17 minute read
Getting Back Into Focus: Revisiting Reasons for the Hospital Readmissions Reduction Program CE2
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
Since 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 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.
According to data from the Centers for Medicare & Medicaid Services (CMS), acute hospital readmissions (defined as a 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. 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.
reducing potentially preventable readmissions. Under Section 3025 of the Affordable Care Act, the establishment of the Hospital Readmissions Reduction Program requires CMS to reduce payments to participating hospitals with excess readmissions effective October 1, 2012 (Centers for Medicare & Medicaid, 2015).
Quality initiatives such as The Joint Commission on Accreditation of Healthcare Organizations’ and the National Quality Forum’s increased focused on medication reconciliation, the discharge planning process, and examining performance measures for posthospitalization care coordination are examples of endeavors to improve the transitions of care process. Additionally, the Institute of Medicine has advocated for pay for performance measures to motivate health care providers to improve patient care coordination across settings. The result is a focus on transitional care, patient satisfaction, and overall quality of care.
The guidelines rolled out by Medicare in 2010 and confirmed by the PPACA in 2012 state readmissions within a 30-day period are reviewed very closely and, in some instances, will not be reimbursed (Centers for Medicare & Medicaid Services, 2012). Facilities with significant readmission rates for certain target diagnoses also run risk of further financial penalties being imposed. Readmission reduction programs have been recommended for implementation and acute care hospitals have been facing yearly penalties based on readmission rates since the 2012 target date discussed in the original Medpac report (Medpac, 2007).
The PPACA proposed the methodology for calculating the readmission payment adjustment factor and the process for hospitals to review readmission information and submit corrections as needed. The maximum penalty for 2013 was capped at 1% of total Medicare reimbursement; in 2014 this penalty rose to 2% of total Medicare reimbursement, and in 2015 hospitals can be penalized as much as 3% of their total annual Medicare payment and will also receive reduced payment for each hospital admission/length of stay for the target diagnoses (Centers for Medicare & Medicaid Services, 2015). The initial 2013 penalty is determined by data collected on the identified diagnoses during the initial evaluation period of July 2010 to June 2013 to determine if the hospital had too many readmissions. This created a baseline for each facility from which improvement/failure to improve would be measured against in subsequent periods via CMS.
Timeline of the Hospital Readmissions Reduction Program (HRRP) Evolution
In 2012, the HRRP established the definition of readmissions and the initial diagnoses to be followed. These included CHF, acute myocardial infarction, and pneumonia. The 3-year lookback period to establish baseline readmission data was also set. Additional diagnoses were added in 2014: COPD, total hip arthroplasty, and total knee arthroplasty. In 2015, coronary artery bypass graft was added.
The year 2016 marked the adoption of the “Extraordinary Circumstances Exemption” that allowed hospitals that experience a significant disaster or other extraordinary circumstance beyond the hospital’s control (hurricane, flood, fire) to request an exemption from the HRRP for a period of time.
The 21st Century Cures Act in 2018 directed CMS to assess a hospital’s performance relative to other hospitals with a similar proportion of patients who are dually eligible for Medicare and full Medicaid benefits beginning in FY2019. Starting in FY2019, CMS takes into account the proportion of low-income patients within a hospital because they are more likely to be readmitted due to other socioeconomic factors. Finally, a focus on the impact of social determinants of health on readmissions!
The year 2019 also gave us finalized definitions of dual eligible, dual proportion, and the applicable period of dual eligibility. It also created alignment with the Meaningful Measures initiative and, beginning FY2020, the 6 readmission measures were removed from the Hospital Inpatient Quality Reporting Program so that hospitals were not facing penalties twice for the same measure.
Current Readmissions Data
Current readmission data shows that 15.5% of Medicare patients are readmitted within 30 days. Data from 2010 show a Medicare All Cause Readmissions rate of 18.3%, and
data from 2014 reported readmission rates of 17.3%. The total overall readmission reduction for Medicare All Cause Readmissions for 2010 versus 2019 is 2.8%. Condition-specific Medicare readmissions decreased significantly for heart failure (from 34.0% to 21.9%) and for COPD (from 27.0% to 19.7%). Patient populations with chronic conditions will continue to rise from 133 million in 2020 to a projected 170 million in 2030. Costs of care will also rise accordingly.
According to the Institute for Healthcare Improvement (Institute for Healthcare Improvement, 2017), current research has demonstrated that the rate of readmissions can be reduced by improving discharge planning and care coordination between all levels of the care continuum concurrent with providing increased opportunities for patient coaching, education, and support for self-management. Implementation of these interventions from the time of admission through the immediate 30-day postacute period may decrease readmissions and improve quality of care.
