Preventing 30 day hospital U turns

The high readmission rate of patients discharged from the hospitals is a major concern for US healthcare system. It is estimated that 20% of all Medicare patients are readmitted within 30 days and 34% are readmitted within 90 days. The cause of high readmissions is thought to be because of deep seated problems with quality of health care delivery in hospitals and lack of communication and care coordination post discharge.

To address this, section 3025 of the 2010 affordable care act was established to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals for excess readmissions beginning October 1, 2012. This program called the Hospital Readmissions Reduction Program is a pay-for-performance program that reduces payments to hospitals with excess readmissions. In 2012, it was focused on 3 conditions: Heart failure, Myocardial infarction and pneumonia. The 2017 changes and updates include focus on 6 conditions: Acute Myocardial Infarction (AMI), Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Pneumonia, Coronary Artery Bypass Graft (CABG) Surgery, Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA).

Financial impact of the program

CMS adjusts the payments to these hospitals using ERR (excess readmission ratio). If a hospital performs better than an average hospital that admitted similar patients (patients with similar risk factors for readmission such as age and comorbidities), ERR is less than 1.0000. If a hospital performs worse than average, the ERR is greater than 1.0000. The ERR of each condition is used to calculate the aggregate payments for excess readmissions (using the base DRG), which is further used to calculate the readmission adjustment factor. Any number between 0.9999 and 0.9700 would lead to a payment reduction. The maximum penalty in 2017 is 3%.  In FY 2016, nearly 77% of all eligible hospitals received some degree of readmissions penalty, losing a combined total of $420 million in Medicare reimbursement.

Reducing readmissions

Reducing readmissions can be overwhelming for many healthcare organizations. Several organizations have adopted different methods/toolkits to reduce readmissions. Some of the innovative methods that have been and can be used by hospitals to reduce readmissions include

Predictive analytic models: To determine which patients are high risk is important to efficiently use the resources. While some organizations are using LACE index, a risk assessment tool that considers length of stay, acuity of admission, Charlson comorbidity index and number of ED visits in the previous six months, other are using customized models based on institutional characteristics. Predictive models are complex but can be worthwhile to learn. Using excel add-in functions (LogisticRegTrain, LogisticRegPredict, sum product of Confusion matrix and cost matrix), you can not only determine the probability of readmit but also the cost-benefit analysis of the program.

Extensivist Model: In this model, once the high-risk patients are identified, they are followed by Extensivist (hospitalist) who works with a team including the nurse, case manager/social work and care coordinators. The team has a panel of about 100 patients and admits the patients, takes care of them through the hospitalization, does the discharge planning and follows them for 30 days in outpatient and post-acute care setting. Modified versions of this model have been implemented by various organizations and have shown great success in reducing readmissions.

Tele health services: Establishing a telehealth department in the hospitals can provide several tools for close monitoring of high risk patients. Remote monitoring of vitals, weights, customized patient education videos, follow up appointments with physicians through teleconferencing can help in the process of reducing readmissions. Despite reimbursement challenges, the ROI of these services comes from increase efficiency and overall clinical outcomes.

At the most basic level, a coordinated team effort is required by any organization to add significant value to the readmission reduction process. Preventing avoidable readmissions can improve both the quality of care for patients and the financial wellbeing of healthcare organizations.