CE2
Approved for 1 hour of CCM, CDMS, and nursing education credit Exam expires on October 15, 2022
Getting Back Into Focus: Revisiting Reasons for the Hospital Readmissions Reduction Program Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN
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ince 2009, there has been a focus on reducing and preventing hospital readmissions in acute care facilities. Potentially preventable readmissions have been related to failed or ineffective discharge planning, especially for patients with chronic high-focus diseases such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Chronic condition management is a major factor in rising health care costs. The extensive costs per hospital admission associated with CHF and COPD (including care, medication, and therapy) represents a major financial liability to health care systems, and a significant component of these costs is unplanned avoidable readmissions. From the perspective of the facility, the factors that are driving the need to reduce readmissions include cost containment, achievement of performance initiatives, penalty avoidance, and improvement of quality indicators and patient experience. National awareness of adverse medical outcomes occurring within care settings continues to rise through quality data reporting, patient satisfaction reports, and a dedication to health care transparency. The expanding evidence base points to comparable problems occurring during the transitions between care settings. There is a key opportunity to develop interventions to improve the quality of patient transitions from acute care to community with a goal of reducing readmissions. Case managers are in an optimal position to develop interventional programs for effective patient transitions. These specially trained health care professionals are adept at developing discharge plans and accessing resources for postacute care. With an eye to the revenue cycle, they can make an impact by helping the facility avoid the potential financial ramifications associated with readmissions by improving patients’ outcomes and by helping patients remain in their own environment which, in turn, improves patient satisfaction.
Historical Information
According to data from the Centers for Medicare & Medicaid Services (CMS), acute hospital readmissions (defined as a 16 CareManagement April/May 2022
readmission within 30 days following postacute discharge) for chronic condition management were associated with $26 billion in Medicare spending in 2011. According to CMS, the population of people diagnosed with chronic medical conditions is predicted to rise to 125 million by the year 2020 (Centers for Medicare & Medicaid Services, 2012). A significant increase in this population will lead to increased spending at a time when the Medicare program itself appears to be in financial trouble. As an example of the impact, the 30-day readmission rates for patients with CHF are reported to be as high as 34% and the cost of managing CHF in the United States is estimated to be at least $10 billion per year. The current COPD population is estimated at 12.7 million diagnosed people, and COPD 30-day readmission rates are reported to be 27% nationwide with associated costs estimated to be $11.9 billion annually in health care dollars and an average annual cost per beneficiary of $9,545 according to Medicare claims data (Centers for Medicare & Medicaid Services, 2017). In a review of 2004 Medicare claims data, Medpac reported that readmissions accounted for almost 10% of all Medicare expenditures; $17.4 million in spending was attributed to unplanned hospital readmissions, of which $12.0 million was traced to what were identified/defined as “preventable readmissions” (Medpac, 2007). Readmission reduction is included in the Patient Protection and Affordable Care Act (PPACA), providing for both penalties and incentives for failure or success in Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN, is the Regional Director of Case Management for Pipeline Health Systems/Chicago Market. She has held positions at several acute care facilities and managed care entities in Illinois, overseeing utilization review, case management, and social services for over 14 years. Her current passion is in the area of improving health literacy. She is the recipient of the CMSA Foundation Practice Improvement Award (2020) and ANA Illinois Practice Improvement Award (2020) for her work in this area.
