Hospital Readmissions: Unlocking the Mystery

readmission management

Recent studies have shown that while hospital readmissions occur across the country, there are significant geographical differences. States like Utah have a very low readmission rate of 15.1%. Whereas states like Mississippi have a much higher rate of 28.1% (Mor et al., 2010). Hospital readmission rates have become increasingly scrutinized due to the alarming cost that results from the readmissions. In 2010, they accounted for a whopping $4.34 billion. Even more shocking, was that 78% of those admissions were considered avoidable. Now that we have some perspective, let’s talk about what this means to skilled nursing facilities.

In order for a skilled nursing facility to qualify for the quality point in the hospital readmission category, each facility will be evaluated on their number of preventable hospital readmissions. This point is one of the five points that each facility has the potential to earn. Facilities will earn one point if their facility’s actual hospital readmission rate is at, or below, the risk-adjusted expected rate calculated for the facility.

Another notable aspect in the calculation of this point is the fact that all of the data will be obtained from the actual hospital claims. Each claim submitted from the hospital that has a Medicaid number on it will be included in the calculation. This includes crossover claims, even if Medicaid is not the primary payer. There are some specifics to bear in mind:

  • The resident must be an inpatient in your facility for at least 14 days in order to be included in the hospital readmission rate.
  • Residents who have resided in your facility in the two days prior to hospital readmission will be included in the calculation. This means that if a resident is discharged and then readmits to the hospital within 48 hours, that resident will be included in the calculation.
  • “SNF stays where the patient had one or more intervening PAC admissions (IRF or LTCH) that occurred either between the prior proximal hospital discharge and SNF admission or after the SNF discharge within the 30-day risk window” will be excluded.
  • “SNF stays with a gap of greater than one day between discharge from the prior proximal hospitalization and the SNF admission” will be excluded.
  • “SNF stays where the patient did not have at least 12 months of FFS Part A Medicare enrollment before the proximal hospital discharge (measured as enrollment during the month of proximal hospital discharge and the 11 months before that month)” will be excluded.
  • “SNF stays in which the patient did not have FFS Part A Medicare enrollment for the entire risk period (measured as enrollment during the month of proximal hospital discharge and the month after the month of discharge)” will be excluded.
  • “SNF stays in which the principal diagnosis for the prior proximal hospitalization was for the medical treatment of cancer” will be excluded.
  • “SNF stays where the patient was discharged from the SNF against medical advice” will be excluded.
  • “SNF stays in which the principal diagnosis for the prior proximal hospitalization was for rehabilitation care; fitting of prostheses and for the adjustment of devices” will be excluded.

The facility Expected Admission Rate (EAR), “will be calculated using Medicaid hospital claims (including crossover claims) for nursing facility residents who meet specific criteria as noted below for the 12 month period prior to the measurement period. The DRG determined by the hospital will be used to assign each resident to one of 26 Aggregate Clinical Risk Groups (ACRG). The EAR will be calculated, and risk adjusted, for each of the ACRGs using claims data for all of the residents in each of the CRGs during the time period.” This implication being that the facility has very little control over the calculation of the EAR.

“The numerator is more specifically defined as the risk-adjusted estimate of the number of SNF stays with unplanned readmissions that occurred within 30 days of discharge from the prior proximal acute hospitalization. The numerator is mathematically related to the number of SNF stays where there was hospitalization readmission. The measure does not have a simple form for the numerator and denominator — that is, the risk adjustment method used does not make the observed number of readmissions the numerator and a predicted number the denominator. The numerator, as defined, includes risk adjustment for patient characteristics and a statistical estimate of the facility effect beyond patient mix.”

In an effort to manage your hospital readmissions at the facility level, education should be your primary focus. The more aware your staff is, the more likely it is that your staff will identify issues.

  • Educate physicians, nurse practitioners, and physician assistants on the specific interventions that are available to your facility. Some examples may be: stat labs, IV fluids, or IV antibiotics.
  • Educate your nursing staff on the appropriate identification of resident changes of condition. This should include symptom management, facility nursing policy on change in condition.

There are some great tools available to help in fostering this education. There is the e-Interact Situation, Background, Assessment, Recommendation, most often referred to as the SBAR tool. The SBAR will allow the nurses to gather the appropriate information to prepare for calling the physician regarding a resident change in condition. This will help to ensure the complete resident condition is relayed to the physician in a timely and organized manner. Another tool that is available for use is the e-Interact Stop and Watch form. This form can be used by all staff in the LTPAC setting. By implementing this form and process you will be able to identify resident changes in

Another tool that is available for use is the eInteract Stop and Watch form. This form can be used by all staff in the LTPAC setting. By implementing this form and process you will be able to identify resident changes in condition more readily because you are including more staff members. Stop and Watch forms can be initiated by housekeeping, dietary, activities, social service, therapy as well as nursing. The more people watching the residents for those subtle changes the better chance you will have to identify changes sooner.

The last piece in your hospital readmissions puzzle will be to include these metrics in your facility Quality Assurance Performance Improvement (QAPI) process. This is an excellent way to monitor for trends and identify opportunities for additional education. The QAPI team will also be able to introduce Performance Improvement Plans in an effort to enhance facility’s overall processes and policies.

Click here to learn more about the tools available for reducing readmission rates and becoming a preferred referral partner.

Read More: Narrowing Networks: Picking the Right Care Partner

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