Healthcare Theory in Action
Patient coaching and education need to be tailored to the individual patient’s needs. Watson’s Caring Model and Ray’s Theory of Bureaucratic Caring stress that a patient’s individualism must be considered in all aspects of care. Case management uses the ethics of care to develop a patientcentered plan of care across the continuum with a focus on the right care, the right setting, and the right timing as well as patient engagement in the plan. While creating a patient’s discharge plan, the goals of the patient are considered concurrently with their ongoing medical needs. By working holistically and considering the patient’s perspective, a mutually satisfactory discharge plan can be developed with a greater potential for success.
Watson’s Caring Theory reminds us that people are not objects and live in context with their surroundings. Watson reminds us that “caring is possible and must be present as much as when curing has failed as when cure is possible” (Nelson-Marten, 1998). In the case of chronic condition management, where a “cure” is not achievable for the patient, it is the duty of nursing to find solutions to provide the best possible outcomes for all stakeholders involved.
With the ongoing changes to the healthcare environment, especially when considering reimbursement and access to care, Watson prompts health care leaders to incorporate Caring Theory into active daily practice. Current models in place have co-opted the language of Caring Theory to refer not to the quality of care or holistic healing offered to patients but rather to having the most advanced technology available, recruiting well-known practitioners, and having other services available. Use of the terms “health care consumer,” “provider,” or “health care worker” depersonalizes the intensely personal “business of health care” and shifts the focus from authentic caring to an economic exchange of fees for goods or services (Watson, 2006). Caring should be recognized as a “legitimate economic resource” as studies have demonstrated that patients who experienced caring reported “emotional-spiritual well-being, increase in patient safety, decrease in costs, increase in trust relationships” (Watson, 2006).
The Theory of Bureaucratic Caring by M.A. Ray identifies that caring is distinguished by the situation in which it is being applied but is patient-centric no matter the circumstance. In Ray’s theory, the stakeholders integrate a holistic approach to patient care using an interprofessional care team and transform the outcomes; this demonstrates the belief that nurses can challenge and change organizational culture while reinforcing the commitment to caring. This theory has been reviewed and updated several times since it was first published in 1987; the most recent update incorporates the spiritual and ethical origin with other perspectives, including political, economic, and other nontraditional healthcare focus areas. Bureaucratic Caring Theory has been demonstrated to make a positive impact on chronic condition management to achieve high-quality outcomes for this at-risk population.
Additionally, Wagner’s Chronic Care Model seeks to “optimize each healthcare team member’s abilities, expertise and willingness to achieve high-quality health outcomes…that are safe, necessary, cost-effective, timely, desired and patient-centered” (Potter and Wilson, 2017). Patients in programs that use this model reported higher satisfaction with the health care team and increased confidence in managing their chronic conditions.
Case management applies these theories by coordination of care and postacute care services or resources in alignment with the patient’s needs, provider’s recommendations, and
benefits available under the patient’s payer plan and network. The Standards of Practice for Case Management direct case managers to be advocates for patients and to contribute to improved health outcomes by fostering case management growth and development, impacting health care policy, and providing evidence-based tools and resources. Professionals in the case manager role assume the role of “advocates who help patients understand their current health status, what they can do about it, and why those treatments are important…by guiding patients and providing cohesion to other professionals in the health care delivery team, enabling their clients to achieve goals more effectively and efficiently” (Case Management Society of America, 2016). Through specific case management interventions, patients benefit from strategies to manage wellness and chronic conditions through a decrease in the fragmentation of the health care system (Brock, 2011).
Evidence-Based Practice Interventions to Reduce Readmissions
The interventions for readmission reduction can be classified into the following major categories: telephonic follow-up calls, discharge planning services, patient education/teaching, and comprehensive care coordination.
Telephonic follow-up models can be grouped into 2 subcategories of single-call and multiple-call formats. Single-call models focus on addressing gaps in education and medication reconciliation. Outcomes from Harris et al. (2016), using a single-call model for a COPD population, demonstrated a decrease in 30-day readmissions from 20.05% preintervention to 11.25% postintervention. Melton et al. (2016) implemented a single post-discharge call intervention that was focused on three topics: review of discharge instructions, medication education, and confirmation of scheduled follow-up appointments. This single event intervention demonstrated a 22% reduction in readmission for the population of 1,994 participants.
Multiple-call formats include programs with duration of 30 days to 1 year postdischarge. A study by Copeland et al. (2010) reported significant decreases in readmission rates for CHF patients within 60 days postdischarge; after 1 year, there were no significant differences in the pre- or postintervention populations. Call content included patient education, lifestyle changes, diet, medication, and early identification of symptom exacerbation. Takeda et al. (2012) followed patients for 6 months with a specially trained nurse (RN) to provide education and medication reconciliation and to schedule medical appointments. This program demonstrated a 58% reduction in readmissions for the CHF population.
Patient education is a focus of all the interventions reviewed in this proposal. Several of the studies evaluated intensive “education only” plans. Blee et al. (2015) used a pharmacist-driven medication education program to increase understanding and compliance with medication usage. Readmissions for COPD were reduced from 21.3% preintervention to 8.6% postintervention. Cavalier and Sickels (2015) developed a checklist for chronic care management education that was focused on patients with CHF and COPD. The checklist drives the patient education throughout the inpatient admission to account for all education required for effective diagnosis management. Use of the checklist reduced readmission from 28.8% to 17.4%.
