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 http://www.ihi.org/staar, 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!!
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