Evidenced Based- Analyzing articles

EVIDENCE- BASED CARE SHEET

Author Hillary Mennella, DNP, ANCC-BC

Cinahl Information Systems, Glendale, CA

Reviewers Darlene Strayer, RN, MBA

Cinahl Information Systems, Glendale, CA

Jocelyn Cajanap-Gantman, RN, MSN, FNP, CNS

Sepsis Coordinator, Glendale Adventist Medical Center

Nursing Executive Practice Council Glendale Adventist Medical Center,

Glendale, CA

Editor Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

June 22, 2018

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Hospital Readmissions: United States Centers for Medicare and Medicaid Services (CMS)

What We Know › Hospital readmission is an expensive and often avoidable patient care outcome(4,9,12)

› In 2013, an estimated 18% of Medicare patients were readmitted to the hospital within 30 days of discharge. Annual Medicare costs related to readmissions are estimated at $26 billion, with potentially preventable readmissions accounting for approximately $17 billion of that cost(1)

› All healthcare providers are responsible for identifying patient discharge needs and developing a thorough discharge plan to reduce the risk for hospital readmissions(3)

› In accordance with the legislative passing of the Affordable Care Act (ACA), the United States Centers for Medicare and Medicaid Services (CMS) established the Hospital Readmissions Reduction Program (HRRP) to decrease the frequency of hospital readmissions of Medicare beneficiaries. Effective October 1, 2012, the provisions of the HRRP permit the CMS to reduce payments to hospitals under the inpatient prospective payment system (IPPS) for readmission rates that are reviewed by CMS and determined to be excessive. The HRRP adjusts hospital reimbursement based on the data for excessive readmissions following patient admissions for acute myocardial infarction (AMI), congestive heart failure (CHF), pneumonia (PN), coronary artery bypass graft (CABG), chronic obstructive lung disease (COPD), stroke, and complications related to readmissions for total hip/knee replacements (THR/TKR)(4,9,12)

• Under the HRRP, readmission is defined by the CMS as “an admission to a subsection hospital within 30 days of a discharge from the same or another subsection hospital”(4)

–The hospital readmission rate is calculated from the date of discharge, plus 30 days. For example, for a patient who is discharged on October 1, the last day for the postdischarge follow-up period is October 31

–The CMS recognizes 30 days as an industry standard that is strongly influenced by the quality of care

–Hospital readmissions exclude those involving a patient’s death in the hospital, enrollment in the Medicare fee-for-service program, hospital admission after at least 30 days post-hospital discharge, and planned hospital readmission (i.e., a nonacute readmission for a scheduled procedure)

–CMS does not consider preventability when calculating readmission rates(11)

- A standard for identifying and defining what is considered to be a preventable readmission does not exist(11)

–Hospital readmission rates are assigned a “yes/no” readmission status regardless of the number of readmissions for a patient during the 30-day postdischarge time period

› Each year during the period 2003–2004, according to billing claims from the CMS, an estimated 2.3 million Medicare beneficiaries were readmitted to the hospital within 30 days of discharge. Investigators in a study of 11,855,702 Medicare beneficiaries reported that(8)

• 19.6% were discharged from the hospital and rehospitalized within 30 days –Of this group, 50.25% did not have a bill for a follow-upvisit to a physician’s office

between the time of discharge to the community and rehospitalization

• 34% were discharged from the hospital and rehospitalized within 30 days –An estimated 10% were planned hospital readmissions

• 67.1% of Medicare beneficiaries with medical conditions who were discharged from the hospital were rehospitalized or died within the first year after discharge

• 51.5% of Medicare beneficiaries who were discharged from the hospital after surgical procedures were rehospitalized or died within the first year after discharge –Of this group, 70.5% were rehospitalized with a medical condition

› The CMS began reporting the 30-day mortality rates for the quality outcome measures for AMI and CHF in 2007 and for PN in 2008. These quality outcome measures are publicly reported in an effort by CMS to increase transparency and accountability of hospitals for patient care services and treatment(2,12)

