Skip to main content

5 Questions to Determine Readmission Rate Effectiveness

By Joan Moss, RN, MSN, Senior Vice President, Sg2, for HealthLeaders Media  
   June 30, 2011

Hospitals have always known that reducing readmissions should be a priority quality goal but, until now, the payment incentives have not been in place. Like it or not, health care reform has provided a new impetus to do the right thing.

Financial penalties on providers with "excess" readmissions will begin in fiscal year 2013, but claims data collection on those penalties starts this October. The Centers for Medicare & Medicaid Services (CMS) measures readmissions within a 30-day time frame after patients are discharged for their initial admission. A readmission to any acute care hospital, for any reason, regardless of whether it is to the hospital from which the patient was originally discharged, or whether the readmission has any relation to the original hospital stay, will be counted. This is the definition of an "all-cause" readmission and does not exclude elective or planned admissions.

CMS will risk adjust readmissions penalties based on comorbidities and other patient variables, and initial penalties will focus on excess readmissions for congestive heart failure (CHF), pneumonia and acute myocardial infarction (AMI). Additional readmission penalties for chronic obstructive pulmonary disease (COPD), coronary artery bypass graft, percutaneous coronary intervention and other vascular procedures will begin in fiscal year 2015. What these penalties really indicate, however, is a larger CMS goal to move to a value proposition in terms of what it will pay for. To make sure your organization is on the right side of that value proposition relative to readmissions, have your leadership team ask themselves the following 5 questions.

Question 1: What is our business exposure based on CMS penalties and future accountable care organization (ACO) quality reporting requirements?
Put another way, what is your strategy for managing readmissions based on your current readmission rates? How much of your revenue could be at stake?

Effectively answering this question starts with good analytics, going beyond inpatient numbers to take a broader view of system-wide performance and benchmarking yourself against peer organizations. The more you can "peel the onion" on where readmissions are happening, the better—and 30-day readmission rates are also a good proxy for how well your post-acute care setting referrals are performing. The Sg2 Value Index™ offers an excellent tool for measuring overall clinical performance within these parameters and assessing your penalty risk. Most likely, hospitals in the bottom quartile of performance will bear the brunt of CMS penalties.

Question 2: How can we reduce readmissions without adversely affecting our current financial goals?
This is an important question to analyze with your financial staff, since there is no question that readmissions do make money and if they are reduced in one area, the income needs to be made up in another. Sg2 analysis shows that non-30-day readmission discharges or, in other words, new admissions for conditions not facing penalties, could be one answer. Drilling down to find the best leverage points for readmission prevention allows for focused interventions that are financially feasible, whether by disease, physician or patient geographic origin. A related question might be: How can you craft a multifaceted readmission strategy with a wide range of post-acute care settings? Lower-margin readmissions can also be "backfilled" with higher-margin cases, but health systems must keep in mind that under new payment models, such as ACOs and bundled payment, they will have to pay for readmissions.

Question 3: How can we better manage AMI, CHF and pneumonia patients?
CHF and pneumonia drive 30-day readmission volumes, with CHF accounting for more than 6% of all 30-day readmits, seconded by pneumonia at 4.8%. Nearly 1 in 4 CHF patients (24%) return to the hospital within 30 days with unresolved CHF. Typically, this is because they did not have a follow-up primary care or cardiology exam within 2 to 5 days after discharge, were released to the wrong post-acute care setting, or did not have their medications reconciled with a nurse or pharmacist within the first day or 2 after discharge. Like CHF patients, 66% of AMI readmissions are usually related to recurrence of the same cardiac event or an attack in a new cardiac site.

AMI patients need to see their cardiologist within 7 days after discharge and should be enrolled in cardiac rehabilitation. Readmission rates for pneumonia patients, who typically return with unresolved pneumonia or COPD, vary significantly by hospital, ranging from 15% to more than 22%. Mortality rates are even more striking, ranging from 6.7% to nearly 21%. It is important to treat the elderly and immunocompromised patients further upstream with vaccines, and timely blood cultures and antibiotic treatments should begin within 2 to 4 hours of diagnosis. The majority of all hospital readmissions are usually due to the original admission or related conditions, but the reasons vary more widely between 7, 14 and 30 days postdischarge.

Question 4: What post-acute referral locations create our greatest readmission risks?
Regardless of whether or not a hospital or health system owns a post-acute care site, it will be held accountable for readmissions from that site. Readmission rates for post-acute care providers differ, with skilled nursing facilities and home health care typically showing the highest rates of inpatient readmission. Clinical leaders should meet with their post-acute care providers to discuss what kinds of patients they are seeing, how ill those patients are and how transitions can be improved. Post-acute data by disease and site of care need to be understood and managed with all stakeholders brought into the process.

Question 5: How can we more effectively manage readmissions overall?
This boils down to organizational strategy, moving from data to action to measurable results. Good analytics entail drilling down by physician, disease and service line to see where readmissions are happening and why. Benchmark yourself against peer hospitals and systems to know where to set and raise the bar and make measurement ongoing with monthly performance reports. Managing to better analytics works, as proven by the many health systems we have worked with to address readmissions and other performance issues. You can't improve what you can't measure—and you can't wait to do either, as penalties for readmissions begin in just a few short months.


Joan Moss, RN, MSN, is a senior vice president at Sg2.


Pages

Tagged Under:


Get the latest on healthcare leadership in your inbox.