1.
Managing Readmissions:
The Key to Impacting Your Bottom Line
Dr. Jyoti Kamal
Chief Data Scientist
Health Care DataWorks
A Division of Fathom®
Sherrie Smith
Consultant
Maestro Strategies

2.
 Readmissions Issue Overview
 Readmissions Reduction Policies
 Readmissions Reduction Strategy
• Visibility into current state
• Ability to identify high risk patients and disease groups
• Plan intervention programs for high risk patients
• Ability to monitor progress
 Other Drivers of Readmission Reductions
• Root Cause Analysis: Actionable Information
• Process Changes
• Getting Results
 Recap
Presentation Outline

3.
 Higher rates of readmissions has become a quality of care issue at many hospitals
and health systems
 Readmissions are contributing to the high cost of care
 Nearly 1 in 5 patients are readmitted within 30 days
 Analysis of Medicare claims data shows 75% of these readmissions are
preventable
 Excessive readmissions are costing CMS 17.5 billion dollar annually
 CMS ruling in 2009 to make readmission rates publically available as a way to
incentivize hospitals to pay more attention to care coordination had little effect
on reducing readmissions. In fact readmission rates went up as hospitals had no
financial incentives to reduce readmissions
Readmissions Overview

4.
 CMS is instituting new rulings and stricter penalties for readmissions
 In accordance with the Affordable Care Act, new CMS rulings are aimed at
improving quality of care, reducing readmissions and lowering Medicare
spending
 The Readmissions Reduction Program became effective October 1, 2012
• Unlike the budget neutral VBP, CMS aims to recover millions of dollars through
readmission penalties
• In FY 2013, CMS recovered $280M in readmission penalties (only .3% of CMS
reimbursements)
 Penalties based on reductions of base operating DRG payment amount
• FY 2013: 1% reduction
• FY 2014: 2% reduction
• FY 2015: 3% reduction
Readmission Penalties

5.
Managing Readmissions Strategy
To avoid financial penalties, and provide cost-effective care hospitals must implement strategies to
manage readmissions:
 Provide visibility into current state of readmissions
 Analyze planned and unplanned readmissions for both medical and surgical service lines to
identify problem areas for focus
 Identify patients at high risk for readmissions through predictive algorithms
 Monitor and intervene with patients at high risk of readmission while they are still in house
• Create care coordination plans
• Engage patient and family in education programs for medication and nutrition management
• Ensure proper discharge planning and instructions
• Coordinate follow up calls and appointments
• Coordinate home care
 Observe readmissions trends for the AMI, HF, and pneumonia populations, both for Medicare
and non-Medicare patients to ensure effectiveness of the interventions

6.
Solutions for Readmissions
Management
How do we enable these strategies?
 As a first step we need data that can be readily accessed without manual extraction or intervention
 An automated data collection and integration process
 The data should be modeled and curated to ensure accuracy, consistency and reliability
 There should be a presentation layer through which this data can be consumed and analyzed. It should
be intuitive to navigate with drill down capabilities to provide
– Retrospective reviews of data as part of performance improvement initiatives for readmissions
– Predictive algorithms to assess the likelihood of readmission before patients are discharged so
hospitals have the ability to intervene while the patient is still in-house
– Detail information for root cause analysis and insights into the operations
 Empowerment to make process changes

7.
The solution we are going to discuss today is a dashboard from HCD’s KnowledgeEdge suite of
tools.
The dashboard includes two areas of focus:
 Provide an executive summary of readmission trends for all patient populations with drill
downs by hospitals, service lines, nurse stations, physicians down to patient detail
• Allows tracking and monitoring of patients readmitted within any time period within 30 days or
beyond for deeper visibility into the hospital operations and problem areas
 A risk scoring algorithm based on the LACE model provides daily risk stratified reports
showing all in-house patients sorted by their risk level for readmission.
• Action worklists present opportunities for timely intervention and care coordination
 Can be filtered for Medicare population
 Can be also be filtered by hospital, nurse station, working diagnosis
Readmissions Management Dashboard

8.
The LACE model used in the dashboard calculates a risk score for all in-house
patients by associating points to each of the attributes listed below
The output of the calculation is a score between 1 and 17
LACE Scoring Model
L= Length of Stay in the hospital for the current admission
A= Acuity of the current admission (urgent or emergent)
C= Comorbidities derived from the billing diagnosis in the last one year
E= ED Visits in the last six months

9.
Risk Levels and Interventions

10.
Data Used for dashboard
Dashboard uses commonly available patient visit and billing data such as
• In-house patient list
• Current LOS
• Patient acuity
• Billing diagnosis codes
• Visit type, such as, Inpatient, outpatient or ED
• DRG
• Payer information
• Clinical service
• Patient location in the hospital
• Physician information

