Scrutinize your readmissions and take steps to avoid them

CMS to begin penalizing hospitals when patients come back

If you haven't started analyzing your hospital's readmission rates and the role case managers can play in reducing readmissions, it's time to start so your hospital can avoid penalties from the Centers for Medicare & Medicaid Services (CMS).

Beginning in 2010, CMS will penalize hospitals when patients with acute myocardial infarction (MI), heart failure, or pneumonia are readmitted within 30 days of discharge and the readmission is deemed "potentially preventable."

By 2013, chronic obstructive pulmonary disease, coronary artery bypass graft, and coronary angioplasty will be added to the list along with other diagnoses yet to be identified, according to Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and health care consultant and partner in Case Management Concepts LLC.

"As we roll into 2010, readmissions are going to become a bigger and bigger piece of the pie. We don't want the patients to come back. It's not good for them psychologically or financially, and in the future, the hospital's bottom line will take a financial hit as we are penalized for readmissions within 30 days of discharge," says Cynthia Lawson, RN-BC, MBA, CPHQ, director of case management at North Hills (TX) Hospital.

This means that hospital case managers will have to do more to make sure that patients and caregivers have everything they need to ensure that the patient can safely transition to the community or to the next level of care, adds Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital and health care consultant and partner in Case Management Concepts LLC.

"There is a fine balance between moving the patient through the continuum and making sure they have everything they need to be safely discharged. In addition to planning the stay in the hospital, we need to collaborate with other providers as we move the patient to the next level of care," she says.

CMS has required hospitals to report 30-day readmissions for congestive heart failure, pneumonia, and acute MI since 2008 and began posting readmission rates on the Hospital Compare web site in July 2009.

The agency has announced its intention to modify or deny reimbursement for readmissions in the future. In fact, President Obama's executive budget for 2010 includes $8.4 billion in savings over a 10-year period based on reductions in Medicare readmissions.

"It's not clear how the program will work, but we do know that hospitals can expect to lose reimbursement, beginning in fiscal year 2011, if patients are readmitted within 30 days for heart failure, acute MI, or pneumonia," Cesta says.

Readmissions are expensive, even before CMS begins to assess penalties, Cunningham points out.

The average patient who is readmitted spends a length of stay of 0.6 days longer than other patients admitted for the same diagnosis, she says.

"When we add 0.6 days onto the typical diagnosis, it adds up to a lot of money. Many Medicare managed care patients are DRG-reimbursed, and it gets expensive when you provide care for an additional 0.6 days without additional reimbursement," Cunningham says.

Using the 0.6 days as a benchmark, hospitals can get an idea of what their cost would be when patients are readmitted.

"This data can speak loud and clear to the chief financial officer and can be used to justify adding additional discharge planning staff," Cunningham says.

Not all readmissions are avoidable, but some are, Cesta says.

Reasons for avoidable readmissions include a poor or inadequate discharge plan, discharging the patient too soon, no plan for follow-up care, medication compliance issues, and the patient's failure to see a primary care physician for follow-up within a week after discharge.

Medicare is going to assess hospital readmissions in the future, probably by reviewing the charts and using exclusion criteria to determine if the readmission was preventable, Cesta says.

Medicare's list of readmissions that are not preventable includes patient left against medical advice, major or metastatic malignancies, neonates, multiple trauma and burns, transfer to another hospital, obstetrics, specific eye procedures and infections, cystic fibrosis, and the patient died.

Most likely cases for readmission

Heart failure is the No. 1 diagnosis of patients who are readmitted to the hospital. Other medical patients most frequently readmitted are those with pneumonia, chronic obstructive pulmonary disorder, gastrointestinal problems, and psychoses.

Among surgical patients, those with stent placements, major hip or knee surgery, other vascular surgery, major bowel surgery, and other hip and femur surgery are the most likely to be readmitted.

According to a study in the New England Journal of Medicine, nearly 20% of Medicare beneficiaries discharged from the hospital are readmitted within 30 days, and 35% are rehospitalized within 90 days.1 Among readmitted patients, 77.6% of readmitted patients were medical patients and 22.4% were surgical patients.

More than half of those readmitted in the study did not see their doctor for a follow-up visit within 30 days after discharge, Cesta says.

Case managers should identify their potentially preventable readmissions, drill down to find the causes, and develop strategies to avoid them, Cesta says.

Here are some examples of potentially preventable readmissions:

  • patient is admitted with asthma and readmitted eight days later with a diagnosis of asthma;
  • patient treated for acute MI is readmitted eight days later with a diagnosis of diabetes mellitus;
  • the initial diagnosis for a patient is abdominal pain and he or she is readmitted two days later for an appendectomy.

Readmissions that are not potentially preventable are those that are clearly unrelated to the initial admission, such as a patient was discharged after being treated for pneumonia and is readmitted six days later with a fractured skull following an automobile accident.

When patients are readmitted, it's time to ask the hard questions: Did they come back because of something the hospital didn't do, or is it because of what happened at the next level of care?

Develop a core team for examining your readmissions, Cunningham suggests.

Study the charts on a case-by-case basis to determine whether the readmission was related to the original hospitalization and whether it was preventable and look at opportunities for improvement, she adds.

Analyze your readmission data and look for patterns, Cesta suggests.

According to Cesta, among the questions to consider are: What are the most prevalent diagnoses of readmitted patients? Do the patients being readmitted have significant comorbidities, and is there a correlation between the patient's severity of illness and comorbidities?

Other questions Cesta suggests include:

  • Do certain doctors have the most patients being readmitted? If so, do their readmissions make sense clinically?
  • Look at where the patients are coming from. Are they being readmitted from home or a post-acute facility? Did they have home care services? Did they have access to a primary care physician?
  • Determine the setting from which the most patients are readmitted and see if most are coming from a particular post-acute provider.
  • See if there is a relationship between readmissions and the length of stay.
  • Don't limit your analysis to one readmission for each patient. Look beyond the most recent readmission and see if there is a chain of readmissions over time; then look for reasons that particular patient may be coming back repeatedly.
  • After you understand the population that is being readmitted and the factors surrounding the readmissions, divide the readmissions into different time frames.

"Medicare is going to penalize the hospitals for readmissions within 30 days, but patients who are readmitted within seven days or 15 days after discharge may be coming back for different reasons than those who are readmitted after 28 days," she says.

If patients are coming back in a short period of time, it may be that they aren't ready for discharge or there is a flaw in the discharge plan, she adds.

There are some readmission factors over which the hospital has little control, Cunningham points out.

For instance, the patient and family may not follow the discharge instructions and treatment regimen despite the hospital staff's best efforts.

"We can teach them what they need to do and get them ready to leave, but if they choose not to do it, there is little we can do," she says.

The payer's choice of post-acute vendors also can have an influence on readmissions, especially when it comes to Medicare managed care payers, Cunningham says.

"We're going to have to collaborate closely with payers and providers at the next level of care to make sure the patients get the services they need to stay out of the hospital," she adds.

Expect to expand your discharge planning services on weekends and holidays, Cunningham says.

"At most hospitals, coverage drops off significantly on weekends. That's not something that is going to work for us in the future," she adds.

(Editor's note: Toni Cesta and Beverly Cunningham's webinar: "Playing Nice in the Sandbox: An Across-the-Continuum Approach to Managing and Reducing Readmissions" takes a comprehensive look at readmissions. The CD of the 90-minute program is available at http://www.ahcmedia


  1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med 2009; 360(14):1,418-1,428.