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Gina Pugliese, RN, MS, editor


Readmission penalties begin - 2000 hospitals forfeit $280 million

Starting October 1, more than 2000 hospitals will forfeit about $280 million in Medicare funds over the next year as a penalty for hospitals when patients with heart failure, heart attacks and pneumonia are readmitted within 30 days, according to a recent article in Kaiser Health News. Authorized by the 2010 Patient Protection and Affordable Care Act and with the national average readmission rate remaining steady at 19 percent for several years, Medicare is using the payment penalty to provide a clear  financial incentive to drive improvements in quality, and healthcare executives are paying attention.

The program penalties, which are up to 1.0 percent of base operating DRG payments, rising to 2 percent in 2014 and 3 percent in 2015, could have a serious impact on those hospitals who can least afford the penalties, those with the most vulnerable patient populations.

CMS has forged ahead despite concerns raised by the Premier healthcare alliance and other hospital groups about the potential for some safety net hospitals, those treating disproportionately large numbers of low income patients, to face penalties that they can least afford. There are also concerns about a lack of consideration in the penalties for planned or unrelated readmissions. Questions also continue about the methodology for measurement and lack of adjustment for socio-economic status.

Many programs achieve success - resources being shared
There are many successful initiatives that have led to decreased readmission rates for patients, many of them being shared among hospitals participating in one of CMS' innovative healthcare improvement models, Partnership for Patients. One goal of this partnership is to achieve a reduction of preventable hospital acquired conditions by 40 percent and readmissions by 20 percent by 2013. The Premier Hospital Engagement Network (HEN), one of the largest of the 26 CMS HENs with more than 450 hospitals, is collaborating to reduce harm, including preventable readmissions.

Another CMS initiative, Reducing Avoidable Hospitalizations Among Nursing Facility Residents, is a grant funded program that is part of CMS' Community-based Care Transitions Program (CCTP) to support community organization to more effectively manage post discharge care. This initiative supports the Partnership for Patients goal of reducing hospital readmission rates and focuses on high risk Medicare beneficiaries.

The Agency for Healthcare Research and Quality's Project RED (re-engineering hospital discharge) is also helping hospitals reduce readmissions by re-engineering the hospital workflow process by using a nurse discharge advocate that reinforces action steps to improve the discharge process and decrease hospital readmissions. Patients who had a clear understanding of their after-hospital care instructions, including how to take their medicine and when to make follow-up appointments with their doctors were found to be 30 percent less likely to be readmitted or visit the emergency department, according to a study by Dr. Brian Jack and colleagues at Boston University where the program was developed that appeared in the Annals of Internal Medicine.

What strategies work?
Because the CMS calculates penalties for readmissions using data from a prior three year period - July 1, 2008 to June 30, 2011 - it will be a while before we know exactly how effective all these programs are. It may not always be easy to identify those patients at highest risk for readmission for targeted interventions, however, successful programs focus on a combination of enhanced assessment and discharge planning for all patients before they leave the hospital. This planning takes into account a patient's social support structure, partnerships with post-acute and community care providers, scheduling post discharge follow-up, including phone calls and visits that include checking on the understanding and availability of prescription medications. Scheduled follow-up medical visits with providers, including availability of transportation and other services must also be addressed. One additional key element of success of these programs is to dispel the notion that hospital staff have minimal control over what the patient does nor does not do during their transition to the community and help them understand that engagement of all healthcare professionals in the key to success.



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