NOVEMBER 29, 2012

Welcome to the Medicare Readmissions Update eNewsletter
Editor: Philip L. Ronning
This issue sponsored by the Dual Eligibles Summit

Reducing CMS Readmission Penalties: Stay Two Years Ahead of the Data
Because penalties under the CMS Hospital Readmission Reduction Program are based on a three-year rolling average of readmission data, today's performance will be just one-third of the 2016 score used to determine penalties. "You should look at the current penalty and the projected penalties that your hospital is experiencing not only for this year but for the 2 percent increase planned for FY 2014 and then the 3 percent increase in fiscal 2015," advised Amy Boutwell, MD, President of Collaborative Healthcare Strategies and co-founder of the STAAR (State Action on Avoidable Rehospitalizations) initiative, jointly sponsored by the Commonwealth Fund and the Institute for Healthcare Improvement. Boutwell also advised looking ahead to future program expansion plans such as new diagnoses and reporting requirements for the HCAHPS survey. (Healthcare Intelligence Network, November 19, 2012)

Quantitative Tools for Addressing Hospital Readmissions
A study published in BioMed Central examined the value of a variety of quantitative tools in reducing readmissions and described quantitative tools such as definitions, risk estimation, and tracking of patients for reducing hospital readmissions. Tools such as the 3M grouper Potentially Preventable Readmissions Classification System were reviewed. The authors conclude that "...the study demonstrated that quantitative tools including the development of definitions of readmissions, estimation of the risk of readmission, and patient specific spreadsheets could contribute to the improvement of patient outcomes in hospitals." (BioMed Central, November 2, 2102)

Reducing Hospital Readmissions: Lessons from Project BOOST
Mark V. Williams, MD, Professor and Chief of the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine and an investigator in an important 2011 New England Journal of Medicine rehospitalization study, and a project leader at Project BOOST (Better Outcomes for Older adults through Safe Transitions), shared details and lessons learned from the project at a recent Clinical Impact Symposium. Project BOOST, which has been implemented in 130 hospitals, provides members with a toolkit that includes project management tools, clinical tools, and the "secret sauce" of Project Boost: mentored implementation. "We bring someone in to figure how to integrate these tools into the workflow, and hold their feet to the fire when necessary," said Williams. Checklists are often helpful. For example, four drugs are responsible for two thirds of emergency hospitalizations for adverse drug events in older Americans. A checklist listing these drugs for providers can remind them to integrate this concern into discharge planning if necessary. Teachback, one of their tools, encourages discharging clinicians to make certain patients understand discharge instructions. The video below is used to stress the importance of Teachback:

(The Kindred Continuum, November 13, 2012)

Four Parts of a Successful Strategy to Reduce Hospital Readmissions
Four principal strategies are recommended here for reducing readmissions: 1) form partnerships with nursing home practitioners and provide detailed discharge guides, 2) leverage available technologies, 3) tailor the discharge plan to the patient, and 4) address medication issues. It is necessary to create a comprehensive strategy to limit readmissions. The author advises detailed strategies be developed using proven techniques tailored towards meeting the needs of the patient, finding the right facility or caregiver for the patient upon discharge, and taking advantage of advances in technology that allow for more effective discharges. (MedCity News, November 12, 2012)

Palliative Care, End-of-life Discussions Curb Readmissions, Aggressive Care
According to the Center to Advance Palliative Care (CAPC) hospital palliative care has increased 138% in the past decade. Palliative care is focused on serious illness, end-of-life care and pain relief in order to improve patient experience but also quality outcomes. But palliative care can create readmission issues for hospitals. A joint American Hospital Association - CAPC committee recommends the following actions: 1) create a planning committee of administrators and clinicians to maximize palliative care, 2) complete a needs assessment of palliative services, 3) review priorities of palliative services that improve outcomes, 4) collect data for baseline measurement, 5) communicate with peer institutions that have been successful in integrating palliative care into ICUs, emergency departments, hospitalist programs and outpatient services, and 6) develop a strategic plan and budget. (FierceHealthcare, November 19, 2012)

Cardiologist vs. Hospitalist: Who Curbs More Readmissions?
According to a study by the Minneapolis Heart Institute Foundation, cardiologists curb more readmission of heart failure patients than hospitalists. This is viewed as a controversial finding given that an increasing percentage of heart patients are discharged by hospitalists. Although the study found cardiologists improved readmission outcomes, length of stay was similar for both cohorts. However, cardiologist-led care cost a mean $9,850, compared to $7,741 for hospitalists. (FierceHealthcare, November 12, 2012)

Hospitals Offer Wide Array of Services to Keep Patients from Needing to Return
As Medicare cracks down on readmissions, hospitals are paying more attention to patients after discharge using techniques such as dispatching nurses, transportation, culturally specific diet tips, free medications and even bathroom scales to patients deemed at risk of relapsing. Hospitals are also no longer leaving to patients the responsibility for setting up follow-up appointments or filling new prescriptions. A survey of 377 elderly patients at Yale-New Haven Hospital recently published in The Journal of General Internal Medicine, found that 81 percent of the patients either didn't understand what all their prescriptions were for; were prescribed the wrong drug or the wrong dose; were taken off a drug they needed, or never picked up a new prescription. (Kaiser Health News, November 27, 2012)

Caregiver Factors Influence Hospital Readmissions
New research suggests understanding how social environmental factors contribute to re-hospitalization of home health care patients would improve care for those patients, while at the same time managing Medicare spending. In a recent Advances in Nursing Science meeting, Hong Tao, R.N., Ph.D., of University of Wisconsin - Milwaukee and colleagues, looked at factors such as whether the patient lived alone or with others, whether he or she had a primary informal caregiver, and the type and frequency of informal care provided, and how these factors affected the risk of repeated hospital admissions among the 1,268 elderly patients receiving home health care they studied. The researchers found some significant associations between social environmental factors and readmission. They noted that the greater the difference between the patients' clinical condition and functional status, the greater the risk of rehospitalization. "Informal caregivers are part of the solution in preventing unnecessary hospitalizations and more attention needs to be given to how these caregivers are supported in their roles. [Our] findings may help home healthcare nurses to recognize those patients who are in need of certain services that may reduce hospitalization, such as those that lack the support of the patient's family or assistance from paid informal caregivers." (PsychCentral, November 13, 2012)

Hospital Guidelines Not Linked to Readmissions: Study
Michaela S. Stefan, MD, an academic hospitalist at Baystate Medical Center in Springfield, MA, was lead author of a study on procedural guidelines designed to improve quality and how these affected readmissions. "The idea was, increasing the quality of care provided by these hospitals would improve the outcomes," but the study found no such connection. Overall, they found that hospitals with the best scores for following guidelines did not have "meaningfully" lower readmissions than hospitals with the worst scores. "Even when the associations were statistically significant, the differences in the readmission rates of high and low-performing hospitals were small," the team writes in the Journal of General Internal Medicine. (Reuters, November 8, 2012)

Contemporary Evidence about Hospital Strategies for Reducing 30-Day Readmissions: A National Study

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Template for Calculating Revenue Loss to Reduced Readmission

Rosemary Rotty
UMass Memorial Medical Center, Worcester, MA