• The CMS recommends that hospitals review their 30-day mortality outcome measures in conjunction with their 30-day hospital readmission data in order to modify the quality and type of care provided to reduce hospital readmissions

› The financial penalties for the HRRP were calculated by the CMS using data from July 2008 through June 2011 for the readmission rates for all hospitalizations for AMI, PN, and CHF; these rates were adjusted for age, gender, patient frailty, and coexisting medical conditions and compared with the actual readmission rates over the same period of time using a methodology that is endorsed by the National Quality Forum (NQF)(4,9,12)

• A hospital’s calculated readmission rate for MI, PN, CHF, COPD, CABG, stroke, and THR/TKR is the performance measure of that hospital’s readmission rate compared with the national average for a hospital’s set of patients with the same applicable conditions

• For the fiscal year 2013, hospital readmission rates were calculated from data on discharges from July 1, 2008, through June 30, 2011

• In the fiscal year 2014, an estimated 80% of hospitals were penalized, at a cost of $428 million(1)

• Kaiser Health News (KHN) reported 4 out of 5 hospitals were penalized for readmissions based on patient discharge data analyzed between July 2013 and June 2016(13)

–The average penalty between October 1, 2017 and September 30, 2018 is expected to be 0.73% for each payment Medicare makes per patient(13)

› The CMS levied financial penalties of up to 1% of hospital reimbursement rates for readmission of Medicare beneficiaries. The financial penalties increased to 2% in 2014 and to a maximum of 3% in 2015(9)

› The CMS 30-day hospital readmission measures are federally mandated to be publicly available under the Hospital Inpatient Quality Reporting Program(12)

› The CMS provides hospitals with Hospital-Specific Reports (HSRs) under the Hospital Inpatient Quality Reporting (IQR) program to promote hospital quality improvement efforts. The HSRs provide detailed information on a hospital’s readmission rates, discharge data, and specific risk factor data(4,12)

› Investigators analyzing the publicly available data from July 2008 through June 2011 for 3,282 hospitals found that large hospitals, teaching hospitals, and safety-net hospitals (i.e., a hospital system that provides care to a large number of uninsured or low-income patients) had higher readmission rates compared with small hospitals and non-teaching hospitals. Of this sample, 2,189 hospitals, or 66.7% of hospitals, will receive financial penalties as a result of the HRRP. Investigators call for additional research to determine why large hospitals, teaching hospitals, and safety-net hospitals have higher readmission rates than small and non-teaching hospitals(10)

› Researchers evaluating the impact of community factors on hospital readmission rates noted that a large portion of readmission rates is affected by the characteristics of the local healthcare community (e.g., quality of nursing homes, access to primary care), specifically the county where the hospital is located. This suggests that penalizing hospitals with high readmission rates might not be equitable and that interventions aimed at community-based readmission reduction strategies might result in improved outcomes(6)

› As new data emerge on hospital readmission rates, the CMS should consider the impact on underserved medical communities and make necessary adjustments to the policies regarding hospital readmission. Debate exists about financially penalizing hospitals for excessive readmission rates. Experts argue that the CMS rules are inherently discriminatory toward hospitals that serve low-income groups and/or severely ill patients. Experts argue the following issues:(9,12)

• At the inception of the HRRP, the CMS did not adjust for socioeconomic status (SES) or severity of comorbid illness in the calculation of the hospital readmission measures

–The CMS argued that adjustment for SES implies that it is acceptable for low-income patient groups to receive less than standard quality of care

–Experts contend that the CMS should adjust for SES to place all hospitals at the same level –Researchers have suggested weighting HRRP penalties according to the timing of readmissions. For example, hospital

readmission within the first few days after discharge can indicate poor discharge planning compared with hospital readmission 3 weeks after discharge, which is more likely to indicate the severity of the patient’s underlying illness and/ or comorbid diseases. This suggestion offers hospitals the opportunity to make improvements to their discharge planning process while caring for severely ill and low-income groups of patients

• Events leading to hospital readmissions might be out of the hospital’s control. Hospitals serving a larger population of patients from a lower SES often have higher rates for readmission compared to the national average resulting in lower Medicare reimbursements. Patients from a lower SES can have difficulty procuring follow-up appointments, food, and medications after discharge(5)

