The In s and Out s of the CMS Readmission Program Kristi Sidel MHA, BSN, RN Director of Quality Initiatives Objectives General overview of the Hospital Readmission Reductions Program Description of measures What Avera is doing to improve our readmission rates Todays Inspiration 1
Meaningful Measures Initiative CMS s new initiative, Meaningful Measures, is a component of Patients Over Paperwork initiative Launched in 2017 to identify high priority areas for quality measurement and improvement For more information: https://www.cms.gov/medicare/quality Initiatives Patient Assessment Instruments/QualityInitiativesGenInfo/CMS Quality Strategy.html Meaningful Measures Source: CMS FY 2019 IPPS Final Rule Acute Care Hospital Quality Reporting Programs Overview 9.12.18 Hospital Value Based Purchasing Programs Hospital quality initiatives are aimed at improving the quality, efficiency and overall value of healthcare Inpatient hospital programs: Hospital Inpatient Quality Program (IQR) Hospital Value Based Purchasing Program (HVBP) Hospital Readmissions Reduction Program (HRRP) Hospital Acquired Condition Reduction Program (HAC) 2
What is the Hospital Readmissions Reduction Program (HRRP)?? What is the Hospital Readmissions Reduction Program (HRRP)?? Of the three P4P (pay for performance) program, the readmission penalties are the most significant for inpatient payments. Hospitals can lose up to 3% of reimbursement depending on their readmission performance Background Mandated by the Affordable Care Act requires CMS to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions Program supports CMS s national goal of improving healthcare by linking payment and the quality of hospital care Strong financial incentive to: Improve communication Improve care coordination efforts Better engage patients and caregivers in post discharge planning 3
Always Looking Ahead The First Six Years National Reality 4
Readmission National Penalties The HRRP hospitals do not include: Long term care hospitals Critical access hospitals Rehabilitation hospitals and units Psychiatric hospitals and units Children s hospitals PPS exempt cancer hospitals What is a 30d Readmission? A patient who is admitted for any reason to the same or another acute care hospital within 30 days of discharge. 5
Factors Affecting Readmissions: Patient s diagnosis Severity of illness Patient s behavior Adherence to discharge instructions Availability and quality of post discharge care What hospitalizations are not readmissions? The following types of admissions are not considered readmissions in the measure: Planned readmissions (chemotherapy or pre planned surgery) Same day readmissions to the same hospital for the same condition Observation stays and Emergency Department visits Admissions to facilities other than short term acute care hospitals (such as rehab, neonates, psych, hospice, LTC, and skilled nursing facilities) do not meet definition Continuing Controversy Observation vs. Inpatient All Readmissions vs. avoidable readmissions Lack of risk adjustment for key socioeconomic factors (usually outside the hospitals control) The inclusion of readmissions unrelated to the initial admission 6
30 day Readmission Measures Inclusion Criteria 1. Having a principal discharge diagnosis of AMI, COPD, HF, pneumonia for each respective measure 2. Enrolled in Medicare FFS or are VA beneficiaries 3. Aged 65 and over 4. Discharged alive from a non federal shortterm acute care hospital or VA hospital 5. Not transferred to another acute care facility Procedure Specific Inclusion Criteria 1. Having a qualifying isolated CABG surgery or elective primary THA/TKA procedure during the index admission 2. Enrolled in Medicare Fee For Service (FFS) Part A and Part B 3. Aged 65 or over 4. Discharged alive from a non federal shortterm acute care hospital 7
Exclusion Criteria 1. Without at least 30 days of post discharge enrollment in FFS Medicare 2. Discharged against medical advice (AMA) 3. Same day discharges What is a planned readmission? Transfer Scenarios 8
Swingbed Stays A swingbed admission itself is not eligible to be an index admission (or a readmission), as only short term acute care hospitalizations are considered for index admissions or readmissions How were Readmissions Measured Goal < 1.000 Calculate Excess Readmission Ratio Facility Observed Value Facility Expected Value Excess Readmission Ratio > 1.000 = PENALTY How were Readmissions Measured Non Stratified HRRP Payment Methodology 9
