Assistance

EVIDENCE- BASED CARE SHEET

Authors Hillary Mennella, DNP, ANCC-BC

Cinahl Information Systems, Glendale, CA

Monica Key, ANP-C, APRN, AOCNP, CCRN

Cinahl Information Systems, Glendale, CA

Reviewers Debra Balderrama, RN, MSCIS

Clinical Informatics Services, Tujunga, CA

Alysia Gilreath-Osoff, RN, MSN Cinahl Information Systems, Glendale, CA

Nursing Executive Practice Council Glendale Adventist Medical Center,

Glendale, CA

Editor Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

May 20, 2022

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2022, 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

Case Management: Readmissions

What We Know › Readmission is defined as a patient admission to the same or a different hospital within a

period of 30 days of discharge(3,4)

• In the United States, the estimated 30-day, all-cause, hospital readmission rate was 13.9% in 2016, down from 14.2% in 2010(2)

–Readmission rates in 2016 varied by patient insurance status, as follows: - Medicare: 17.1% - Medicaid: 13.4% - Uninsured: 11.8% - Private insurance: 8.6%

• Common reasons for readmission include premature discharge, inappropriate treatment, and inadequate patient education, discharge planning, and post-discharge monitoring and management(6)

–Hospitals serving a higher population of patients from a lower socioeconomic status often have readmission higher rates than the national average. Patients from a lower socioeconomic status can have difficulty procuring follow-upappointments, food, and medications after discharge

› In 2010 the Affordable Care Act (ACA) established the Hospital Readmissions Reduction Program, which provides financial incentives to hospitals to reduce readmissions(3,4)

• The program requires a reduction in Medicare and Medicaid reimbursement to applicable hospitals for excess readmissions for acute myocardial infarction (AMI), heart failure (HF), pneumonia, chronic obstructive pulmonary disease (COPD), elective hip and/or total knee replacement, and coronary artery bypass graft (CABG) surgery(3,4)

–Readmission reimbursement calculations for individual hospitals are based on national readmission rates for these specific diagnoses and are intended to improve health care for beneficiaries and control unnecessary spending of healthcare dollars. Hospitals with high readmission rates will receive lower payments or may be denied payment(3,11)

- In a study on 276 hospital year observations in Washington state, researchers observed that decreased readmission rates for AMI were associated with increased hospital operating revenues(11)

• Successful strategies to avoid readmissions include coordination/collaboration between care providers, post-dischargetelephone follow-up calls and home visits by a healthcare provider (e.g., nurse, pharmacist, physician), and formalized discharge planning that addresses social determinants of health (e.g., housing conditions, access to healthy food and transportation)(9,12)

› Case managers play a vital role in the patient discharge process and in the prevention of unnecessary readmissions. Discharge is a shared responsibility between staff members, the patient, caregivers, and the case manager. Responsibilities of the case manager include identifying high-risk patients, assessing/ensuring self-management skills needed for safe hospital discharge, and ensuringpatient access to supplies required for self-management and adequate outpatient follow-up(5,10)

• A growing body of evidence supports the role of case management in decreasing readmission rates

–Authors of a systematic review published in 2017 noted that most studies reported a reduction in hospital readmission rates after case management implementation(8)

–Researchers assessed the impact of an integrated case management intervention on hospital readmission rates among high-risk patients with HF and diabetes mellitus. They reported an 18.4% readmission rate for patients who received the intervention compared with 52.6% for those who received usual care(10)

–In a 600-bed tertiary care hospital, implementation of program that expanded the role of diabetes educators to include case management resulted in a decrease in readmission rates. Researchers analyzed 34,472 discharged patient records from an 18-month preintervention period and 32,046 from an 18-month postintervention period and found that the 30-day readmission rate declined from 20.1% to 17.6%(5)

–In a study of 1,564 patients with COPD who received care at five large hospitals in Vancouver, BC, Canada, researchers found that implementation of a comprehensive case management was associated with a 45% reduction in risk of readmission at 1 year and a 49% reduction in readmission at 2 years(1)

–Cochrane reviewers pooled data from four studies involving 773 children with chronic lung diseases such as asthma and bronchiectasis. They concluded that discharge planning by a case manager was associated with a 71% reduction in risk of readmission for an acute exacerbation(7)

–In Tampa, Florida the Veterans Administration Health Center used telehealth and phone care initiatives to reduce HF hospital readmission rates by 5%, while also providing a decrease in costs, and improved veteran satisfaction with overall care experience - Similarly, in 2013, case management leadership in Flagstaff, Arizona used the Better Outcomes for Older Adults

through Safe Transitions (BOOST; a tool used for evidence-based quality improvement in the hospital setting) program to implement telehealth and follow-up phone calls,effectively reducing all-cause 30-day readmissions from 23% to 12%. In 2014. The program was implemented in another Flagstaff system hospital to include pneumonia, COPD, total joint replacements, and AMI, demonstrating an all-cause Medicare 30-dayreadmission rate of 10.8% compared to the national average of over 18%