–Patients that are eligible for Medicare and Medicaid are defined as “dual-eligibles.” They tend to be medically complex patients with high levels of healthcare utilization. As a result of the 21st Century Cures Act of 2016 the CMS proposed changes for calculating financial penalties under the HRRP beginning fiscal year 2019 among hospitals with high readmission rates of patients from low SES backgrounds. The new calculations are risk-adjustment strategies that include comparisons of social economic risk factors among hospitals(7,14)

• The HRRP was criticized by experts that the program had the potential to exacerbate disparities in patient care and generate disincentives to provide care for patients with severe illness and/or complex comorbidities

What We Can Do › Become knowledgeable about hospital readmissions so you can adhere to the CMS quality outcome measures and the

HRRP; share this information with your colleagues › Review publicly available hospital readmission rates to compare your organization against national benchmarks; for more

information, see http://www.qualitynet.org › Collaborate with colleagues in your facility to

• review your HSR to promote hospital quality improvement efforts • develop an individualized discharge plan for your patients • provide high-quality healthcare to your patients to promote positive patient outcomes and reduce the risk for hospital

readmissions

Coding Matrix References are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentations or other such materials

CP Conference proceedings, abstracts, presentation

References 1. Boozary, A. S., Manchin, J., III, & Wicker, R. F. (2015). The Medicare Hospital Readmissions Reduction Program: Time for reform. JAMA: Journal of the American Medical

Association, 314(4), 347-348. doi:10.1001/jama.2015.6507 (R)

2. Centers for Medicare and Medicaid Services. (2017). Outcomes measures. Retrieved June 15, 2018, from https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/outcomemeasures.html (G)

3. Centers for Medicare and Medicaid Services. (2013). Revision to State Operations Manual (SOM), Hospital Appendix A - Interpretive Guidelines for 42 CFR 482.43, Discharge Planning. Retrieved June 15, 2018, from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-13-32.html (G)

4. Centers for Medicare and Medicaid Services. (2018, April 27). Readmissions reduction program. Retrieved June 15, 2018, from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html (G)

5. Changes to readmissions rule will help, but no panacea. (2017). Case Management Advisor, 28(9), 14-15. (X)

6. Herrin, J., St. Andre, J., Kenward, K., Joshi, M. S., Audet, A. J., & Hines, S. C. (2015). Community factors and hospital readmission rates. Health Services Research, 50(1), 20-39. doi:10.111/1475-6773.12177 (R)

7. Hospitals can now factor socioeconomic status into readmissions. (2017). Hospital Case Management, 25(3), 41-42. (GI)

8. Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418-1428. doi:10.1056/NEJMsa0803563 (R)

9. Joynt, K. E., & Jha, A. K. (2013). A path forward on Medicare readmissions. New England Journal of Medicine, 368(13), 1175-1177. doi:10.1056/NEJMp1300122 (GI)

10. Joynt, K. E., & Jha, A. K. (2013). Characteristics of hospitals receiving penalties under the Hospital Readmissions Reduction Program. JAMA, 309(4), 342-343. doi:10.1001/ jama.2012.94856 (R)

11. Lavenberg, J. G., Leas, B., Unscheid, C. A., Williams, K., Goldman, D. R., & Kripalani, S. (2014). Assessing preventability in the quest to reduce hospital readmissions. Journal of Hospital Medicine, 9(9), 598-603. doi:10.1002/jhm.2226 (R)

12. QualityNet. (n.d.). Readmission measures overview. Retrieved June 15, 2018, from http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage %2FQnetTier2&cid=1219069855273 (G)

13. Rau, J. (2017). Medicare readmission penalties for hospitals continue under Trump. Retrieved June 15, 2018, from http://www.healthcarefinancenews.com/news/medicare-readmission-penalties-hospitals-continue-under-trump (GI)

14. Whitman, E. (2017). Dual-eligibles could offer relief for hospital readmissions penalties. Modern Healthcare, 47(17), 0010. (GI)