Creating a strategic approach for decreasing readmission penalties

Readmission rates are often viewed as success markers for quality of care in hospitals and skilled nursing facilities.

As the result of legislation introduced as part of the Affordable Care Act, hospitals that report above-average readmission rates for certain diseases within a 30-day window are subject to Medicare penalties from the Centers for Medicare and Medicaid Services (CMS). According to government officials, approximately 12 percent of Medicare patients are readmitted for avoidable reasons, and these readmissions cost billions of dollars annually.

However, there are efforts that can be made by hospitals and other medical facilities to reduce readmissions, and ultimately the penalties that go with them. These include understanding the readmission penalty formula, focusing on the patient experience post-discharge, improving how patient files are coded, and physician/staff alignment.

CMS has created a formula for calculating readmission penalties that takes into account the facility's number of admissions and readmissions for certain diagnoses (currently Acute Myocardial Infarction, Heart Failure, Pneumonia, Chronic Obstructive Pulmonary Disease and total knee/hip replacement) are under the microscope. Facilities are paid for both the admission and readmission of a patient, however the facilities are subject to a decrease in their base Medicare rate based on the readmission penalty. CMS looks at these numbers over a three-year period and imposes the readmission penalty 15 months later. Therefore, facilities are challenged with facing penalties reflective of performance from previous years. Even if readmission numbers have decreased, facilities can still feel the effects of past rates.

In hospitals and skilled nursing facilities, patients' conditions are closely monitored by staff. Once the patient is discharged, however, they need monitoring and professional follow-up to stay healthy and avoid preventable readmission. Software such as NexusConnexions™ can help facilities, as well as recovering patients, by providing patient relationship management software which gives facility caregivers the tools to keep patients healthy for the 30 days after discharge and afterwards. Best practices have included assisting with prescription refills, facilitating follow-up doctor appointments and medical equipment needs, as well as educating patients regarding signs and symptoms to look for and when to call for help.

While readmission penalties are based off the number of admissions and readmissions, that number can be altered based on risk stratification processes that take into account other factors such as the patient's medical history, comorbidities, family support and other psychosocial factors. In order for these to be taken into account, a coordinated coding effort between physician and nursing documentation and revenue cycle diligence is required.

The last aspect of this strategic approach is to ensure that all staff is aware of these penalties and is working together to decrease avoidable readmissions. By requiring accountability, staff will be more inclined to carefully capture all aspects of the patient's diagnosis. Increased physician alignment improves communication amongst clinical stakeholders and best practice documentation, leading to more accurately coded reports which can help lower readmission penalties.

With a strategic plan, hospitals and skilled medical facilities can avoid readmissions and the penalties that result from them, ultimately improving quality of care while saving valuable dollars.

Dr. Feldman founded Nexus Health Resources to make a difference in the healthcare delivery system by effectively coordinating healthcare among patients and providers during the transition from hospital to home. She combines the expertise of a practicing surgeon, the compassion of a healthcare professional, and the leadership skills to manage and grow an organization successfully. Dr. Feldman graduated from New York Medical College in 1991 and completed her residency in General Surgery at St. Vincent's Hospital in New York City, and her residency in Otolaryngology at the New York Eye and Ear Infirmary. In 1997, she joined Hudson Valley Ear, Nose & Throat (ENT), serving as President and Managing Partner. Under her guidance, Hudson Valley ENT became the premier ENT practice in the community, and subsequently underwent a strategic merger with ENT and Allergy Associates, the largest ENT practice in the New York/New Jersey Region.

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