Readmission reduction takes center stage
Help your hospital avoid penalties
The stakes are rising in the Centers for Medicare & Medicaid Services’ readmission reduction program, making it important for hospitals to ensure a safe discharge and prevent patients from coming back.
Beginning October 1, penalties for excess readmissions will increase to up to 2% for hospitals that have the most readmissions within 30 days of discharge. The penalty will top out at 3% in fiscal 2015. In the first years of the program, 67% of all hospitals began losing reimbursement for having more readmissions than their peers for heart failure, acute myocardial infarction, and pneumonia. CMS has proposed adding two more measures beginning in fiscal 2014 — readmissions for hip and knee arthroplasty and chronic obstructive pulmonary disease (COPD), which applies to patients with a primary diagnosis, or acute respiratory failure as a principal diagnosis with a secondary diagnosis of COPD.
CMS’s attention to readmissions and the discharge process underscores what case managers have been saying for years: that hospital case management can make a difference in the bottom line, says Peggy Rossi, BSN, MPA, CCM, a retired hospital case management director who now is a consultant for the Center for Case Management.
"Hospitals are finally realizing how important case management is. For years, they’ve seen us only as a product they have to give because of the Medicare Conditions of Participation as opposed to a revenue-producing unit. Now hospitals are saying that case managers may be their method of survival but healthcare is moving so rapidly that case management can’t catch up," Rossi says.
The healthcare arena has changed since the early 1990s, when Teresa C. Fugate, RN, BBA, CCM, CPHQ, a case management consultant based in Knoxville, TN, was ordered to discontinue a readmission reduction program at the hospital where she worked at the time.
"The program was preventing about 20 readmissions a week and at the time, that was considered to be a bad thing. Now the payment structure is catching up with what case management has been trying to achieve all along," she says.
Preventing readmissions not only helps hospitals do well in CMS’ readmission prevention and value-based purchasing programs — it allows hospitals to utilize resources for other patients, Fugate says.
Patients who are readmitted are likely to give hospitals lower patient satisfaction scores than those who have a successful discharge, she points out. From a quality standpoint, patients are at greater risk of falls, medication errors, and infections when they are in the hospital, she says.
"It’s better for the patient and for the hospital to avoid unnecessary readmissions. CMS is putting a huge emphasis on discharge planning and reducing readmissions for just this reason," she adds.
Patients move so fast through the continuum that case managers don’t have the time to do everything they should do to prevent readmissions, Rossi says.
"Patients come in when they are in crisis and are treated, stabilized, and discharged, often in just three days. Case managers must start early in the stay to ensure that the continuum of care is there to provide for patient needs after discharge," says Cindy Reilly, RN, BSN, vice president of quality and patient safety at Marlborough (MA) Hospital, part of UMass Memorial Healthcare. Reilly served on a multidisciplinary expert panel assembled by the state of Massachusetts to look at readmissions and what clinicians can do to prevent them.
In many hospitals, case managers have unrealistic caseloads and too many roles so they can’t perform all of them well, Rossi points out. For instance, many case managers have a caseload of 25 patients and have to do utilization review every day to make sure patients meet continued stay criteria. At 15 minutes a patient, utilization review would take five hours, leaving only three hours to complete all their other tasks, Rossi adds.
Many case managers are tasked with utilization management as well as care coordination and discharge planning, she says. In some hospitals, social workers often have the dual role of discharge planning and dealing with psychosocial issues.
Rossi advises case management directors to educate the hospital administration on the changing Medicare requirements, the patient population being served, the hospital’s readmission rate and what’s bringing patients back. Ask that the department be staffed accordingly, keeping in mind that case managers need a minimum of 30 minutes to complete an assessment even on an uncomplicated discharge. For complex patients, the assessment querying needed can often take an hour or more.
Penalties are increasing, but they may not be high enough yet for hospital executives to see the benefit of adding the necessary staff for a readmission prevention program, Fugate says. As CMS adds DRGs and increases the penalties, hospitals may start losing enough revenue to make a readmission reduction program more cost-effective, she says.
"Readmissions can be a vicious cycle. Patients are treated, stabilized and discharged, but once they get home, they begin to decompensate and are readmitted and treated again with nobody looking at the first discharge plan to determine what went wrong," Reilly says.
When patients are admitted, do a mini root-cause analysis to determine what happened after discharge, Reilly suggests. Find out if patients had everything they needed at home or what happened at the skilled nursing facility that caused the patient to bounce back. "Look at what you are doing during the current stay to enhance patient stabilization so patients can return as much as possible to their previous status," she says.
The medical factors behind readmission have been the primary focus in the healthcare system, but that needs to change, adds Anne Meara, RN, MBA, associate vice president for Network Care Management at Montefiore Medical Center in Bronx, NY. "We need to look beyond the medical issues and find out about other factors that could result in the patient coming back. We need to delve deeply into other reasons for readmissions, such as housing, finances, transportation, and the ability to obtain medication and food," Meara says.
"There are many variables that contribute to readmissions. We might not be able to prevent all readmissions, but we can do a full assessment to get a realistic idea of patients and living situations, educate the family, make sure that patients understand their treatment plan, and that they can afford their co-pays and any other out-of-pocket expenses," Reilly adds.
Since the majority of unplanned readmissions start in the emergency department, that’s where case managers should start the assessment, Reilly suggests. Start assessing their needs and find out what they see as their discharge destination. The emergency department often is the best place to get information from family members since they may work and visit the patient in the evenings, when case managers are not on duty, Reilly says.
Case managers should sit down with patients and find out the full picture, Meara says. For instance, instead of just asking if the patient has a caregiver and checking off a box, ask where the caregiver resides. It might be in another state.
Spend time talking to patients and family members about the costs of healthcare they may incur once they leave the hospital, or even when they’re still in the hospital, Rossi says. "Talking about finances is the most valuable part of an assessment. We tend to think that because patients have insurance, the cost of care is covered. Case managers need to look at the specific things that are covered by the policy and how the patient is going to pay for them," she says. For instance, after the Medicare benefits for a skilled nursing stay are exhausted, can the patient afford the daily rate? What are the limits of home health services, and is the patient likely to need more than his or her policy covers?
It’s not always the clinical situation that brings patients back to the hospital, Meara points out. "We can do everything right in the hospital but if the patient’s life circumstances interfere with the ability to follow the treatment plan, it’s likely to result in a readmission," Meara says.
Case managers need to assess patients for their health literacy to make sure they understand their treatment plan, Rossi says.
Understanding patients’ perception of their healthcare and ability to manage after discharge is an important part of developing a successful discharge plan, Reilly says. Ask patients how they felt at home and how they feel now. Find out about their social setting and the support they have at home, she says.
"Massachusetts is very lucky to have a lot of resources for patients after discharge, such as Meals on Wheels, the Visiting Nurse Association, and other agencies that provide assistance to patients. Somebody has to have a conversation with patients and find out that these services are needed," Reilly says.
- Teresa C. Fugate, RN, BBA, CCM, CPHQ, Case Management Consultant, Knoxville, TN. Email: email@example.com.
- Anne Meara, RN, MBA, Associate Vice President, Network Care Management, Montefiore Medical Center in Bronx, NY. E-mail: AMEARA@montefiore.org.
- Peggy Rossi, BSN, MPA, CCM, Consultant for the Center for Case Management. email: firstname.lastname@example.org.