Per new federal healthcare policy, acute care hospitals are now being measured on their 30-day admissions for pneumonia, congestive heart failure and acute myocardial infarction — and being penalized for their rate of readmission.
These newly-introduced measures are included in the Hospital Readmission Reduction Program, a part of the Patient Protection and Affordable Care Act signed into law in January 2010. The penalties began in October 2012 (CMS fiscal year 2013) with a maximum 1 percent reduction to the acute care facility's entire Medicare base rate but have since seen an uptick — the penalties increased to 2 percent in October 2013 and are scheduled to increase to a maximum of 3 percent in October 2014.
Additional diagnoses are being added, and legislation will likely extend to all diagnoses in the near future. Currently, there are 2,225 hospitals — out of 4,973 hospitals nationwide — being penalized.
At Nexus Health Resources, we implement a program for acute care hospitals that allows for decreased readmissions. We have found the following methods paramount in reducing readmissions and avoiding costly penalties:
1. Inpatient best practice quality measures and length of stay. Acute care facilities have been attempting to reduce length of stay for patients as a result of current CMS and private payment methods. With this pressure in mind, it is important that quality best practices are followed from start to finish. A successful discharge is a result of outstanding care from beginning to end.
2. Medicine delivery to bedside. Patients often have their chronic medications waiting at home, but any new medication — including a change in dosing — needs to be delivered the day of discharge either to the bedside or to the patient's home. Patient education about medications is best done during the hospitalization a few days prior to discharge. A review of the medications to be taken at home (discharge medicine reconciliation) is best done the day of discharge.
3. Follow-up appointments made prior to hospital discharge. Patient compliance in scheduling physician appointments and attending them is much greater if the appointments are set prior to patients leaving the hospital. Further, we ensure transportation to the appointment is confirmed beforehand.
4. Understanding signs and symptoms. There needs to be constant education from all clinicians involved in the patient's care to ensure the patient has a clear understand of their disease process. Patients should also be aware of what signs and symptoms to look for at home and which ones require immediate attention.
5. Confront patients' unrealistic expectations of self-care. Many patients are unwilling to check into a skilled nursing facility for a few weeks after discharge, even for a short period of time. Other patients are uncomfortable with the idea of a visiting nurse making home visits after discharge. When a patient refuses care they qualify for — like skilled nursing facilities or visiting nurses — it is imperative to communicate the consequent risk. These forms of care are essential in combatting readmission.
6. Patient self-advocating when a problem arises. Patients are often hesitant to "bother" a family member, friend or physician when they notice concerning signs or symptoms of their disease. Our Health Care Coordinators contact the patient proactively in the first 24 hours after discharge, and then throughout the following 30-day period, to ensure all of the patient's concerns are addressed swiftly and safely. By acting quickly, Nexus Health typically allows for follow-up care to be delivered at home rather than at the acute care facility.
7. Communication between healthcare facilities and providers. Communication between facilities is essential, particularly between emergency rooms and skilled nursing facilities. Frequently, a patient can receive needed diagnostic testing, evaluation and treatment all at the skilled nursing facility. And if the emergency room is aware of these capabilities, the coordination process becomes much smoother.
These methods are best addressed with the quality, nursing and emergency departments of the acute care hospital actively working alongside the care coordinator. Remember, communication with the patient starts during hospitalization and continues into the days after discharge. By implementing these methods, an acute care facility can expect to reach national norms for percentage readmission and thus avoid any CMS penalties to their base reimbursement rates.
Virginia Feldman, MD, is the founder, president and CEO of Nexus Health Resources and an attending physician at Orange Regional Medical Center in Middletown, N.Y. Dr. Feldman also co-founded Hudson Valley Ambulatory Surgery Care Center and previously served as President and Managing Partner of Hudson Valley Ear, Nose & Throat (ENT).
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