Preventing Unnecessary Hospital Readmissions. Wednesday, February 26th, 2014

Transcription

1 Preventing Unnecessary Hospital Readmissions Wednesday, February 26th, 2014

2 Speaker Sue Dill Calloway RN, Esq. CPHRM, CCMSCP AD, BA, BSN, MSN, JD President of Patient Safety and Education Board Member Emergency Medicine Patient Safety Foundation

3 Learning Objectives 1. Explain measures a hospital can take to reduce unnecessary readmissions 2. Describe the financial penalties associated with readmissions 3

4 Hospitals Penalized for Excess Readmissions First year started October 2012 and Medicare penalized 2,217 hospitals for excess readmission rates Hospitals forfeited $280 million dollars in the first year which was 2 out of every 3 hospitals 2 million Medicare patients are readmitted within 30 days per year Second year, starting with October, 2013, hospitals forfeited $217 million dollars Still about 2 out of every 3 with 2,225 hospitals penalized 4

5 Bonuses and Penalties for Hospitals Medicare has two payment incentive programs for hospitals Medicare cut payments by 1% and this money was set aside for a bonus pool ($850 million) for those that did better than average on a number of measures One given bonuses and penalties for how well they perform on 24 quality measures called VBP or value based purchasing The second penalties hospitals with excess readmission rates Hospitals could gain up to 1.25% in payment or lose as much as 3.25% for the programs combined 5

6 Hospitals Penalized for Excess Readmissions 6

7 Chart Shows Readmission Penalty in

8 2014 List of Hospitals ews.org/index.php/2014/01/n ew-medicare-data-showhospitals-with-high-rates-ofreadmissions/ 8

9 Hospital Wide All Cause Unplanned Readmits ww.qualitynet.org/dcs/ ContentServer?c=Pag e&pagename=qnetpu blic%2fpage%2fqne ttier4&cid=

10 Readmission Rates All Conditions 10

11 Readmission Reduction Program CMS established a policy of using the risk adjustment methodology endorsed by the National Quality Forum (NQF) for the readmissions measures for AMI, HF and PN to calculate the excess readmission ratios See CMS website on readmission reduction program Also higher rates of readmission for all causes increases chance of being selected for third pilot of CMS worksheets All cause readmission rates are important because Medicare Payment Advisory Board (MedPAC) is advising Congress to use this measure when determining financial penalties 11

12 jects/nqf_all- Cause_Readmissions_Pr oject.aspx 12

13 CMS Readmission Program Website Payment/AcuteInpatientPPS/Readmissions- Reduction-Program.html 13

14 CMS Website Hospital Readmissions mpare/readmission-reductionprogram.html 14

15 CMS Website Hospital Readmissions Lists the following: Name of hospital Provider number and state Measure (readmission PN, AMI, HF etc.) Number of discharges Excess readmission rate Predicted readmission rate Expected readmission rate Number of readmissions with start and end date of data 15

16 CMS Readmissions Reduction Program Service- Payment/AcuteInpatientPPS/Readmissions -Reduction-Program.html 16

17 CMS Readmissions Reduction Program FY 2012 (starting Oct 2012) IPPS rules defined readmission as admission within 30 days Adopted for measures for MI, pneumonia and heart failure Established methodology to calculate excess readmission rate compared to national average Risk adjusted as endorsed by National Quality Forum which included patient demographic characteristics, comorbidities, and patient frailty Used 3 years of discharge data and at least 25 cases 17

18 CMS Readmissions Reduction Program FY 2013 rate based on discharges for 3 year period from July 1, 2008 to June 30, 2011 FY 2014 based on 3 years discharges from July 1, 2009 and June 2012 In expanding conditions for FY 2015 to include: (1) patients admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) and (2) patients admitted for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) 18

19 CMS Readmissions Reduction Program CMS said about 1.4 million TKA and THA procedures are performed on Medicare patients per year CMS found significant variation in readmission rates of these patients CMS said readmission rate for COPD was 22% and ranged from 18 to 25% across 4,546 hospitals 19

20 Formula to Calculate Readmission Adj Factor 20

21 Formula to Compute Payment Adjustment 21

22 Meaningful Use Stage 2 and Readmissions Hospitals that want to get incentive money for developing electronic health records have to follow the standards for meaningful use Stage 2 has one element that could help reduce unnecessary readmissions This is referenced in the CMS discharge planning worksheet Also in the revised CMS 39 pages of discharge planning standards 22

23 Meaningful Use Stage 2 and Readmissions The Eligible Professional (EP) who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide a summary care record for each transition of care or referral Most hospitals send a continuity of care form or transfer form if transfer to another hospital or LTC This one has three measures Details available off the CMS website at Guidance/Legislation/EHRIncentivePrograms/downloads/Stage 2_EPCore_15_SummaryCare.pdf 23

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25 Discharge Planning Revisions ongeninfo/pmsr/list.asp#top OfPage 25

26 Third Revised Worksheets ninfo/pmsr/list.asp#topofpage 26

27 Discharge Planning Worksheet If transferred to another inpatient facility was the discharge summary ready and sent with patient? The following controversial section was changed in the 3 rd revision Was discharge summary sent before first postdischarge appointment or within 7 days of discharge? Was follow up appointment scheduled? Now says send necessary medical record information to providers the patient was referred prior to the first post-discharge appointment or 7 days, whichever comes first 27

28 Discharge Planning Worksheet Was the necessary medical record information ready at the time of transfer if patient sent to another facility Was there any part of the discharge plan that the hospital failed to implement that resulted in a delay in discharge Was there documentation in the medical record of results of tests pending at the time of discharge both to the patient and the post hospital provider? Was patient readmitted within 30 days? 28

29 ACGME 6 Core Areas Include Care Transitions Accreditation Council for Graduate Medical Education has released a guidance for assessing the clinical learning environment in US teaching hospitals Includes 6 core areas which include care transitions Other areas include patient safety; health care quality; supervision; duty hours, fatigue management and mitigation; and professionalism 29

30 LERNewsRelease.pdf 30

31 ACA Driving Drop in Readmission Rates After holding steady at 19% from 2007 to 2011, The all-cause 30-day hospital readmission rate among Medicare fee-for-service beneficiaries fell to 18.5% in 2012, It continued to fall in 2013 According to an entry posted on The CMS Blog website. Preliminary claims data shows the Medicare readmission rate averaged less than 18% through August. Dec