Education has long been seen as a way to empower and engage patients in their self-management. The importance of patient education is underscored by the need to effectively coach patients through self-management strategies. Linden and Butterworth (2014) reported on use of motivation interviewing techniques to increase patient engagement; these techniques were started while the patient was hospitalized and continued periodically through the initial 90 days postdischarge. While this intervention did not produce a statistically significant reduction in 30-day readmission rates, patients reported feeling more educated about their chronic conditions and more engaged in their self-management. Pomerantz et al. (2010) investigated the use of “care coaches” in a telephonic engagement model to improve clinical outcomes. The care coaches were identified as RNs with experience in behavior modification strategies and were supported by an interprofessional care team. Their primary intervention was “to educate and motivate patients to achieve sustained behavior change” (Pomerantz et al., 2010). Through the establishment of one-on-one relationships and a scheduled structured outreach program over a 1-year period that included 3,305 participants, the care coach program demonstrated a decrease in admissions per thousand from 44.91 to 23.66. The study also noted a decrease in the average length of stay and decrease in the use of the emergency department, which were associated with a reduction in cost of care for the population.
Comprehensive care coordination models have been shown to demonstrate the most impact on reducing readmissions for the target populations. Six demonstration program studies were reviewed. Each model featured the goal of using a holistic approach to develop collaborative interdisciplinary teams to facilitate patient self-management from the time of admission through a defined postdischarge period and included vital interventions currently absent from the standard discharge process. Assessment and evaluation of the patient’s available social supports and the need to restructure the discharge process to eliminate fragmentation and communication breakdowns were acknowledged as top priorities. Top strategies include the consistent use of
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.
continuous medication reconciliation at each level of care, use of standardized tools and patient education across the care continuum, active coordination of follow-up appointments including making and confirming follow-up appointments before discharge, an effective real-time handoff to the next level of care, and making contact with the patient within 48–72 hours postdischarge to review and reinforce the discharge plan; these strategies increase the communication needed to effect a successful transition.
Recognized comprehensive case management programs using these techniques, which include Project BOOST (Better Outcomes for Older Adults through Safe Transitions), Project RED (Re-engineering Discharge), STAAR (State Action on Avoiding Rehospitalization), Naylor’s Transitions of Care Model (TOC), Coleman’s Care Transitions Interventions (CTI), and Hospital to Home (H2H), have all produced documented decreases in readmission rates with use of varied strategies. BOOST reported a 21% reduction, and RED reported readmission rates decreasing from 24% to 16% on average. CTI data demonstrate a 13.8% readmission rate in the control group versus an 8.9% readmission rate in the study group. TOC did not report 30-day readmission rates but did note a reduction in patient days for the target population. The control group used 760 inpatient days versus 270 inpatient days for the study group. Bobay et al. (2015) noted that many of the 32 hospitals surveyed are using one of these identified transitional care models as a base, although they have customized their programs by combining features of other models to address their specific populations and needs.
Conclusion
The use of some type of transitional care has been demonstrated to produce measurable results in readmission reduction while also linking the patient with support and resources in the 30-day postacute hospitalization period. The current state of the discharge process continues to be shown to be ineffective at successfully transitioning patients with chronic conditions back to the community. The current discharge process needs to evolve from physician orders and written discharge instructions accompanied by a stack of indecipherable patient education handouts and recommendations with a suggested follow-up time frame to a true transitional process with active navigation through the immediate postacute care period; the focus should be on process improvement, stakeholder education, and creation of an active interprofessional collaboration to provide the best support and education for each patient. Research and the growing evidence base demonstrate that interventions started in the acute facility and carried through the transition to the community for a minimum of 30 days are effective at reducing readmissions. Case management research is important in providing our patients with a safety net for success! CE II
CE exams may be taken online!
Click the link below to take the test online and then immediately print your certificate after successfully completing the test. Members only benefit! This exam expires October 15, 2022.
Take this exam online >
Members who prefer to print and mail exams, click here. You must be an ACCM member to take the exam, click here to join ACCM.
References
Blee, J., Roux, R., Gautreaux, S., Sherer, J. and Garey, K. (2015). Dispensing inhalers to patients with chronic obstructive pulmonary disease on hospital discharge: effects on prescription filling and readmission. American Journal of Health System Pharmaceuticals, 72 (6), 1204-1208. Bobay, K., Bahr, S. and Weiss, M. (2015). Models of discharge care in Magnet® hospitals. The Journal of Nursing Administration, 45(10), 485-491. Brock, J. (2011). How care coordination affects you. CMSA Today, 1(2), 8. Case Management Society of America. (2016). Standards of practice for case management. CMSA, Little Rock, AR. Cavalier, D. & Sickels, L. (2015). The fundamentals of reducing HF readmissions.
continued on page 36
