New Programs Help Hospitals to Reduce Unnecessary Readmissions

A recent story reported by Kaiser Health News highlighted the problems hospitals are facing, due to the new Medicare payment policies. As related in the article, Beth Israel Deaconess Medical Center in Boston received word in 2012 that it had one of the highest Medicare readmission rates in the nation, and would be subject to federal penalties of over one million dollars. This came as a shock to many in the Beth Israel Deaconess community, because the renowned teaching hospital is affiliated with Harvard Medical School and is widely regarded to provide high-quality care.

• Penalties for high readmission rates will also expand in 2014, up to 3% of a hospital’s reimbursement rate.

The article went on to report how Beth Israel Deaconess responded to this problem, by using a $5 million grant from the Centers for Medicare and Medicaid Services (CMS) to establish a new PACT program. PACT stands for post-acute care transitions, and the program charges nurses and pharmacists with tracking Medicare patients who are at high risk for readmission within 30 days, for a problem directly related to the condition they were initially hospitalized for. PACT will focus on integrating care, improving transitions of care, and using a wide array of evidence-based best practices to prevent complications and better communicate with patients about disease and medication self-management.

So far, Beth Israel Deaconess has been able to reduce readmissions by about 25 percent, reducing its fines in the process. By avoiding a second, avoidable hospitalization, CMS projects that it will save nearly $13 million over three years.

According to a Kaiser Health News analysis, many other hospitals have been penalized as well, since the Patient Protection and Affordable Care Act (PPACA) established a hospital readmission reduction program in 2012. The program has defined benchmarks for acceptable readmission rates. It was designed to combat what economists have called a “system of perverse incentives” – meaning that hospitals have, in the past, made more money when a patient develops a complication and lands right back in the hospital.

Here’s a quick rundown of how the readmissions penalties work:

  • Beginning in October of 2012, the program tracked readmission rates for three key conditions: heart failure, heart attack, and pneumonia.
  • Hospitals that have readmission rates over set benchmarks will lose either 1% or 2% of their reimbursement.
  • Later this year, the list of conditions will be expanded to include three more conditions that have typically seen high readmission rates: COPD, coronary artery bypass surgery, and coronary angioplasty.
  • Penalties for high readmission rates will also expand in 2014, up to 3% of a hospital’s reimbursement rate.

On the day a patient is discharged, a floor nurse may spend just ten minutes or less going over discharge instructions. In the past, a social worker may have assisted with very complex cases, to help the family arrange for durable medical equipment, home health aides, etc. This paradigm is changing quickly, however. With their economic viability on the line, hospitals are searching for ways to ensure their patients recover uneventfully at home, rather than suffering complications. And they are concluding that more thorough, focused discharge planning is the answer, with an extra emphasis on follow-up care. 

As this trend continues and discharge planning takes on an urgency not seen before, skilled case managers will be in demand. At most hospitals, case managers will be involved with all patients, assessing them in person and beginning the process of discharge planning as soon as a patient is admitted. Because readmission rates are now being tracked, case managers will be ever more accountable for the results of their discharge plans, so they’ll be working closely with hospitalists to make sure primary care physicians have immediate access to discharge summaries and coordinating patient coaching, so patients and caregivers understand their roles in the care transition.

Case management appears to be an excellent career path for nurses wanting to take on an important role as health care reform evolves. Online nursing degrees like American Sentinel’s MSN with a case management specialization can make you attractive to employers, provide you with case management knowledge and skills, and give you the academic background you’ll need to pass the credentialing exam.

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