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33 49 States Reduced All Cause Readmissions The only state that did not see a decrease Utah already had one of the lowest readmission rates in the country 33

34 FY 2014 Hospital Readmission Program 34

35 Why Reduce Avoidable Readmissions?? CMS has implemented value based purchasing or VBP to improve patient outcomes Hospitals have been financially penalized since October 1, ,225 hospitals penalized 1% penalty So if billed $40,000 on a Medicare patient would lose $ ,508 hospitals penalized 2% penalty Increase for 1,317 hospitals and decrease for 1,074 hospitals 2015 Penalty goes to 3% Incentive payments but by 2017 CMS will penalize up to 8% of Medicare payments 35

36 Why Reduce Avoidable Readmissions?? CMS says identifying and reducing avoidable readmissions will improve patient safety, enhance quality of care, and lower health care spending This is why CMS, consumers, hospital leaders, policymakers and the medical community is focused on this issue Program defines "readmission" as "an admission to a hospital within 30 days of a discharge from the same or another hospital 36

37 CMS Hospital Value Based Purchasing VBP heet.asp?counter=

38 CMS Value Based Purchasing pital-vbp.html 38

39 CMS Value Based Purchasing

40 Includes Quality Measures for Hospitals VBP 40

41 CMS Quality Measures for Hospitals VBP To see final rule go to 41

42 NQF Readmissions Measures All-cause hospital-wide readmissions measure 42

43 NQF Readmissions Measures 1789 NQF Board endorses all-cause hospital wide readmission measure developed by Yale University and CMS CMS agreed to defer this readmission reason in readmission reduction program until MAP recommended MAP (Measure Application Partnership) has role to advise on best use of measures in payment and public reporting Steering committee voted to endorse this measure within one year 43

44 The Cost of Readmissions Medicare wants to pay less to hospitals with higher than average costs for patient care stating that readmissions cost $26 billion dollars in a decade Part of the push to make hospitals the hub for coordinating care Traditionally when hospitals discharged the patient they saw their job as done But hospitals could be on the hook with what happens after discharge CMS thinks hospitals are best able to take the lead in overseeing patient care 44

45 Is This Fair? Hospitals argue that it could punish them for things they can not control like patients who can not afford their medications Many feel this is not a quality measure for a hospital Evidence is mounting that the link between readmission and quality of care is more complex than assumed Role of other factors such as patient s demographics, socioeconomic characteristics, social support structure, and co-morbid conditions and risk adjustment is not fully understood 45

46 Patient Protection and Affordable Care Act The Patient Protection and Affordable Care Act or PPACA (also abbreviated ACA) was the law that set up the financial penalties for hospitals with excessive readmissions The new law establishes a VBP program, or value-bases purchasing, to pay hospitals for their actual performance Included initiatives to prevent hospital readmission through a comprehensive program for hospital discharge planning 46

47 Hospital Readmissions Sec 3015 Expected to save $7.1 billion over ten years Beginning in fiscal year 2013 hospitals (started Oct 1, 2012) with higher than expected readmission rates will experience decreased Medicare payments for all Medicare discharges Secretary of HHS must make available a program to improve their readmission rates through PSO CAH and post-acute care providers are exempt Performance data are based on 30 day readmission 47

48 Hospital Readmissions and CMS Beginning in 2015, hospitals with certain hospital acquired conditions (HACs) will receive additional payment reductions from Medicare. CMS will evaluate performance based on achievement and improvement on selected measures In FY 2013 CMS will measure hospital performance using two domains; Clinical process of care domain (12 process of care) Patient experience (patient satisfaction or HCAHPS) 48

49 AMI, HF, and Pneumonia FY

50 HAI and Surgical Care Improvement 50

51 Patient Experience of Care Measures 51

52 HCAHPS 52

53 Sign Up for Free Newsletter To view and subscribe to other e-newsletters go to 53

54 Readmission Update Newsletter Topics Some hospitals have a RED team or a committee to reduce unnecessary readmissions Following the evidenced based literature for tips to help reduce the unnecessary readmission rate can help Medicare identifies the best and worst hospitals for THA and TKA Hospitals with more elderly and poor patients likely to face readmission penalties Hospitals prohibit early elective C-sections 54

55 Readmission Update Newsletter Topics Hospital compare offers data on % of patients with THA and TKA who were readmitted and excess readmission data 24 evidenced based practice competencies to ensure staff have knowledge and skills which can reduce complications and costs by 30% Role of chronic conditions in readmissions 20 item tool that predicts patients with increased risk of readmissions Called the 8P scale of the target screen of BOOST 55

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57 Readmission Update Newsletter Topics 13 most frequent primary diagnoses for readmissions COPD, CHF, cardiac ischemic disease, arrhythmia, CV disease, ADE, renal failure, nutritional and metabolic disorders, venous thromboembolism, liver disorders, GI disorders, infectious diseases and neoplasm Some hospital readmissions are avoidable Most common reason for readmission related to chronic medical conditions Hospital reduces readmissions by 37% by using analytics to help which course of treatment is most effective 57

58 Readmission Update Newsletter Topics Readmissions for Medicare patients fall for a second year Average avoidable readmission rate for first 8 months of 2013 was 18% Rate had been at 19% for five years This means 130,000 fewer readmissions New model predicts risk for readmission from LTC Indiana Health Information Exchange (IHIE) details its use of predictive analysis to reduce readmission rates 58

59 Recent Articles in Readmission Update Racial and economic disparities are prevalent in hospital readmission rates Hospital readmissions for COPD highest among black patients A shorter delay to primary PCI for STEMI patients was associated with a reduced rate of readmission Ten proven ways to reduce readmission 59

60 Ten proven Ways to Reduce Readmission Understand which patient populations are at greatest risk of readmission Healthcare Cost and Utilization Project suggest that Medicaid and uninsured patients are at higher risk Target patients with limited English proficiency Join a readmission prevention focus collaborative such as a state hospital initiative Ensure patients schedule a seven day follow up appointment Implement a robust home healthcare program 60

61 Ten proven Ways to Reduce Readmission Clearly communicate post-discharge instructions Install telemonitoring technology in the homes of chronically ill patients Effectively staff nurses during patient care Researchers found higher RN overtime staffing increased readmissions as well as ED visits Meanwhile, higher non-overtime RN staffing was found to decrease ED visits indirectly due to improved discharge teaching quality and discharge readiness 61

