1. Powell, Suzanne K. MBA, RN, CCM, CPHQ

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The headlines read, "Medicare to Stop Paying for Many Hospital Readmissions in 2012." It certainly caught my attention. But don't stop reading here if you are not a hospital case manager; it's not only about hospitals-and anyone who has been around long enough knows that those persnickety regulations that start out in the acute care setting most often move on down the line to all settings; no setting is ultimately exempt from financial "take-backs." And there is another reason to keep reading: A patient always goes somewhere else-to your facility or agency, perhaps? Good transitions should equate to less readmissions, and we can't do this without one another. Much of this editorial is about the new readmissions regulation because "knowledge is power," but please keep in mind that between the lines and behind the scenes, the more important issue is safe transitions and quality of life. Without a doubt, case management will be looked to, applauded, and/or blamed for however this turns out financially for the hospitals.


Although we can count on the details changing between now and 2012, the gist of it is something like this: On October 1, 2012, the new health reform law's "Hospital Readmissions Reduction Program" takes effect, authorizing a complex formula that will reduce the amount of money paid to hospitals with higher than average readmission rates. (See Box of Definitions for evidence of the complexity!!) The Hospital Readmissions Reduction Program is a provision that directs Centers for Medicare & Medicaid Services to track national and hospital-specific data on the readmission rates of Medicare-participating hospitals for certain high-cost conditions that have high rates of potentially avoidable hospital readmissions (H.R. 3590, [S] 3025).


The truth is that readmissions are a problem, although the statistics vary across the country. There are studies that state as many as one in five Medicare patients experience unplanned readmissions to a hospital within 30 days of being discharged; the estimated cost is $17.4 billion annually. In a 2007 study by the Medicare Payment Advisory Commission, it analyzed Medicare-reimbursed hospital readmissions and found that federal funds now pay about


* $5 billion for potentially preventable readmissions within 7 days,


* $8 billion for readmissions within 15 days, and


* $12 billion for those readmitted within 30 days and that


* 76% were potentially preventable. (Medicare Payment Advisory Commission, 2007)



It's no wonder that Medicare is seeing dollar signs and is planning a way to make someone accountable. The Patient Protection and Affordable Care Act, recently signed into law, will provide incentives for reducing rehospitalization-and disincentives for preventable readmissions. The program starts by reducing Medicare payments for acute myocardial infarction (AMI), heart failure (HF), and pneumonia readmissions. This program may also begin to expand within a year, starting with four additional conditions/procedures identified by the Medicare Payment Advisory Commission: chronic obstructive pulmonary disease, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, and other vascular procedures. Although it is too early to say exactly what the measures will be, according to the "Medicare Fact Sheet," measures for consideration include the following (Centers for Medicare & Medicaid Services, 2010). Note that each topic includes a "composite measure." For those who have had experience in Centers for Medicare & Medicaid Services' composite measures, we know these have multiple parts and are often difficult to "pass."


Care Transitions for AMI


* 30-Day Post-Hospital AMI Discharge ED Visit Measure


* 30-Day Post-Hospital AMI Discharge Evaluation and Management Service Measure


* 30-Day Post-Hospital AMI Discharge Care Transition Composite Measure


Care Transitions for HF


* 30-Day Post-Hospital HF Discharge ED Visit Measure


* 30-Day Post-Hospital HF Discharge Evaluation and Management Service Measure


* 30-Day Post-Hospital HF Discharge Care Transition Composite Measure


Care Transitions for Pneumonia


* 30-Day Post-Hospital Pneumonia Discharge ED Visit Measure


* 30-Day Post-Hospital Pneumonia Discharge Evaluation and Management Service Measure


* 30-Day Post-Hospital Pneumonia Discharge Care Transition Composite Measure


We don't have to wait for the financial hammer to drop on our institutions. There are plenty of resources available on safe transitions. One strategy is to take some practical "first steps" in order to see where your organization stands at this time. Before evaluating and changing processes, an organization must first see if there is a problem and look for causes of the problem(s). The Institute for Healthcare Improvement has some practical advice from its STate Action on Avoidable Rehospitalizations (STAAR) initiative. There are several strategies to prevent readmissions at, but four good ones are as follows (Institute for Healthcare Improvement, 2010):


Measure your hospital's "all-cause 30-day readmission" rate.


Form a continuum team of receivers (those who "receive" the patients): nursing homes, home health agencies, skilled nursing facilities, hospice, and office practice and include a patient/family representative.