What We Can Do › Become knowledgeable about case management as an approach to reduce patient readmissions so you can accurately assess

your patients’ personal characteristics and health education needs; share this information with your colleagues › Collaborate with others in your healthcare facility to initiate a case management program to meet the needs of every patient

and to maintain compliance with healthcare reform quality outcome readmission measures › Track and trend readmission rates and analyze core reasons for rehospitalization › Involve patients and their caregivers in the discharge planning process, provide education, and use the teach-back method to

confirm patient/caregiver ability to perform patient care after discharge to home › Collaborate with others in your healthcare facility to identify and implement validated and reliable screening tools for

increased risk for readmission among your patient population › Participate in continuing education for implementation of readmission screening surveys

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. Alshabanat, A., Otterstatter, M. C., Sin, D. D., Road, J., Rempel, C., Burns, J., ... FitzGerald, J. M. (2017). Impact of a COPD comprehensive case management program on

hospital length of stay and readmission rates. International Journal of Chronic Obstructive Pulmonary Disease, 12, 961–971. doi:10.2147/COPD.S124385 (R)

2. Bailey, M. K., Weiss, A. J., Barrett, M. L., & Jiang, J. (2019). Characteristics of 30-Day All-Cause Hospital Readmissions, 2010–2016: Statistical Brief #248. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Retrieved from (R)

3. Centers for Medicare & Medicaid Services. (2020, August 11). The Hospital Readmissions Reduction Program (HRRP). Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HRRP/Hospital-Readmission-Reduction-Program.html (GI)

4. Department of Health and Human Services. (2012). 42 CRF Parts 412, 413, 424, et al. Medicare Program; Hospital inpatient prospective payment systems for acute care hospitals and the long-term are hospital prospective payment system and fiscal year 2013 rates; hospitals' resident caps for graduate medical education payment purposes; quality reporting requirements for specific providers and for ambulatory surgical centers, 77(170), 53258-53750. Retrieved from http://www.gpo.gov/fdsys/pkg/FR-2012-08-31/pdf/2012-19079.pdf (L)

5. Drincic, A., Pfeffer, E., Luo, J., & Goldner, W. S. (2017). The effect of diabetes case management and Diabetes Resource Nurse program on readmissions of patients with diabetes mellitus. Journal of Clinical & Translational Endocrinology, 8, 29–34. doi:10.1016/j.jcte.2017.03.003 (R)

6. Graham, K. L., Auerbach, A. D., Schnipper, J. L., Flanders, S. A., Kim, C. S., Robinson, E. J., ... Herzig, S. J. (2018). Preventability of early versus late hospital readmissions in a national cohort of general medicine patients. Annals of Internal Medicine, 168(11), 766–774. doi:10.7326/M17-1724 (R)

7. Hall, K. K., Petsky, H. L., Chang, A. B., & O'Grady, K. F. (2018). Caseworker-assigned discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness. Cochrane Database of Systematic Reviews, 11. Art. No.: CD012315. doi:10.1002/14651858.CD012315.pub2 (M)

8. Joo, J. Y., & Liu, M. F. (2017). Case management effectiveness in reducing hospital use: A systematic review. International Nursing Review, 64(2), 296–308. doi:10.1111/ inr.12335 (SR)

9. Kash, B. A., Baek, J., Cheon, O., Coleman, N. E., & Jones, S. L. (2018). Successful hospital readmission reduction initiatives: Top five strategies to consider implementing today. Journal of Hospital Administration, 7(6), 16-23. doi:10.5430/jha.v7n6p16 (RV)

10. McCants, K. M., Reid, K. B., Williams, I., Williams, I., Miller, D. E., Rubin, R., & Dutton, S. (2019). The impact of case management on reducing readmission for patients diagnosed with heart failure and diabetes. Professional Case Management, 24(4), 177-193. doi:10.1097/NCM.0000000000000359 (R)

11. Upadhyay, S., Stephenson, A. L., & Smith, D. G. (2019). Readmission rates and their impact on hospital financial performance: A study of Washington hospitals. Inquiry, 56, 46958019860386. doi:10.1177/0046958019860386 (R)

12. Warchol, S. J., Monestime, J. P., Mayer, R. W., & Chien, W. W. (2019). Strategies to reduce hospital readmission rates in a non-Medicaid-expansion state. Perspectives in Health Information Management, 16(Summer), 1a. (R)