62 Why Patients Are Readmitted They do not know their diagnosis and do not understand what is wrong with them Confused on what medications to take and when Primary care physicians are not provided with important information about hospitalization or test results A follow up appointment is not scheduled Patient or family members lack proper knowledge to provide needed care Dartmouth Institute Study 4 page document

63 Readmission Rates to Hospital and ED Readmission rates to hospitals within 30 days Medical conditions national average is 16.1% Surgical procedures national average is 12.7% ED visit rate within 30 days Medical conditions national average is 18.8% Surgical procedures national average is 15.2% 14 days outpatient visit rate national average 62.5% Dartmouth Institute study 2013 and based on 2009 data 63

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65 Recent Articles in Readmission Update It takes a team approach to reduce readmissions VA Hospital Readmission Rates Deal a Blow to Medicare Home Monitoring Reduces Readmissions Heart Failure Program Cuts Readmission Rates by 30% Is Reducing Hospital Admissions an Answer? Care by Hospitalist Offset by Higher Readmissions A Look at the 7 Hospitals with Highest Rates of Readmissions 65

66 Recent Articles in Readmission Update Study published Dec 2013 in BMJ found the following; Studies 11,000 adult discharges from Boston Medical Center 22.3% were readmitted within 30 days Only 8% were potentially avoidable readmissions Comorbidities were the most common cause of readmission and most common readmits were infection, neoplasm, heart failure, GI disorders and liver disorders Study concluded need to have a strategy that focuses on managing chronic comorbidities and not just the primary reason for admission 66

67 Post Hospital Syndrome Readmissions can be due to post hospital syndrome Readmissions due to stress, sleep loss, pain, discomfort, malnutrition and inactivity that occurs with hospitalization Discharge assessments need to go beyond the cause of the initial hospitalization Need implement interventions to eliminate sleep disturbances, minimize pain, address nutritional deficiencies and increase physical activity NEJM January 10,

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69 CMS Report 2014 CMS says multiple factors contribute to hospital readmission rates Premature discharge Poor quality of care Lack of education to patients before they left Most common patients returning to the hospital were CHF, COPD, pneumonia and high blood pressure 85% of hospitals had an average readmission rate 8% of hospitals had a higher rate or 364 hospitals 69

70 AHA Publishes Trend Reports AHANewsNowArticle/data/ann_091411_trendwatch 70

71 Hospital Readmission Rates Hospitals started reporting hospital readmission rates voluntarily to CMS in 2009 This is on the hospital compare website at hospitalcompare.hhs.gov Made so the public can review this data Do you know what the average readmission rate is? Do you know what your rate of readmission is? 2013 study shows that 7% of acute care hospitals had a higher than expected readmission rates or 307 out of 4,498 and 8% in 2014 data 71

72 Risk Adjusted 30 day readmission rates for MI, HF, and pneumonia is risk adjusted Beginning in FY 2013 Risk adjusted for age, gender, medical diagnosis, and selected medical history Rate of excess readmission will be penalized In FY 2009 the follow were the % of inpatients 2.5% of patients had a diagnosis of AMI 4.2% of patients had a diagnosis of pneumonia 5.7% has heart failure 72

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74 Risk Adjusted Dual Eligible Patients Risk adjusters proposed for use in the Hospital Readmission Reduction Program or HRRP does not capture certain important factors Does not capture dual eligible status where patient qualified for Medicare and Medicaid There are 9 million patients with dual eligible status These patients are the most chronically ill Their healthcare costs are nearly 5 times those of other Medicare beneficiaries 74

75 Risk Adjusted Dual Eligible Patients Other challenges in risk adjustment include: Race and ethnicity TJC in the patient centered communication standard requires all hospitals to collect race and ethnicity information on all patients including outpatients Limited English Proficiency There are 50 million patients in the US whose primary language is not English Need to ensure there is an interpreter when indicated Also standard in the TJC Patient Centered Communication Standards Source: AHA Trend Watch September

76 CMS Hospital Compare Website 76

77 Rate of Readmissions MI, CHF, and Pneumonia 77

78 Rate of Readmissions MI, CHF, and Pneumonia 78

79 Rate of Readmission for MI is 18.3%

80 National Rate of Readmission MI 18.3% 80

81 Rate of Readmission for CHF 23%

82 National Rate of HF Patients is 23% 82

83 Pneumonia Rate National is 17.6%

84 National Rate Readmission Pneumonia 17.6% 84

85 Rate of Readmission Pneumonia 20.3%

86 Hip and Knee Replacements CMS publishes outcomes of knee and hip replacement first in Dec 2013 In first report, identified 97 hospitals with best outcomes and 95 with adverse outcomes Covered surgeries between July 2009 and June 2012 Some hospitals complained assessments outdated In 2010 there were 719,000 knee replacements costing 12 billion dollars and 332,000 hip replacements costing 8 billion 86

87 CDC Data on Number of Procedures stats/insurg.htm 87

88 National Rate of Readmission is 5.4%

89 Rate of Readmission TKA THA 6.5% 89

90 Rate of Readmission After Discharge 16%

91 Partnership for Patients Another initiative tied to the CMS Hospital Value- Based Purchasing Program is the Partnership for Patients This is a public-private partnership to improve the quality, safety, and affordability of healthcare It has the potential to save up to $35 billion in healthcare cost It could reduce Medicare costs by up to $50 billion States that 1 in 20 patients has an infection related to their hospital care 91

92 Partnership for Patients pforpatients.cm s.gov/ 92

93 Partnership for Patients States 1 in 7 Medicare patients harmed in course of their care costing 4.4 billion every year Program may use as much as $1 billion in new funding To keep patients from getting injured or sicker in the health care system $500 million for community based care transition program CMS has a Care Transition website for resources and websites 93

94 Partnership for Patients HENS or Hospital Engagement Networks with 26 organizations working with 3,700 hospitals Also focus on patient and family engagement The goal is to reduce HACs by 40% The goal is a 20% reduction in readmission rates There are 102 organizations participating in the community based transitions program to improve transitions from hospitals to other settings 94

95 CMS Community Care Transition Program 95

96 CMS Care Transition Program 96

97 Partnership for Patients Focus Areas Resources atients.cms.gov/p4p_ resources/lpresource s.html 97

98 Readmissions Resources P4P 98

99 Readmissions Resources Includes link and information on many of the evidenced based projects to reduce unnecessary readmissions Updated Project RED (Re-Engineered Discharge) Care Transitions (Dr Coleman University of Colorado) Transitional Care Model (TCM, Dr. Mary Naylor, University of Pa) BOOST or Better Outcomes for Older Americans (Society of Hospital Medicine) IHI Transforming Care at the Bedside, Medicare Demonstration Project, INTERACT, GRACE, etc. 99