Review the stories of five recently readmitted patients. Oftentimes stories are more revealing than mere data!!


Improve core processes, in collaboration with partners on the cross continuum team. Use the entire hospital stay to educate the patient and family on postdischarge care and communicate with postdischarge providers to ensure some follow-up with the patient, such as a home visit or a phone call.



Also, hidden in some of the language of the Hospital Readmissions Reduction Program are some hints that may give your departments data points to collect and issues to work on (Eve, 2010). In a section B, Interventional Proposal, it speaks of the following:


Initiating care transition services for a high-risk Medicare beneficiary not later than 24 hours prior to the discharge of the beneficiary from the eligible entity.


Arranging timely postdischarge follow-up services to the high-risk Medicare beneficiary to provide the beneficiary (and, as appropriate, the primary caregiver of the beneficiary) with information regarding response to symptoms that may indicate an additional health problem or a deteriorating condition.


Providing the high-risk Medicare beneficiary (and, as appropriate, the primary caregiver of the beneficiary) with assistance to ensure productive and timely interactions between patients and postacute and outpatient providers.


Assessing and actively engaging with a high-risk Medicare beneficiary (and, as appropriate, the primary caregiver of the beneficiary) through the provision of self-management support and relevant information that is specific to the beneficiary's condition.


Conducting comprehensive medication review and management (including, if appropriate, counseling and self-management support).



As said earlier, the most important issue at hand is case management orchestrating safe discharges for optimal quality of life. Professional Case Management journal has had cutting-edge content on transitions of care and we continually publish information on the subject (see "Case Management Accountability for Safe, Smooth, and Sustained Transitions" by Karen Zander in this issue). Whether that "transition" is from hospital to skilled nursing facility, from hospital or skilled nursing facility to home, or any other combination, the thoroughness of that transition can, literally, make a difference between life and death, or more often, between no readmission or another readmission. This is our time to shine!!




1. Centers for Medicare & Medicaid Services. (2010). Proposals for improving quality of care during inpatient stays in acute care hospitals in the fiscal year 2011 notice of proposed rulemaking. Washington, DC: Author.


2. Eve P. (March 31, 2010). Some interesting things in the H. R. 3590 health reform bill. Retrieved April 18, 2010, from Associated Content Web site: [Context Link]


3. Institute for Healthcare Improvement. STate Action on Avoidable Rehospitalizations (STAAR) initiative. Retrieved April 18, 2010, from http//


4. Medicare Payment Advisory Commission. (2007). Report to Congress; promoting greater efficiency in Medicare. Retrieved April 18, 2010, from http//

Definition of Terms


Readmission: in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge. Insofar as the discharge relates to an applicable condition for which there is an endorsed measure described in subparagraph (A)(ii)(I), such time period (such as 30 days) shall be consistent with the time period specified for such measure.


Excess readmissions ratio: with respect to an applicable condition (see below) for a hospital for an applicable period, the ratio (but not less than 1.0) of-" (I) the risk adjusted readmissions based on actual readmissions, as determined consistent with a readmission measure methodology that has been endorsed under paragraph (5)(A)(ii)(I), for an applicable hospital for such condition with respect to such applicable period; to" (II) the risk adjusted expected readmissions (as determined consistent with such a methodology) for such hospital for such condition with respect to such applicable period. "(ii) EXCLUSION OF CERTAIN READMISSIONS.-For purposes of clause (i), with respect to a hospital, excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number (as determined by the Secretary) of discharges for such applicable condition for the applicable period and such hospital.


High-risk Medicare Beneficiary: a Medicare beneficiary who has attained a minimum hierarchical condition category score, as determined by the Secretary, based on a diagnosis of multiple chronic conditions or other risk factors associated with a hospital readmission or substandard transition into post-hospitalization care, which may include 1 or more of the following: (A) Cognitive impairment. (B) Depression. (C) A history of multiple readmissions. (D) Any other chronic disease or risk factor as determined by the Secretary.


Eligible hospital: a hospital that the Secretary determines has a high rate of risk adjusted readmissions for the conditions described in section 1886(q)(8)(A) of the Social Security Act and has not taken appropriate steps to reduce such readmissions and improve patient safety as evidenced through historically high rates of readmissions, as determined by the Secretary.


All patients: patients who are treated on an inpatient basis and discharged from a specified hospital.


