. The
INTERACT Advanced Care Planning Tool
aides in developing a person centered care
plan
Medication Reconciliation Worksheet is
designed to help with safe medication orders
at the time of admission

INTERACT
Implementation Elements (continued)
Stop and Watch Tool to be used by CNAs
to identify changes in resident and clearly
communicate those changes to the
licensed staff.
The tool also can be used with staff who
have direct contact with resident and may
observe changes (Rehab, environmental
services, dietary)

INTERACT
Once a nurse is alerted to a change in condition
the Care Paths and Change in Condition File
Cards can be used as decision support tools to
help with the recognition, management and
reporting of specific symptoms and signs.
Include criteria for notifying primary care
clinician

INTERACT
SBAR Form and Acute Change in Condition
Progress Note to enhance the evaluation of
and documentation with acute changes and
improve the communication utilizing a
structure.
Transfer Checklist and Transfer Forms used
to communicate clearly and succinctly
information that is critical for the ED and
other hospital staff to care for the resident.

INTERACT
Quality Improvement Tools
The Hospitalization Rate Tracking Tool
Quality Improvement Tool
Both tools assist with:
Tracking, trending, and benchmarking
measures
Conducting root cause analysis that identify
areas for improvement

INTERACT
Four Key Strategies for implementation
essential for success
Make INTERACT an integral component of
QAPI program
Integrate the INTERACT program and tools
into everyday care
Tools are visible and accessible for everyday
care
Culture Change-change takes time and to be
mindful of this

INTERACT
Commonwealth Fund Project Results
100 bed Nursing Home the average reduction
of 0.69 hospitalizations/1000 resident days
equates
25 fewer hospitalizations in a year
$125,000 in savings to Medicare Part A
(conservative)
The Interventions as implemented as part of the
project cost $7,700 per a facility
The savings could aide the facility infrastructure

Medicare Readmission Rates showed
Meaningful decline in 2012 per a
publication of the Center for Medicare
& Medicaid Services, Office of
Information Products & Data Analytics

Descriptive analysis of 30-day, all
cause hospital readmission rate
patterns from 2007-2012 .
Population: Medicare FFS
beneficiaries experiencing at least one
acute inpatient hospital stay.

Method: Chronic Condition Data
Warehouse claims, estimate unadjusted,
monthly readmission rates for the nation,
within the Dartmouth Hospital Referral
Region (HRR), and compare participating
and non-participating hospitals in the
Partnership for Patients(P4P) program
(overall and by number of inpatient beds at
each facility)

Results:
From 2007-2011 the national 30-day all cause
hospital readmission rate averaged 19%
2012 readmission rate averaged 18.4%

Current Readmission Rates

CMS hopes to lower Hospital
readmissions Rate by 20% by 2013
utilizing evidenced based interventions

The Affordable Care Act established
the Hospital Readmission Reduction
Program (HRRP) which ties payment to
Performance on Measures
HRRP begins October 1, 2012
Lowers Medicare payment rate for
hospitals with greater than expected
readmission rates for specific conditions

Conditions beginning FY 2013
Heart Failure
Acute Myocardial Infarction
Pneumonia
These three conditions made up
approximately 10% of hospital
discharges in 2009
(Avalere analysis of 2009 Medicare 100 Percent Standard Analytic files claims data from CMS.)

Conditions Beginning FY 2015
Chronic Obstructive Pulmonary Disease
Coronary Bypass Graft
Percutaneous Transluminal Coronary
Angioplasty
Other Vascular Conditions

Payment reduction is determined by an
adjustment factor based on an
assessment of excess readmissions

Hospitals with excessive readmission
rates will have their Medicare payments
reduced by up to
1% in fiscal year 2013
2% in 2014
3% by fiscal year 2015 and beyond

Hospitals with risk adjusted 30 day
readmission performance in the lowest quartile
will incur penalties against their total
Medicare Payment beginning in fiscal year
2013 (starting October 1, 2012)
CMS will evaluate prior year’s readmission
data starting October 1, 2011

Preparing for Payment Penalties:
Know your readmission metrics including original
discharge disposition and origin of readmission
Calculate readmission rates by condition, physician
performance and post acute care facility
Identify opportunities based on patient
demographics and common readmissions
Screen and target patients based on risk assessments
Compare disease specific outcome measures to
national and local competitor rates

Four stages of care that allow effective interventions
Preparation for discharge, a process starting on
admission making staff aware of home
environment
Hand-off to the out patient physician
Medication reconciliation to make sure new
prescriptions are filled and that patients are not
falling back on their old medication routines
Home visits and/or phone call, daily or weekly for
first 30 days

American Healthcare Association Goal:
Reduce Hospital Re-admissions within 30
days during a SNF stay by 15% by March
2015

Definition of Readmission 30 Day
Readmission Measure
Readmission occurs when a patient is
discharged from the applicable hospital to
a non-acute setting and then is admitted to
the same or another acute care hospital
within 30 days for any reason

Definition of Readmission 30 Day
Readmission Measure
Exclusion to Readmission Definition:
Transfers and planned readmissions are
excluded
An exception for AMI for planned readmission for
revascularization procedures (CABG PTCA)

1 in 5 Medicare FFS Beneficiaries are
Readmitted to the hospital within 30 days
Hospital Discharge
Condition
30-Day Rate for Re-
hospitalization
AMI 19.8
Heart Failure 24.8
Pneumonia 18.4
Hospital Compare National Readmission Rate: http://www.medicare.gov/Download/DownloaddbInterim.asp. Jan 20, 2012