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101 Partnering to Heal One of the Partnership for Patients is a video every healthcare practitioner should see It is related to the hospital initiative to reduce the number of healthcare associated infections (HAIs) It is a computer-based, video simulation training program Hospitals should consider making it mandatory for direct care givers it is that good! Partnering to heal video at /

102 Video on Preventing HAI 102

103 Readmission Rates Vary Readmission rates vary widely in the US Too often quality of care during transition from hospital to home is not good Data shows readmission rate for MI and CHF vary Found only modest association between performance on discharge measures and patient readmission rates Public reporting unlikely to yield large reductions in unnecessary readmissions We need to improve in the ambulatory section See A. K. Jha, E. J. Orav, and A. M. Epstein, Preventing Readmissions with Improved Hospital Discharge Planning, NEJM Dec 31, (27):

104 Geographic Variation in Hospital Readmissions 2007 Medicare SAF data

105 Many Good Resources Commonwealth Website Abstracts/2010/Jan/Preventing-Readmissions-with-Improved-Hospital-Discharge- Planning.aspx 105

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107 Variation of Readmissions Rates JMsa ?siteid=nejm&keytype=ref &ijkey=3cqjs3yxxjoty 107

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109 CMS Data on Readmission Rates 20% of hospitals in the following states have higher readmission rates that the national average Maryland, New York, Illinois, Massachusetts, New Jersey and Rhode Island 364 hospitals in US have high readmission rates States with the lowest readmission rates include Hawaii, Idaho, Colorado, Oregon, South Carolina, Utah and Washington 13 to 16% of hospitals in these states have lower rates January 2014 article 109

110 CMS Data on Readmission Rates 2014 Second round of readmission penalties that went into effect October 1, 2013 (Kaiser, 2014) 18 of the 2,225 hospitals were hit with the maximum penalty which is now 2% Penalties for two-thirds of all hospitals CMS indicated that readmission rates for Medicare patients is on the decline Rate fell below 18% for the first 8 months of

111 Chart Worst and Best Readmission Rates g/index.php/2014/01/new-medicaredata-show-hospitals-with-high-ratesof-readmissions/ 111

112 Readmissions and Discharges One in 5 hospital discharges (20%) is complicated by adverse event within 30 days which is about 2 million Medicare patients per year (March 2011 data) 20% were readmitted within 30 days with 1/3 leading to disability Often leads to visits to the ED and rehospitalization 6% of these patients had preventable adverse events 66% were adverse drug events so focus on medications when patients discharged The incidence and severity of adverse events affecting patients after discharge from the hospital. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Ann Intern Med. 2003;138:

113 Preventing Readmissions Studies differ on rate of preventable readmissions and one said 76% of readmissions are thought to be preventable It is the preventable ones that hospitals need to work on Medicare data shows that over half of patients readmitted received no follow up care Recent studies show interventions targeted at post-acute care transition can reduce readmissions by one third (Coleman and Naylor) Technologies for Improving Post-acute Care Transitions, Center for technology and Aging, Sept

114 Preventing Readmissions HHS study finds a high rate of Medicare patient deaths due to adverse events (AE) 15,000 Medicare patients experience an AE during healthcare delivery that lead to their death every month Nov 16, 2010 OIG study Found 1 in every 7 discharges (13.5%) experience an AE and the cost to CMS is $324 million 44% of all AE were preventable and 51% were not November 2010, OEI

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116 Preventing Readmissions Care Transitions Intervention and Transitional Care Model are two common interventions that focus on the post-acute care transitions Guided care and Geriatric Resources for Assessment and Care of Elderly are promising care coordination intervention models Technologies to improve medication adherence, medication reconciliation, patient monitoring, communication between clinicians, risk assessment are important aspects of care transitions 116

117 Readmissions and Discharges 40% of patients who were discharged had test results pending Many discharged patients had pending workups with interventions to be followed up by outpatient physicians More than 1/3 of the recommended follow ups were not followed Frequently because the discharge summary did not contain the details of the necessary work up But availability of discharge summary increased likelihood of work ups being done Tying up loose ends: discharging patients with unresolved medical issues. Moore C, McGinn T, Halm E. Arch Intern Med. 2007;167:

118 Readmissions and Discharges Another study finds that 41% of inpatients were discharged with a study pending It was also discovered that 2/3 of the physicians were not aware of the results 37% of the tests required some action on behalf of the physician Inpatient physicians were dissatisfied with system for following up test results returning after discharge Roy, Christopher etc. Patient Safety Concerns Arising from Test Results that Return after Hospital Discharge, Ann Intern Med 2005; 143(2):

119 Readmissions and Discharges Many were not done because the discharge summary was not available at the time of the first clinic or office visit Later study found that 78% of patients who went for the first post hospital visit the primary care physician did not have a discharge summary for the patient Note NQF 34 Safe Practices to dictate the discharge summary when patient discharged and ensure it gets to the PCP timely and document this communication Why CMS includes in DP standards and worksheet Incomplete handoffs lead to unnecessary readmission Care transition important for high risk and the elderly 119

120 Readmissions and Discharges 37.2% of patients did not know the purpose of their medication Only 14% knew the side effects of the medications they were taking Only 41.9% of patients were unable to state their diagnosis Hospitals may want to focus on ensuring adequate medication information, discharge diagnosis and plan of care information to the patient Patient Understanding of their Treatment Plans and Discharge Diagnosis at Discharge, Mayo Clinic Proceedings, Aug 2005;80(8):

121 Readmissions and Discharges This lead to the development of a formal discharge checklist to ensure communication at discharge Transition of care for hospitalized elderly patients development of a discharge checklist for hospitalists. Halasyamani L, Kripalani S, Coleman E, et al. J Hosp Med. 2006;1: The Pa Patient Safety Authority has excellent resources including suggested elements for a discharge checklist See Care at discharge a critical juncture for transition to posthospital care. Pa Pat Saf Advis 2008 Jun;5(2):

122 PaPSA Checklist 122

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124 Tools/PatientSafetyTools/tk_discharge/Pag es/home.aspx 124