How are Readmissions Measured Now CMS FY18 IPPS Final Rule Congress Mandates HRRP Adjust for Dual Eligibility Hospitals will be sorted into five peer hospital cohorts Cohorts defined by quintile of dual eligible inpatient stays as a proportion of total Medicare inpatient stays during HRRP performance period Within cohorts, hospitals excess readmission ratio (ERR) for each condition compared to cohort s median ERR for that condition. Hospitals with ERRs exceeding group s median will earn penalty How are Readmissions Measured Now Stratified Methodology 10
Risk Adjustment Once again the severity of illness based on comorbid conditions influences the risk adjustment. Sicker patients are expected to have higher readmission rates, so hospitals with a patient population reflecting higher severity will have their readmission rate adjusted downward and therefore are less likely to be penalized. Pinson & Tang, 2016 CDI Pocket Guide Risk Adjustment All Diagnoses There are tons of them! Metastatic cancer or leukemia Diabetes Mellitus Protein calorie malnutrition Disorders of fluid, electrolyte, or acid base Dementia Iron deficiency Liver or biliary disease Depression Drug/alcohol abuse, dependence or psychosis Cardio respiratory failure or shock Septicemia/shock Hemiplegia, paraplegia, paralysis, functional disability Respiratory dependence/failure CHF Angina Asthma Stroke COPD Pneumonia ESRD or dialysis Decubitus ulcer or chronic skin ulcer 11
Noncompliance & Readmissions 89.7% Reason for readmission listed as other 10.3% Reason for readmission listed as dietary or medication noncompliance related 47% of adults have limited health literacy skills 44% of adults are functionally health illiterate The Advisory Board Company, 2016 Noncompliance CDI specialists can assist facilities by identifying when noncompliance plays a role in the readmission. By securing the necessary documentation to allow coders to report [noncompliance], hospitals can use this documentation and coded date to help prevent or appeal denials If [it] is reported on the UB 04, [it allows] the payer to have the knowledge that patient noncompliance may have contributed to the readmission. ACDIS Social Risk Factors CMS is considering options to address equity and disparities in its value based purchasing programs A recent report from the Assistant Secretary for Planning and Evaluation identified dual eligibility as the most powerful predictor of poor healthcare outcomes among social risk factors tested The goal is to improve health disparities by increasing transparency and comparing those disparities across hospitals 12
Are you feeling like this yet? Avera s Game Plan Serving 86 counties in a five state region 13
Footprint Readmissions Why Now? Variety of initiatives across Avera throwing the kitchen sink at readmissions Historical performance Current performance trending up New Final Rule that increases penalty potential The Kitchen Sink 14
System wide Approach Medical Staff HIM/CDI Nursing C Suite Case Management IT Quality Finance Patient Flow 15
Readmission Lunch and Learn Concept Endorsement was received by the Chief Medical Officers to deep dive into readmissions across the system. Next steps included: Identification of key stakeholders across the system to form a readmissions steering committee Time limited steering committee Role is to guide content for lunch and learns Monthly lunch and learn sessions to share best practices and collaboration across continuums In Person readmissions summit to wrap the series up Lunch and Learn Topics Intro to HRRP Care Transitions Med Rec Discharge Planning Coordinated Care / Long Term Care ACO 101 Home Health Emergency Department Performance Improvement 16
Strategies to improve Promote a culture of transparency and integrity Know where your hospital stands on each selected measure Run, use and share reports look at your data Severity of illness Risk of mortality Present on admission PSI Length of stay Readmissions Cost per patient In Conclusion The numbers don t lie patients you are sicker, with more chronic conditions, have an increased risk of readmissions. However During chart reviews, you are already identifying ways to improve your patients severity of illness or risk of mortality (SOI & ROM) scores Work with your Quality team to identify all diagnoses that, if established in the record, can best benefit a hospital s risk adjustment Data isn t just Numbers 17
Questions? 18