11.
Data Integration and Automation
Readmissions Dashboard
Readmissions Risk Dashboard
High Risk Patient Work List

12.
Readmissions Management
Dashboard
Readmission Management Dashboard

13.
Daily LACE Readmissions
Dashboard

14.
Daily LACE Readmissions
Dashboard
Provides daily risk
stratified reports, by
LACE score or DRG,
showing in-house
patients at high risk for
readmission

15.
LACE Risk Level Drill Down
2

16.
LACE Risk Level Drill Down
2
Individual component
scores of how LACE
score was calculated
Profile of patient with
this risk level
Worklist that includes
all patients with this risk
level. Can be exported
to Excel for Care
Coordinators
2

17.
Readmissions Summary

18.
Readmissions Summary
Visits broken down by
Planned and
Unplanned admissions
by medical and
surgical Service Line
Out of the box, tile
colors are based on
CMS benchmarks but
can be configured to
customer specific
criteria
Filter on 2, 7, 14, or 30
day readmissions
Provides tracking and monitoring of
readmission trends and statistics
across the hospital or health system

19.
Readmissions Patient Drill Down

20.
Readmissions Patient Drill Down
Index admission details
Patient visit history
Current or most recent
visit details

21.
HCD’s KnowledgeEdge Readmission Management Module helps hospitals gain
visibility into its operations.
 Integrates a predictive algorithm, providing daily readmission risk stratification
 Provides action worklist for timely intervention and care coordination
 Monitors readmission trends to help identify problem areas and promote
accountability
 Helps reduce readmissions and penalties by providing information for root cause
analysis to make necessary process changes
Dashboard Summary

22.
Multiple Components of a
Readmission Reduction Program
 Root Cause Analysis (RCA) includes
• Identification of high risk patients
• Identification of other drivers
 Ineffective processes
 Staff skills and knowledge
 Post-acute care providers
 Community dynamics
 Identifying high risk patients is also a
tool used daily to mitigate known
potential readmissions

23.
Actionable Information
Now that you know which patients require what level of
intervention…
Processes must be implemented to act on the information
• Who has overall responsibility for each patient?
• Do you create a new position for “transitional care managers”?
• Who makes post-discharge phone calls to the patient (if that is an intervention you
selected)?
– Do you have scripts / decision trees to address types of calls?
– Do you intervene when a call results in more actionable information? How?
– Do you track how many services you arrange post-discharge (i.e., home health,
hospice) to quantify benefit to the patient AND the hospital ?
• Do you provide feedback of information you learn to appropriate hospital
staff to make process changes as needed (patient teaching, medication management,
discharge, etc.)?

24.
Getting Results
• Charter teams to drive the initiative (i.e., project team, chronic disease teams, multi-provider teams, etc.)
• Identify and collaborate with key community leaders to address community related issues
• Train teams and key staff members in the principles and tools of problem solving,
identifying and mitigating latent and active errors, conducting an effective RCA, etc.
• Conduct RCA to identify drivers of readmissions (patients, processes, providers, community, etc.)
• Use HCD KnowledgeEdge™ Readmissions Management Dashboard to identify and
manage high risk patients
• Implement interventions based on RCA findings (evidence-based interventions, home-grown
interventions—or both)
• Collect performance data, track results and make adjustments to processes as needed
• Celebrate your improvement!

25.
• Real Example: Located in New Jersey is a 250+ bed hospital having
several Joint Commission Centers of Excellence—A good hospital
• Because of their high readmission rate
– They received the maximum 1% penalty (FY2013)
– Resulting in a loss in Medicare payment of $446,000
Penalty Number of Hospitals Percentage of Hospitals
No penalty 1,134 33.8%
Up to 1% 2,054 61.1%
1% - 2% 153 4.5%
2% 18 0.6%
Total 3,359 100%
Financial Impact of Penalties
Statistics from Inpatient
Prospective Payment System
Fiscal Year 2014 Final Regulation
Source: American Hospital
Association

26.
Recap
Process changes
With Encounter and Encounter billing as the foundational sources for data
integration, dashboard can be easily deployed to provide at a glance view of
readmission trends and identify areas of opportunity
Easy
Implementation
Better care coordination. Engaging patients in education programs and their own
health by timely follow ups and calls
Daily worklists for high and moderate risk patients allows care to be appropriately
focused and coordinated between physicians, specialists, social workers, nurses,
families and patients
Improved Care
Information for root cause analysis to make process changes
Improved
Communication
Improved Outcome
Cost Savings
Improved quality of care leading to better patient and staff satisfaction, reduced
readmission and patient days, and millions of dollars in savings.

27.
For more healthcare marketing information & insight,
visit the Fathom Health Blog.
QUESTIONS?
Dr. Jyoti Kamal
jyoti.kamal@hcdataworks.com
Sherrie Smith
smith@maestrostrategies.com