125 PaPSA on Preventing Readmission Had more than 800 reports in 3 ½ year period of harm from patients from incomplete discharge 30% of patients did not receive verbal or written discharge instructions before they left the facility Lack of medication reconciliation was evident Essential parts of the discharge process include Educating the patient and or family including what to do if a problem occurs Assessing the patients understanding of the plan Scheduling follow up appointments Confirming the medication plan 125

126 PaPSA on Preventing Readmissions Some patients received another patients instructions Many patients did not have their IV access device removed prior to discharge Many patients returned with an IV site infection and or phlebitis Discharge of patients before test results were made available to the attending who would have postponed discharge based on the final results Many medication related issues such as lack of instructions 126

127 CMS Checklist CMS, in the QIO 9 th scope of work, has 14 states in the care transition project, Each of the 14 states will summarize their results and these calls are free to listen to Sign up for upcoming sessions at sions.htm CMS has published a checklist which is available at 127

128 Care Transitions Resources and Webinars arning_sessions.htm 128

129 Toolkit integratingcare /toolkit_pdf.ht m 129

130 ent_resources.htm 130

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133 11 Essential Steps of RED Process Greenwald etc. identified 11 essential steps to the reengineered discharge process at Boston Medical Center Educating patients and families about their diagnosis throughout the hospital stay Assessing the patients understanding of the plan by asking them to explain the plan in their own words Advising the patient and family of any tests completed in the hospital with results pending at time of discharge and identifying the clinician responsible for the results 133

134 11 Essential Steps of RED Process Scheduling follow-up appointments and tests to be done following discharge Organizing services to be initiated following discharge Confirming the medication plan Reconciling the discharge plan with national guidelines and critical pathways when relevant 134

135 11 Essential Steps of RED Process Reviewing with the patient what to do if a problem occurs Expediting the transmission of the discharge summary to the healthcare providers who are accepting responsibility for the patient s care Giving the patient written discharge instructions Greenwald JL, Denham CR, Jack BW. The hospital discharge: a review of high risk care transition with highlights of a reengineered discharge process. J Patient Saf 2007 Jun;3(2):

136 Medication List 136

137 Outstanding Labs or Tests 137

138 Appointments for Follow Up 138

139 Project RED Tools /systems/hospital/red/index.html 139

140 Updated RED Program ems/hospital/red/index.html 140

141 professionals/syste ms/hospital/red/inde x.html 141

142 3 Factors Leading to Errors at Discharge Greenwald etc identified factors that lead to error at discharge to three types 1. Hospital care system characteristics Many hospitals don t get discharge summaries to PCP timely Many errors around lack of medication reconciliation at discharge 2. Patient characteristics Factors in literature at risk for hospitalization include lack of social, financial, and familial support and low health literacy, lack of follow up and adherence to treatment 142

143 3 Factors Leading to Errors at Discharge 3. Clinician characteristics These focus on quality and effectiveness of communication and Timeliness and completeness of discharge summaries provided to subsequent caregivers Clinicians with limited time or lack of effort put into educating patients at discharge lead to lack of patient understanding This is why studies that used transition coaches to assist and encourage the patient to participate in their care were successful at unnecessary readmissions 143

144 Transitions Research Research on preventing unnecessary readmissions looks at the studies on improving transitions Transitions is the process designed to ensure coordination and continuity of healthcare as patients transfer between different locations or different levels of care We want to improve the transition to home, long term care, home health, assisted living or other post discharge places How do we do this right so the patient does not have a unnecessary readmission 144

145 Patient Characteristics Play a Role Through out this presentation are various evidenced based articles that discuss patient characteristics that increase the patient s readmission rate Hospitals should be aware of this research to determine high risk patients Patients with co-morbidities are high risk for readmissions The more chronic conditions the patient has the greater the likelihood or readmission See chart on next page 145

146 More Chronic Conditions More Readmissions 146

147 Patient Characteristics Play a Role MedPAC found Medicare patients with end stage renal disease (ESRD) have a higher rate of readmission 31.6% are readmitted within 30 days Compared with 16.9% of non-esrd patients Medicare Payment Advisory Commission. (June 2007). Payment Policy for Inpatient Readmissions. Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC. Patients with CHF were more likely to be admitted if has PVD, diabetes, CVA, or CAD Aranda, J.M., et al. (2009). Current Trends in Heart Failure Readmission Rates: Analysis of Medicare Data. Clinical Cardiology, 32(1),

148 Patient Characteristics Play a Role Studies have also shown the following increase the rate of readmission; Depression especially for patients diagnosed with coronary artery disease Age Gender Race and ethnicity (African Americans had highest rate) Medicaid coverage (Jiang, 2010, JAMA) Language barriers (Karline, LS 2010, Journal Hospital Medicine) Patient in counties with low median income 148

149 Patient Characteristics Play a Role In spite of these studies, little agreement on characteristics that might best predict which patients are at greater risk for readmission Five statistical models intended to predict a patient s risk of readmission found little consistency among patient characteristics Ross, J.S., et al. (2008). Statistical Models and Patient Predictors of Readmission for Heart Failure: A Systematic Review. Archives of Internal Medicine, 168(13), More work is needed to help hospitals better focus their efforts to determine which patients are likely to benefit 149

150 Approaches to Reduce Readmissions One study found that calling CHF patients within 7 days of readmissions reduced readmission Patients with earlier follow up after discharge were less likely to be readmitted There are many other studies such as the RED project that resulted in 30% fewer admissions This will be discussed in detail later Metro Health in Wyoming cut their CHF rate in half, from 15.5% to 7.4% Developed educational material, included diet and self care, scheduled appointments, etc. 150

151 AHA Guide to Reduce Readmissions 151

152 AHA Health Care Leader Guide s/guide-to-reducereadmissions.shtml 152

153 AHA Reducing Avoidable Hospital Readmissions Some readmissions can be avoided by evidenced based practice but the means for achieving this still remains controversial Preventing readmissions is a complex, system-wide problem that involves hospitals, physicians, other providers, patients and their families AHA created a framework AHA included a list of strategies that hospitals might find helpful in both documents AHA worked with 3 states and got payer data on readmissions 153

154 AHA 4 Steps First, examine your hospital s current rate of readmissions Second, assess and prioritize you improvement opportunities Third, develop an action plan of strategies to implement Fourth, monitor you hospital s progress 154

155 Step 1 Current Rate of Admissions Compile data on your readmission rate Hospital compare has 30 day admission rates on CHF, MI, and pneumonia listed at Knowing data will help hospital target strategies for reducing readmissions First, look at rates for different conditions so examine by diagnosis and significant co-morbidities and correlate with patient s severity 155

