Include all diagnoses, payers in readmission projects

Reimbursement penalties are on the way

If you haven't expanded your readmission reduction projects beyond heart failure, pneumonia, and acute myocardial infarction, your hospital may find itself with reduced reimbursement in the future, warns Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Dallas-based Case Management Concepts.

Beginning with discharges on October 1 of this year, the Centers for Medicare & Medicaid Services will begin penalizing hospitals by 1% of their total discharges if they are in the top tier of hospitals with 30-day readmissions for heart failure, pneumonia, and acute myocardial infarction (AMI).

Many hospitals have concentrated their readmission reduction efforts on heart failure because it's their highest-cost, highest-volume diagnosis, and the one that results in the most 30-day readmissions, but that's no longer enough, Cesta says.

"If hospitals keep focusing on reducing readmissions only for certain diagnoses, they are missing the boat. Readmission reduction needs to be a hospitalwide program regardless of diagnoses. Hospitals should take the lessons they've learned from heart failure readmission reduction programs and apply them to diagnoses across the board," Cesta says.

In this year's Inpatient Prospective Payment System (IPPS) final rule, CMS reiterated its intention to add new diagnoses to the readmission reduction initiative beginning in fiscal 2015 but did not specify what diagnoses will be added. Chronic obstructive pulmonary disease, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty (PTCA) and other vascular procedures are among those under consideration. "CMS can look back three years to compile statistics on which they base the readmissions reductions penalties. This means it's important come up with a plan to reduce readmissions now for all diagnoses," Cesta points out. Eventually, hospitals that are in the top tier of hospitals with 30-day readmissions in the diagnoses selected by CMS for the program will be penalized as much as 3% of all Medicare discharges.

Commercial payers and state Medicaid agencies are starting to look at penalizing hospitals for excess readmissions, Cesta says. "We don't know the details in the state programs, but they are likely to be very different from the Medicare program," Cesta says. New York State's Medicaid agency is including all diagnoses in its readmission reduction program, she adds.

Linda Sallee, MS, RN, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago, asserts that case managers should assess every patient in the hospital regardless of payer for the purposes of discharge planning at the time they are assessing them for admissions criteria and level of care. "I'm a firm believer that case managers conduct a discharge planning assessment within 24 hours after admission to identify patients who have the highest potential for readmissions," she says. Then spend extra time developing the discharge plan and beefing up the education for patients who are at greatest risk for coming back, she adds.

Cesta recommends assessing every patient for home care, even if it's just one visit for medication reconciliation. "Hospitals tend to under-refer for home care, which in many cases is covered by insurance, Medicare, or Medicaid. This is a no-cost way to keep patients from coming back to the emergency department or being admitted," she says.

Case managers do a good job of identifying the need for home health for obvious patients, but many patients could benefit from a home health visit for medication reconciliation, she says.

"As much as hospitals try to conduct medication reconciliation, things do fall through the cracks," she says. Even if you give patients a list of medications they are to take upon discharge, they may go home and take a medication that duplicates one they were taking before hospitalization and end up in the emergency room. Older patients are particularly likely to find the new versus old medication regimen confusing, she says.

B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, consulting firm specializing in hospital case management, agrees that home visits go a long way toward making sure patients understand their medication regimen and the rest of the treatment plan and are following it.

"Post-discharge phone calls and referrals to specialty clinics are good ideas, but case managers have to work past the idea and look at the application, and how successful it's likely to be with each individual patient," Kizziar says.

When you call patients after discharge, they may not be totally honest about their medication regimen and their adherence to the treatment plan, she adds. Home visits are more effective because the nurse can look in the medicine cabinet and see three different blood pressure medications or notice that the patient doesn't have a scale and get them one, she says.

"Many hospitals don't want to get into the home care business, but they can partner with a home care agency to follow up with patients in the home environment," she says.

Some hospitals have clinics for specific conditions, such as heart failure, and ask patients to come in shortly after discharge, Kizziar says. "Patients do need follow-up visits, but it obligates patients to leave their home and come to the clinic and to find their own transportation. If this is the only post-acute intervention, providers don't know for sure if patients have filled their prescriptions, if they have a scale or what's in the refrigerators, and if patients can't obtain transportation, they won't show up," she says.

Once you've completed the assessment, start planning for when the patient is going home. When patients transition from one unit to the next, make sure that pertinent information is transmitted, Kizziar suggests. The staff in the intensive care unit may not be developing a discharge plan, but they are observing and gathering information about the family and the home situation that could impact the patient's transition to the next level of care, she says.

Find out about your patients' home situations and take that into account when developing a discharge plan. Determine what resources patients have in the community and at home, determine that patient's financial situation, and determine whether the caregiver can take care of the patient after discharge, Sallee suggests.

Engage the caregivers as early in the process as possible and provide education continuously during the stay instead of cramming it into the last couple of days, Kizziar adds. Make sure the education is provided in the languages that patients understand and at a level that they can comprehend.

It's useful to have the caregiver involved early on, particularly if the patient is very sick, because they can see the patient progress and it won't be as upsetting or overwhelming to them when the patient gets home, Sallee says.


For more information contact:

  • Jackie Birmingham, RN, MSN, MS, Vice President emeritus, Clinical Leadership at Curaspan Health Group, Newton, MA. email:
  • Toni Cesta, RN, PhD, FAAN, Senior Vice President, Operational Efficiency and Capacity Management at Lutheran Medical Center, Brooklyn, NY. email:
  • Carol Levine, director of the Families and Health Care Project for the United Hospital Fund, New York City. e-mail:
  • B.K. Kizziar, RN-BC, CCM, CLP, Owner of B.K. & Associates, Southlake, TX.
  • Kathleen Miodonski, RN, BSN, CMAC, Manager for The Camden Group, Los Angeles. email:
  • Linda Sallee, MS, RN, CMAC, ACM, IQCI, Director, Huron Healthcare with headquarters, Chicago. email:
    For guides and checklists for improving transitions, visit the United Hospital Fund's website: