Payment Reduction Initiatives from Medicare

Ranae N. Beeker, RN,MSN,CCM,ACMAdmissions Coordinator/RN Case Manager

Sue Noyes, RN,BSN,CCMManager Case Management/Social Services

Definition: A readmission is a return hospitalization after an earlier hospital admission. ◦ Medicare is reviewing “all cause” readmissions

for 30 days post hospitalization Exception: Same-day readmissions for the

same condition to the same hospital

Current focus of Center for Medicare and Medicaid Services (CMS) with goal to achieve three-part aim outcomes:

1) Better Care 2) Better Health 3) Lower Costs Readmissions national cost $17 billion annually.

76% considered avoidable

Affordable Care Act directed by Medicare (CMS) will financially penalize hospitals

July 2012 Readmission data publicly reported Readmissions are expensive, adverse events for

patients Indicator for level of quality of care received Effective October 1, 2012 (FFY 2013). 

Medicare payment reductions under this program will be capped at 1.0% in FFY 2013.  The capped reduction amount will increase over time. 

Identified Acute Myocardial Infarction ( AMI) Heart Failure (HF) and Pneumonia (PN) readmissions as common, costly and often preventable.

These conditions impose a substantial burden on patients and the healthcare system and there is marked variation in outcomes by institution.

Measure CTMC RateReadmission

National Rate

AMI 19.6% 19.2%Heart Failure

24.6% 24.7%

Pneumonia 17.0% 18.5%

Based on discharges from July 2008-June 2011 Data from Hospital Compare website.

Working to promote transitions of care are smooth, seamless (Transitions of Care Committee)

Identifying patients with readmission potential on admission

Working with area nursing homes/skilled nursing facilities

Working with our Home Health (as well as other Home Health agencies that service our area).

Sepsis Altered Mental Status related to infection or

encephalopathy Acute Kidney Failure Anemia, Gastrointestinal Bleed Dehydration related to diarrhea or N/V Pneumonia Cardiac Dysrhythmias Chronic Obstructive Pulmonary Disease Acute on Chronic Congestive Heart Failure Acute Myocardial Infarction

Evaluate the spectrum of care for patients Identify systemic or condition-specific changes

to make care safer and more effective Invest in interventions that reduce

complications of care Improve process for assessing the readiness of

patients for discharge Improve discharge instructions Reconcile medications More carefully transition patients to next level

of care i.e outpatient care or other institutional care

End of Life Care Planning opportunity Partner with Home Health Agencies Partner with Nursing Homes Promote smooth transition of care (regardless of

disposition) Establish high-risk criteria for discharge staff (i.e.

Social Workers, Case Managers and nursing staff) Create readmission evaluation tool New concept idea: Huddle (5min) with identified

readmission (team approach) Promote f/u appt for all discharge patients within

5-7 days of discharge

CTMC will be providing information as Medicare continues to move forward on budget reduction initiatives.

Work collaboratively with physicians & health care community .

Mode of contact: via your office staff, email, & Medical Staff office.

Do not hesitate to call Case Management or Administration with questions…

This is definitely a work in progress for all hospital systems.

http://www.hret.org/care/projects/resources/Readmission_Guide.pdf

www.rarereadmissions.org/documents/RARE_Discharge_Observation.doc ·

21st Annual Midas+User Symposium: Potentially Preventable Readmissions

Wagonhurst, Patrice “Tools to Successfully Apply for the CMS Community-Based Care Transitions Program

2012.Nikiforakis,K. Cheshire Medical Center. Keene, NH

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