156 Step 1 Examine Current Rate of Readmissions For example, MI, CHF, pneumonia, patients with diabetes, obesity, or COPD Second, look at readmission rate by practitioner to look for patterns or if any type of practitioner is associated with unexpected readmissions Third, look at readmission rates by readmission source such as nursing homes, home health etc. to determine the places where most often patients are being readmitted 156

157 Step 1 Examine Current Rate of Readmissions Lastly, look at readmission rates at different time frames such as 7, 30, 60, and 90 days which can bring into flaws in transitioning patients to the ambulatory setting Hospitals should also pull the charts of a few patients who were readmitted from various setting Purpose is to understand why patient was readmitted and what could have been done to prevent the readmission Look at financial impact on the hospital that reduced payments would have 157

158 2. Prioritize Improvement Opportunities AHA recommends to assess and prioritize your improvement opportunities There are one of more approaches that can be followed Focus on specific patient populations such as older adults with co-morbidity since need a more rigorous assessment process to determine discharge needs COPH, diabetes, renal failure, liver failure etc. 158

159 2. Prioritize Improvement Opportunities Focus on stages of the delivery process so if you identify patients being admitted for the same reason look at the resources available Such as CHF patient, MI, asthma, diabetes, renal failure and pneumonia Patient and family education can help patients take care of their care Focus on the hospital s priority areas and current PI initiatives Look at current PI program and can redesign fundamental care processes See AHA list of past and current PI programs 159

160 3. Develop Action Plan of Strategies Develop an action plan of strategies to implement This is why doing a literature search and have librarian obtain articles from evidence based research Need many in the community to work together to prevent unnecessary readmissions to the hospital See list of major strategies to reduce avoidable readmissions Need to use technology such as remote monitoring, electronic medical records and telehealth 160

161 Strategies During Hospitals Risk screen patients and tailor care Tailor patient care needs based on evidenced based guidelines, clinical practice guidelines, care path Develop pathways that include discharge steps consistent with these evidenced based guidelines CHF CPG, CABG, Pneumonia pathways, Total hip and total knee pathways Pathways are not cook book medicine but assist in ensuring evidenced based practice is followed Include actions to take if variances occur with CPG 161

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163 Strategies During Hospitals Get with the guidelines!!! and Have healthcare worker responsible for discharge planning and define scope of their responsibility Have a social worker or nurse case manager to provide discharge planning services Some have discharge advocate Remember to include education to patients and families about their disease Provide patient with disease specific, low literacy and language and age appropriate educational material 163

164 Strategies During Hospitals Be aware of research that shows patients at increased risk of readmission such as patients with low health literacy 20% of population reads at the 5 th grade level ½ of adults have trouble understanding simple health information (consent, prescriptions, oral instructions) Can not tell health literacy by looking so observe closely in elderly, unemployed, did not finish high school, born in US but English a second language, noncompliant, immigrant, can t name medications, forgot glasses and will read later, etc. High risk patients also include history of readmission, failed teach back, longer stay than expected, high risk conditions, poor, disabled or on dialysis 164

165 Strategies During Hospitals Respond to patient needs for early ambulation, early nutritional interventions, PT, social work etc Nursing assessment and identified criteria to see dietician timely Quality and patient safety initiatives to improve surgical outcomes such as prevention of PE and DVT Develop a multidisciplinary team to evaluate and implement discharge needs Consider a checklist of things to consider in the discharge process See Society of Hospital Medicine at mprovement_tools&template=/cm/contentdisplay.cfm&contentid=

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169 Strategies During Hospitalization Consider putting together a hospital team to evaluate the literature and reengineer the discharge process in your hospital Research shows increased number of readmissions due to phlebitis so consider annual orientation and credentialing of nurses to start IV Strict adherence to the IV standards such as the IV Nurses Infusion Society Standards of Practice Consider infusion nurses Restarting IVs started by squad under less than ideal circumstances Strict adherence to how long IVs can stay in Have a process to ensure all IVs and IV access devices are removed prior to discharge 169

170 Strategies During Hospitalization Evaluate all patients on admission and throughout hospitalization for discharge planning Physical therapist can assess ability to do ADL and environmental barriers in postdischarge care area and what services will be needed after discharge Discuss end of life care wishes Some hospitals require code status of all patients upon admission Studies found that often RRT or code called and then after wards patient was made a DNR Pneumonia readmissions may reflect need for end of life care 170

171 Strategies During Hospitalization Develop community connections to eliminate barriers to successful transition Need to build relationships with other healthcare providers, and public and private groups Parish nurse programs, meals on wheels, etc. Community partners that can help with nonmedical such as behavioral, health literacy, and cultural issues Engage families, patients and caregivers Get their active participation, teach back, Get their feedback in addressing healthcare delivery issues such as understanding discharge instructions 171

172 Strategies at Discharge Implement comprehensive discharge planning Should be written out so the patient can understand Should be comprehensive to include medication use, activity level, symptoms that patient should call the physician or return, TJC has a discharge tracer Provide discharge plan to patient Make sure PCP gets discharge summary 172

173 Strategies at Discharge Implement comprehensive discharge planning (continued) Reconcile discharge plan with national guidelines/cpgs Standardized checklist of transitional services Give patient care record including pending tests The detailed written discharge plan should include how to fill prescription along with a list of all medical problems Instruct patient to bring plan to all appointments 173

174 Strategies at Discharge Use teach back method to educate the patient and their care giver Have the patient repeat back the instructions in their own words to make sure they understand the discharge instructions Focus handoff information on patient and family Make sure patient repeats back what to do if a problem arises Make sure patient has it in writing the signs and symptoms to watch for 174

175 Strategies at Discharge Schedule the patient s follow up appointment Make the appointment for all follow up appointments before the patient is discharged Provide times and information and directions to the patient in writing The nurse case manager or discharge planner can also schedule any further diagnostic tests that were ordered Also want to confirm services to be received before the patient leaves the hospital 175

176 Strategies at Discharge Develop standardized checklist to assess that all discharge components are completed Finalize the plan with the patient and make sure patient verbalizes understanding Perform a final physical assessment with attention to the removal of all IV lines or other access ports Want to get a timely transfer of the discharge summary to the primary care physician and Follow up by telephone 2 to 3 days after discharge to assess optimal care and recovery 176

