RUA

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, BSN, CEN, SANE

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

June 8, 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

Case Management: Readmissions

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

period of 30 days of discharge(1,3,4)

• The estimated national 30-day, all-cause, hospital readmission rate for Medicare beneficiaries in the United States was 18.4% in 2012, down from an average of 19% during the period 2007–2011; this translates to ~ 70,000 fewer readmissions in 2012 than would have occurred if the readmission rate had remained at 19%(7)

–An estimated two-thirds of readmissions are preventable(1)

• Reasons for readmission include premature discharge, inappropriate treatment, and inadequate patient education and discharge planning(1)

–Hospitals serving a higher population of patients from a lower socioeconomic status often have higher rates than the national average for readmission,resulting in lower Medicare reimbursements. Patients from a lower socioeconomic status can have difficulty procuring follow-up appointments, food, and medications after discharge(10)

› Even though readmission rates have decreased, one in five Medicare patients are still being readmitted within a month(6)

› 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), and elective hip and/or total knee replacement. A readmission measure for coronary artery bypass graft (CABG) surgery was added in 2016(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(6)

–As of October 1, 2016, penalties went into effect and are applied to all Medicare discharges, with an average penalty that is less than 1% of the Medicare payment(6)

–By the end of 2016 hospitals lost a total of $420 million in penalties for excess readmissions(6)

–Hospitals can lose up to 3% of their Medicare reimbursement if they have higher than average 30-day readmissions for patients with heart failure, heart attack, elective hip or knee replacement, pneumonia, and an acute exacerbation of COPD(6)

–Current penalties are not large enough to have a big impact on the bottom line and for some hospitals the penalties are not high enough to justify the cost of adding staff or taking other steps to reduce readmissions(6)

–Beginning in 2017 the hospital’s base operating pay could be reduced by 6% from Medicare if a hospital receives the maximum penalties(6)

› Authors of a large study in New York, which utilized data from de-identifiedMedicaid claims discovered that high-value post-discharge utilization resulted in fewer inpatient

re-hospitalizations. This required population-based transitional care strategies to improve continuity between settings and considers the illness complexity of the patient(8)

› Case managers can be utilized to make the difference on the bottom line for hospitals by putting in place processes to reduce readmissions(6)

› A multi-layered approach is necessary to make a positive impact and reduce hospital readmissions. Some hospitals have a group of nurses acting as health coaches for hundreds of at-risk patients. In some cases these nurses will visit the patients in their home and routinely follow up with them(6)

• This multi-layered approach along the entire continuum has been shown to positively impact readmission rates(6)

› A readmission task force can help to analyze hospital data and determine the key diagnoses for the focus of the clinical team to prevent readmissions(6)

› Case managers play an important 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; the case manager is responsible for the safe and smooth transition of care. Collaboration between the case manager, social worker, and treating clinician must lead to change at the practice level to decrease readmission rates • Case managers will require extensive education for the advanced practice role and to perform the readmission screening

surveys that are anticipated to emerge during healthcare reform • In Tampa, Florida the Veterans Administration Health Center used telehealth and phone care initiatives to reduce

congestive heart failure hospital readmission rates by 5%, while also providing a decrease in costs, and improved veteran satisfaction with overall care experience(12)

–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-basedquality improvement in the hospital setting) program to implement telehealth and follow-up phone calls,effectively reducing all-cause 30-day readmissions; the readmission rate decreased 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-day readmission rate of 10.8% compared to the national average of over 18%. and scheduled post-acute follow-up services within one day of patient discharge(2)

• Researchers in a randomized controlled study of 281 older adults with at least two medical diagnoses demonstrated that a nurse-led CM program involving basic care, treatment compliance, and arrangements for outpatient follow-up appointments significantly reduced hospital readmission rates

• New York State has one of the highest readmission rates in the U.S. A New York hospital decreased 30-day readmissions by 70% for their highest-risk patients by implementing a care coordination team of case managers, social workers, and patient service coordinators. The team was trained by the BOOST program and also visited readmitted patients to find out why readmission was necessary

• Pima Council on Aging and Carondelet Health Network have partnered to provide follow-up care coordination for at-risk patients being discharged from the hospital. The U.S. Centers for Medicare & Medicaid Services (CMS) has referred to the program as a National Best Practice in reducing hospital readmission rates(11)

What We Can Do › Case managers and hospitals need to look beyond the hospital walls and determine what happens to patients throughout the

continuum to better avoid readmissions(9)

› Become knowledgeable about CM 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

› Improving communication with post-acute providers is a critical part of reducing readmissions. Sending a written report as well as talking to a clinician at a skilled nursing facility, home health agency, or long-termacute care hospital is one way to improve communication(9)

› Case managers should spend time with the patients and family members for an understanding of patient characteristics, such as culture, language barriers, socioeconomic status, healthcare literacy, and access to social support, and take these dynamics into consideration when developing a discharge plan(9)

› If a patient does not have immediate family or other support, then looking for other resources, such as community agencies, churches, and neighbors becomes vital. Being creative is important for case managers to connect patients with resources before discharge(9)

› Refer appropriate patients to palliative care is a critical part of reducing readmissions; this involves educating patients and family members on palliative care and end-of-life issues(5)

› Work closely with case managers who are embedded in physician offices and other venues of care. They are a great source of information for developing a successful discharge plan because they know what services can safely be provided in which venue of care. One example is residents of supportive living centers might be able to receive home care services and avoid a skilled nursing facility admission(5)

› Facilitate discharges early in the day, considering elderly patients have trouble driving at night and many pharmacies are closed at night(5)

› Follow up with assisted living residents to ensure communication with a clinician to provide the details of the hospitalization and the treatment plan(5)

› Collaborate with others in your healthcare facility to initiate a CM 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 implement the teach-back

method regarding performing 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. Adeoye, S., & Pineo, T. (2014). Reducing excess readmission 101: Evidence-driven strategies and facility-specific initiatives. Journal of Medical Practice Management, 30(1),

42-48. (RV)

2. Care management revamp helps keep readmission rates low. (2017). Hospital Case Management, 25(3), 39-41. (GI)

3. Centers for Medicare & Medicaid Services. (n.d.). The Hospital Readmissions Reduction Program (HRRP). Retrieved May 29, 2018, 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. Five more ways to improve readmissions, according to the experts. (2015). Hospital Case Management, 23(1), 4-5. (QI)

6. Five years later, hospitals still struggle with readmissions. (2015). Hospital Case Management: The Monthly Update on Hospital-Based Care Planning and Critical Paths, 23(11), 141-144. (PP)

7. Gerhardt, G., Yemane, A., Hickman, P., Oelschlaeger, A., Rollins, E., & Brennan, N. (2013). Medicare readmission rates showed meaningful decline in 2012. Medicare & Medicaid Research Review, 3(2), E1-E12. doi:10.5600/mmrr.003.02.b01 (PGR)

8. Hewner, S., Casucci, S., & Castner, J. (2016). The roles of chronic disease complexity, health system integration, and care management in post-discharge healthcare utilization in a low-income population. Research in Nursing & Health, 39(4), 215-228. doi:10.1002/nur.21731 (GI)

9. Hospitals are still struggling with reducing readmissions. (2015). Hospital Case Management, 23(1), 1-4. (PP)

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

11. Hospitals, Council on Aging Partner to reduce readmissions. (2015). Hospital Case Management, 23(1), 9-10. (PP)

12. Messina, W. (2016). Decreasing congestive heart failure readmission rates within 30 days at the Tampa VA. Nursing Administration Quarterly, 40(2), 146-152. doi:10.1097/ NAQ.0000000000000154 (QI)