National Transitions of Care Coalition
Medicare Transitional Care Act of 2012
Improve transition of care for high risk Medicare
beneficiaries at high risk for readmission as they
move from the hospital setting to
Home
Skilled Nursing facility
Next point of care
The bill is step in improving patient outcomes
and reducing unnecessary health-related
expenses

The Medicare Transitional Care Act
puts in place an infrastructure to
promote care transition interventions
that have been proven successful
Seven key elements found in evidence-
based care interventions

Seven Essential Intervention Categories
Medication Management
Transition Planning
Patient and Family Engagement/Education
Information Transfer
Follow-Up Care
Healthcare provider Engagement
Shared Accountability across Providers and
Organizations

Nursing Home Value-Based Purchasing Demonstration Project
CMS initiative to improve Quality and
Efficiency of care to Medicare
beneficiaries
Financial incentives to nursing homes that
meet certain conditions providing high
quality of care
Demonstration includes three states:
Arizona, New York, and Wisconsin

Quality Performance Based on Four Domains:
Staffing
Appropriate Hospitalizations
Minimum Data Set (MDS) Outcomes
Survey Deficiencies
CMS will award points based on performance with
each measure within the domain
Points will summed for an overall quality score

For each state
Nursing home scores in the top 20 %
Homes in the top 20% of improvement in
their scores
Eligible for a share of the State’s savings
pool

Anticipate that potentially avoidable
Hospitalizations may be reduced as a
result of improvement of quality of
care
Reduction in hospitalizations and
subsequent skilled nursing stays result
in Medicare savings
The saving will fund the payment
awards

Clinician and Hospital administrators
are eager to find effective approaches to
reduce Rehospitalizations.
As
Payers, Policy makers and Purchasers
are eager to develop incentives to
improve practice.

Transition in Care
A
Culture Change

SNF Culture Change
WHY A Culture Change?
Needed in order to be successful!
The Affordable Care Act mandates that each
facility have a Quality Assurance and
Performance Improvement Program (QAPI)
Improving Management of acute changes in
condition and reducing unnecessary hospital
transfers is one potential focus to meet QAPI
requirements

SNF Culture Change
Corporate Compliance program in place
and supported by the organization
Support and buy- in from senior
leadership down front line staff
QAPI program
Make readmission an initiative
An organization ready for change
Cross the continuum collaboration

SNF Culture Change
Know your Data
Partner with Hospitals, physician
offices, Home care, Hospice, Assisted
Living, Acute Rehab
Be part of Pilot programs or initiatives
Implement INTERACT
Train and Educate all employees from
top down

SNF Culture Change
Admission Process
Receive complete and accurate admission
information
Manage Admissions times and days
Customer Service
Establish protocols and procedures
Handoff communication
Transition meeting scheduled with 72 hours of
Admission
INTERACT Advanced Care Planning

SNF Culture Change
Customer Services: Making a Good
Impression
Providing pre-admission contact with
patient/family
Staff and room are ready to receive patient
Implement a room readiness checklist
A warm home like atmosphere
A welcome gift

SNF Culture Change
Transition Planning Meeting
Scheduled with 72 hours of Admission
Interdisciplinary
Communication
Goal:
Ease transition into and out of the facility
Length of Stay
Individualized to each patients situation and condition
Reduce readmissions to the hospital

SNF Culture Change (continued)
Education Patient and Family through out
care
Accountability/Communication
Effective Hand Off of Care
Medication Management
Multidisciplinary approach
Discharge planning that starts on
admission

SNF Structural Support
MD/PA/NP availability-“SNF-ist” or Hospitalist
Pharmacy support 24/7 and responsiveness
Respiratory Therapist and Respiratory vendor
support
Training and competency
Infusion Therapy
RN Support
Training and competency
24/7 availability

Questions & Answers

References & Resources
Healthcare Leader Action Guide to reduce
Avoidable Readmissions, 2010 Health
Research & Educational Trust
Report on Medicare Compliance, “CMS
Targets Readmission Through Payment,
Audits; “Coaching” Model Reduces Rates.”
Volume 17,Number 24. June 30, 2008
Reducing Hospital-SNF 30-Day Readmission.
Case Management Monthly. January 2010.

Improving Care Transition and Reducing
Hospital Readmission. The Remington
Report. January/February, 2010 Care
Transitions.
Re-hospitalizations Among Patients in the
Medicare Fee for Service Program. New
England Journal of Medicine, April 2, 2009.
Institute For healthcare Improvement:
Effective Interventions to reduce
Rehospitalizations, March, 2009.

Hospital Collaborate with SNFs, Home Care, Hospice, to
Reduce Readmission by Elaine Zablocki, National
Research Corporation, December 2012 BoardRoom Press
Medicare & Medicaid Research Review 2013: Volume 3,
Number 2, Medicare Readmission Rates Showed
Meaningful Decline 2012, Gerhardt, G., Yemane, A.
Hickman, P., Oelschlaeger,A., Rollins, E., Brennan,N.
Readmission Reduction Program. CMS. Gov,
www.cms.gov/Medicare/Medicare-Fee-for-Service-
payment/AcuteinpatientPPS/Readmission-Reduction-
Program.html

State Action on Avoidable
Rehospitalizations. www.ihi.org

Questions/Answers
Harmony Healthcare International
1 (800) 530 – 4413
dbuckley@harmony-healthcare.com
Harmony Healthcare International, Inc. 141141Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

Harmony Healthcare International
Have you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM
EVALUATION
or
CASE MIX ANALYSIS
for your Facility?
Perhaps your facility has potential for additional revenue
Assess your facility against key indicators and national norms
Email us at for more information
RUGS@harmony-healthcare.com
Analysis is cost & obligation free
Harmony Healthcare International, Inc. 142Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

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