177 Strategies at Discharge Standardize the discharge instruction document and include: primary and secondary diagnosis, patient education, services to be provided dietary and other lifestyle modifications, medications, follow-up appointments pending tests adverse events or complications to watch for, and provider contact information for any problems that occur 177

178 Strategies at Discharge Assist the patient in managing their medications Give patient complete list of medications at discharge Include times to take and reason Pharmacist role in assisting with understanding new medications or high risk medications Some use MAR to have patient document when meds given Use transitional coach to help RARE program has recommendations for mental health patient 178

179 Strategies at Discharge Don t just focus attention on the admitting diagnosis but also on the comorbidities patients have Patients with neoplasm, heart failure, and chronic kidney disease had a higher risk of potentially avoidable readmissions When patient is admitted determine if admitted within last 90 days If so some hospitals are doing a RCA or assessment of the reason for readmission 50% to 60% more likely to be admitted again 179

180 Strategies at Discharge Timing of the physician follow up appointment may be important One hospital found if patient saw doctor day 1-4 the chance of readmission is less than 6% If appointment 6-10 days after discharge readmission rate was 6 to 13% If visits on day 25 then chance went up to 29% Readmission rate increased 1% for every day between discharge and the first physician visit Article published Jan 8, 2014, Detroit Medical Center, Media Health Leaders 180

181 Reducing Avoidable Readmissions 181

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183 Strategies at Discharge When patient are discharged to LTC make sure transfer summary has detailed instructions Make sure a complete list of medications to be taken are provided Include comprehensive information on hospital care and what needs to be done for continuity of care (see CMS requirements in DP standards) Partner with nursing home practitioners Consider call back to see if any questions Use NP in LTC facility 183

184 Strategies Post Discharge Promote patient self management Patients with HTN monitor BP at home Diabetics and patients on Coumadin use home monitoring devices Follow up with patients via telephone Some hospitals have the nurse call the patient to reinforce discharge instructions usually in 2-3 days Many of the transition programs involve calls or visits to the patient in the home Offer telephone support for period post discharge 184

185 Strategies Post Discharge One author noted that hospitals, physicians, HHAs, nursing homes and pharmacist can prevent more readmissions by working together that hospitals can by improving the discharge process alone Slide presentation on Reducing Avoidable Readmissions by Steve Hines PhD, June 4, 2010 Quality of LTC and HHA can drive readmission rates Establish community networks Parish nurse programs, meals on wheels Establish private/public partnerships to meet patient needs Homeless shelters with medical care and dental care 185

186 Strategies Post Discharge The home visit includes an assessment of environmental issues that could result in readmission No food in house, no heat, fall assessment, determine if need transportation for physician visit, make sure any durable medical equipment is connected correctly 186

187 Strategies Post Acute Care Technologies Medication adherence Devices that remind patients to take the right medication at the right time Hospitals should take a serious look at this issue Medication non-adherence contributes to 33%- 69% of medication related hospital admissions The New England Healthcare Institute estimates that $290 billion of health care expenditures could be avoided each year if medication adherence were improved Delate T, Chester EA, Stubbings TW, Barnes CA. Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled nursing facility. Pharmacotherapy. Apr 2008;28(4):

188 Strategies Post Acute Care Technologies Strategies to increase medication adherence include; Simplifying the patient s medication regimen Identifying if the medication has untoward effects Improving patient self-efficacy and activation Providing cues or reminders to take medications as prescribed New England Healthcare Institute. Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. A NEHI Research Brief July

189 Strategies Post Acute Care Technologies Philips Medication Dispensing System Dispenses days worth of medications Reminds patients to take it Can alert physician and 3 others if pills not removed from dispenser Provides alert and dispensing information Has been shown to reduce hospitalizations Especially good for those with cognitive problem on Coumadin 189

190 Strategies Post Acute Care Technologies Mini-mental state exam (MMSE) correlates with medication adherence Medication reconciliation Software that stores medication information and detects certain problems such as duplicate prescriptions Remote patient monitoring Technology to help detect early deterioration of a patient s medical condition Patient or care giver access to medical records 190

191 Strategies Post Discharge Use telehealth in patient care Technology can be used to help prevent readmissions See Technologies for Improving Post-Acute Care Transitions, September 2010 Use of EHR to support care coordination Monitor patient progress such as electronic cardiac monitoring and remote patient telemonitoring Medication reminders and dispensers In home diagnostic devices Videoconferencing 191

192 Strategies Post Discharge Hospitals should consider working with their state QIO JAMA study found that hospitals working with QIOs in communities across the country experienced twice the reduction in readmissions compared with those that did not (Jan 23, 2013) Consider holding monthly meeting with your various partners such as nursing homes and home health staff One study showed this reduced readmissions by 20.8% (Jan 2014 IPRO-NY s QIO) 192

193 4. Monitor the Hospital s Progress The last key to reduce readmissions is for hospital leadership to monitor the progress Look at readmission rates by Different conditions such as MI, CHF, COPD, Pneumonia, TKA, THA, asthma, diabetes, cellulitis, etc By practitioner to look for patterns Over different time frames (7, 30, 60, and 90 days) By readmission source (home, LTC, etc.) Data should be included in key indicators tracked 193

194 Diagnostic Specific Reasons for Readmissions There are reported diagnostic specific reasons for avoidable readmissions Many COPD and pneumonia patients need home health care but do not receive it Cardiologist may rely on primary care physician and not arrange follow up care for HF patients Readmission rate appears higher for HF patients with behavioral diagnosis Dialysis patients are very vulnerable to changes in medications during hospitalization ESRD have higher than average readmission rates (MedPAC) Medicare Payment Advisory Commission Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC: Medicare Payment Advisory Commission, p

195 Diagnostic Specific Reasons for Readmissions Surgeons do not arrange for post surgery primary care Studies show there is inadequate teaching of surgical patients in caring for themselves after surgery Incision care Post CABG patients expecting to be pain free and seek readmission for angina Hospitals should know this information 195

196 HCAPHS and Transition Planning Three questions that were added: During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left When I left the hospital, I had a good understanding of the things I was responsible for in managing my health When I left the hospital, I clearly understood the purpose for taking each of my medications How will you fare? 196

197 The End! Questions?? Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD President of Patient Safety and Education Chief Learning Officer for the Emergency Medicine Patient Safety Foundation See additional slides on CMS and TJC standards, different studies 197