Aggregate payments for excess readmissions: for a hospital for an applicable period, the sum, for applicable conditions (as defined in paragraph(5)(A)), of the product, for each applicable condition, of-"(i) the base operating DRG payment amount for such hospital for such applicable period for such condition;"'(ii) the number of admissions for such condition for such hospital for such applicable period; and" (iii) the excess readmissions ratio (as defined in subparagraph (C)) for such hospital for such applicable period minus 1. (H. R. 3590-292).


Applicable condition: a condition or procedure selected by the Secretary among conditions and procedures for which- ''(i) readmissions (as defined in subparagraph (E)) that represent conditions or procedures that are high volume or high expenditures under this title (or other criteria specified by the Secretary); and" (ii) measures of such readmissions-" (I) have been endorsed by the entity with a contract under section 1890(a); and" (II) such endorsed measures have exclusions for readmissions that are unrelated to the prior discharge (such as a planned readmission or transfer to another applicable hospital). "(B) EXPANSION OF APPLICABLE CONDITIONS.-Beginning with fiscal year 2015, the Secretary shall, to the extent practicable, expand the applicable conditions beyond the 3 conditions for which measures have been endorsed as described in subparagraph (A)(ii)(I) as of the date of the enactment of this subsection to the additional 4 conditions that have been identified by the Medicare Payment Advisory Commission in its report to Congress in June 2007 and to other conditions and procedures as determined appropriate by the Secretary. In expanding such applicable conditions, the Secretary shall seek the endorsement described in subparagraph (A)(ii)(I) but may apply such measures without such an endorsement in the case of a specified area or medical topic determined appropriate by (H. R. 3590-293) the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a) as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary.


Eligible individual with chronic conditions: an individual who-"(i) is eligible for medical assistance under the State plan or under a waiver of such plan; and" (ii) has at least-"(I) 2 chronic conditions;" (II) 1 chronic condition and is at risk of having a second chronic condition; or "(III) 1 serious and persistent mental health condition.


From the Hospital Readmissions Reduction Program (H.R. 3590, [S] 3025)

Health Canada Funds National Case Management Network of Canada to Develop Case Management in Canada


April 20, 2010 (Toronto)-The National Case Management Network of Canada (NCMN) has signed an agreement with the Health Care Policy Contribution Program to support the project "Developing Case Management in Canada: Standards of Practice, Learning Resources and Professional Association." The project aims to align with the health human resource policy framework in order to optimize Canada's health workforce under the increasingly demanding and complex healthcare needs of Canadians. Its primary goal is to identify, attract, and prepare highly skilled interdisciplinary healthcare providers of case management across health care sectors on a national basis, acting as a conduit of information and networking support for professionals in the field. While case management has been identified as a crucial part of developing more cost-effective, accessible, and efficient services throughout Canadian health care, NCMN brings a much-needed centralized body to advance the discipline's mandates and foster collaboration between experts, practitioners, and recipients of care.


Specifically, NCMN will promote excellence and professionalism among case management providers across Canada through


* distribution of Canadian Standards of Practice for case management;


* provision of a dynamic, flexible, and innovative educational venue in an on-line learning library of comprehensive case management, business, and client learning resources;


* development of a national membership base to support and advance the environment, knowledge, and resources case management providers require now and in the future; and


* initiation of the development of a national competency profile as a foundation for future credentialing of case management providers.



Across the country, Canadians, especially those with specialized, complex, and chronic health care needs, experience limited access to and gaps in health care. Every episode of their care involves a complex interplay between numerous individual providers and transfers between different care settings. A dedicated group of case management providers strives to meet the requirements of these care coordination issues while being "siloed" within different sectors and settings.


Thus, the motto of NCMN is "connect, collaborate, and communicate" the power of case management, signifying the mission to connect those who practice and study case management with the individuals who benefit from case management-whether it be through direct receipt of care as patients, clients, and their families or through leading the collaboration of interdisciplinary health care providers. It is a vision of NCMN to communicate the capabilities and competencies of case managers to the many Canadian constituencies.

About NCMN


In November 2006, the NCMN of Canada was established. The NCMN is federally incorporated as a nonprofit professional organization that is membership-based, multidisciplinary, and dedicated to the support and advancement of case management providers. Membership embraces individuals and organizations engaged in the field of case management and represents diverse health and social service domains, which include practice, education, research, quality improvement, and management.


-Joan Park, President


National Case Management Network (


Professional Case Management is the official journal of NCMN.