198 NQF 34 SAFE PRACTICES Released in 2003, updated 2006, 2009 and April 2010 and March Safe Practices for Better Healthcare These should followed in all healthcare facilities All clinical care settings to reduce risk of harm to patients A roadmap to preventing harm States 10 years after IOM report, To Err Is Human, uniformly reliably safety in healthcare has not been achieved 198

199 NQF Safe Practices 15 Discharge System A "Discharge Plan" must be prepared for each patient at the time of hospital discharge, and a concise discharge summary must be prepared for and relayed to caregivers accepting responsibility for postdischarge care in a timely manner Hospital must ensure that there is confirmation of receipt of the discharge information by the LIP who will assume the responsibility for care after discharge TJC and CMS also require discharge summary TJC tracer on discharge process 199

200 15. Patient Discharges Often because of errors from fragmentation of care at discharge High rates of low health literacy, and lack of coordination for post care lead to adverse events Need to do medication reconciliation (TJC requirement) Need structured discharge communication AHRQ has Project Red to improve patient discharges (Re-Engineered Hospital Discharges) 200

201 Safe Practice 15 Discharge System Need discharge P&P to include Roles in the discharge process Preparing for the discharge with documentation throughout hospitalizations Complete discharge summary before discharge Reliable information flow from PCP to referring caregiver and back Benchmarking, measurement, and continuous quality improvement of discharge process 201

202 SP15 NQF Discharge System Written discharge plan must be given to each patient at the time of discharge That is understandable by the patient (remember issue of low health literacy) Discharge plan needs to include reason for hospitalization Medications to be taken post discharge What to do if condition changes Coordination and planning for follow up appointments and follow up tests and for studies if results not available at time of discharge 202

203 15 Discharge System Discharge summary needs to be provided to LIP who is caring for the patient after discharge Current problem where 78% of LIP who see patient for first visit do not have discharge summary Include reason for hospitalization and significant findings, procedures done, medication list, list of tests and studies of results and ones not back Copies of lab, x-ray reports, and tests results in hands of person doing discharge summary Need receipt confirmation by physician caring for patient after discharge of discharge summary by fax, phone, etc 203

204 Discharge instructions Include activity level, medications and education on medications, potential drug food interactions and follow up information TJC RC requires documentation of the patient s discharge information Document if you give patient specific patient education sheets like fracture care sheet-should have copy on chart Ask Me 3 is three most important questions that can help during discharge instructions What is the main problem?, what does the patient need to do? And why it is important for them to do this? ( 204

205 NQF Care Coordination 205

206 NQF NQF has published Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination NQF notes care coordination is important to prevent unnecessary returns to the ED and readmissions Especially important for patients with chronic conditions such as diabetes and hypertension These standards provide structure, process and outcome measures Goal to reduce 30 day readmission rates and preventable ED visits by 50% 206

207 NQF Care Coordination Preferred Practices Has domains on Home with five practices Proactive plan of care and follow-up with five practices Communication with four practices Information systems with three practices Transitions and handoffs with eight practices Plan of care and follow up P&P to create and update plan of care with every patient Follow up of all tests and treatments Include patient education, cardiac rehab for recent CV event 207

208 NQF Care Coordination Preferred Practices Communication Plan of care made available to patient and home team Program to use a partner to support care when patient is hospitalized Care coordination activities are assessed and documented Transition or handoffs Transition program engages patients and families in self management when discharged home Standardized communication template for transition of care process including core data elements 208

209 NQF Performance Measures Cardiac rehab patient referral from inpatient and outpatient setting Biopsy follow up Reconciled medication list by discharge patients Melanoma continuity of care with recall system Transition record with specified elements received by discharged patient Patient with trans ischemic event ED visit who had a follow up in the office 209

210 0/10/Preferred_Practices_and_Perform ance_measures_for_measuring_and_r eporting_care_coordination.aspx 210

211 Patient Characteristics Play a Role Study of 37 children s hospitals found higher rate of readmission associated with use of assistive technology such as G-tube or cerebrospinal fluid shunt (Berry, 2011, JAMA 305(7), 62-69) Study of 6,800 general medicine patients found six co-morbidities associated with readmission CHF, renal disease, cancer both with and without metastasis, weight loss, and iron deficiency anemia Allaudeen, N., et al. (2010). Redefining Readmission Risk Factors for General Medicine Patients. Journal of Hospital Medicine, online. 211

212 AHA Reducing Avoidable Hospital Readmissions MedPac (Medicare Payment Advisory Council) in 2009 concluded that large proportion of rehospitalizations was preventable Improvements needed include better communication and more coordinated care before and after discharge Medicare Payment Advisory Commission. Report to Congress: Improving Incentives in the Medicare Program 2009 Not all readmissions are preventable Predictors of readmission include certain clinical conditions such as CV conditions, stroke, and depression Certain patient demographics such as elderly, dually eligible Medicare enrollees, 212

213 AHA Guide to Reduce Avoidable Readmissions AHA had committees look at the issue of how to reduce unnecessary hospital readmissions September 2011 AHA Trend Watch AHA published several memos and a 2010 Health Care Leader Guide to Reduce Avoidable Readmissions Issues memo on Sept 2009 on Reducing Avoidable Hospital Readmissions Includes evaluation of post acute transition process which is the process of moving from the hospital to home or other settings 213

214 Excluded from Hospital Readmissions The Affordable Care Act specifies that certain readmissions will be excluded from the hospital readmission rate It excludes hospital readmissions that are unrelated to the prior discharge Such as planned admissions Or transfers to another hospital Law reflects the difficulty in distinguishing the four types of admissions Only includes one of the four types 214

215 Excluded from Hospital Readmissions AHA says that how these exclusions are accounted for in the regulation is a key policy concern AHA notes that payers and others commonly use readmission rates and mortality rates as a quality of care indicator Suggests that higher the rates of these two the lower the quality of care However, recently studies suggest this is not true Cleveland Clinic study found patients with higher admission rate for CF had lower mortality Gonodeski, 2010, NEJM 363(3),

216 Readmission Rates and Quality of Care AHA also notes a number of other studies that showed higher readmission rates resulted in less deaths Greater New York Hospital Association analyzed the hospital compare data to find same thing Looked at 50 American Best Hospitals in cardiac surgery and found none of these performed better than expected on both mortality and readmissions Study of 39 children s hospital in 24 states found readmission rate increased as state performing systems went up 216

217 Higher Readmissions but Less Deaths 217