Observational Program Evaluation

This project was an observational study designed to evaluate the impact of Post-MI Transitional Care Program and Advanced Practice Provider Transitional Care Clinic on 30-day readmission rates, medication compliance and length of time to first office follow-up. Retrospective chart review was used to gather data. Prior to October 1, 2015, no formal Transitional Care Program or Advanced Practice Provider Transitional Care Clinic existed at Baptist Hospital. On October 1, 2015, Baptist began a Post-Myocardial Infarction Transitional Care Program and Advanced Practice Provider Transitional Care Clinic which incorporated multiple discipline inpatient education and structured post-discharge clinic which was managed by advanced practice providers who provide comprehensive patient care for the first 30 days after discharge with diagnosis of myocardial infarction.

1) What is the activity utilization rate at each step in the process of providing care? What is the direct labor utilization?

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

This memorandum describes Central Health’s Readmission Reduction Program set to commence in May 2017. The Centers for Medicare and Medicaid Services (CMS) has raised concern over the increasing readmission rate and poor quality of care. To address this issue, Congress has created Hospital Readmission Reduction Program (HRRP) statute under the Affordable Care Act, 2010, which was recently updated under 21st Century Cures Act of 2016. Under the constant pressure of a penalty, Central Health has considered to establish its own Hospital Readmission Reduction Program to address specific imperatives, such as care-coordination, treatment adherence program, and streamlined patient discharge process.

The health care organizations have big opportunity to improve their quality of healthcare service as well as improve life quality of customers through reducing an avoidable readmission. The readmission is defined by Centers for Medicare and Medicaid Service (CMS) “Admission to a subsection hospital within 30 days of a discharge from the same or another subsection hospital” Hoffman, J.H. (2012). Readmissions can be classified four different categories, including (1) Planned readmission which the reason of the readmission is related to the initial admission. For example, reconstructive surgery with subsequent steps or it could be series of treatment such as cancer chemotherapy. (2) Planned but the reason is not related to the initial readmission.

In my current role a President of our integrated care network, one are largest cost outliers in our Medicare cost report was our 30 day readmission rate. The government has defined 30 days as the time period they feel a patient should be not readmitted to a hospital for certain diagnoses. Studies have looked at the groups that have had intervention in terms of discharge planning, and those with no intervention or discharged in a "usual" fashion from an institution. A study in the journal Circulation in 2013 looked at this exact question and found that following certain protocols could reduce the readmission rates in heart failure patients (Bradley, et al., 2013).

The Pennsylvania researchers collected data from 200,000 nurses, and from 412 different hospitals in Pennsylvania, New Jersey and California. The research concluded that readmission less than 30 days of Medicare patients older than 65 years with acute myocardial infarction, pneumonia and heart failure, had a 10% lower rate of readmission. The good outcome was as a result of better nurse working environment and controllable patient workloads for

Reduction in Medicare reimbursements related to 30-day readmissions, have made readmission prevention a hot topic in healthcare today. In an effort to reduce our 30 day readmission rate, my hospital has invested in a software program that pulls information from over 60 sources and then calculates an “All Causes Risk for Readmission Score”, classifying patients as low, moderate, or high risk for readmission. The case managers do an in-depth assessment on all Medicare patients classified as high risk. This assessment typically takes 1-2 hours of conversation with the patient and family to complete, and addresses the patient’s medication compliance, financial concerns, social support, and living environment, and understanding of their disease

One such study designed a tool for discharge to assist providers in making sure that patients received all appropriate information regarding methods to care for themselves prior to being discharged to another level of care or to home. Hence, the AHRQ along with Boston University Medical Center, prepared the Reengineered Discharge (RED). As per the patients’ needs for safe and effective discharge the RED tool was designed to provide the provider with a clear and concise method to discharge all patients. The RED process is an evidence-based intervention that has been implemented in over 300 hospitals in the U.S. and found to decrease hospital readmissions by 30% (Joint Commission Resources, 2016). While the program has been noted to be significantly effective, the implementation to be done correctly and effectively may take from 6-12 months or longer (Agency for Healthcare and Administration, 2013). Although it appears an extensive period, the goal is designed to improve the care coordination that is offered to patients at any specific site. The RED tool provides organizations information on how to align with the AHRQ practices and to encourage communication amongst providers to better assess the best plan for patients and promote follow through for each level of care. One barrier that can affect the proper and successful

In the United States, approximately 20% of 30-day hospital readmissions are due to inconsistent transition of care (TOC).5, 13 This means the expenditure of billions of unnecessary dollars that could have been prevented if the patients had received proper, coordinated, and consistent care from discharge back to the community. In fact, Medicare reports show more than 17 billion dollars a year are spent on preventable readmissions, leading cause being improper medication usage after discharge.1 Up to 2% of these medication discrepancies were life-threatening and even led to death.7 Medication discrepancies often occur when patients have a lack of understanding of discharge medication plans, inadequate literacy to understand the dismissal notes, become nonadherent to medication regimen, and/or experience adverse drug events.8, 11 Expanding community pharmacists’ involvement in post-discharge TOC and improving communication will benefit patients, healthcare providers, and the healthcare system through decreased hospital readmission, medication related adverse events, and financial burden.

The Medicare Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals with higher than expected 30-day readmission rates for Medicare patients by reducing annual reimbursements by up to 3% (AHA, 2015; Barnett et al., 2015). Most hospitals and health care systems have focused on implementing evidence-based programs to improve performance and patient outcomes in order to prevent

The changing cores consider the following. Every 10 years, one-fourth of all current knowledge and accepted practices in the healthcare and other industries will be obsolete (Allen, 2015). Effective October 1, 2013, new rules for inpatient hospital reimbursement under the Medicare program make final two sets of proposed rules that the Centers for Medicare & Medicaid Services (CMS) published in the Spring 2013–the definition of an inpatient hospital stay based on time and a hospital rebilling option (CMS, 2013). Working at Howard County General Hospital, for individual to become an inpatient at a skilled nursing facility after a three day minimum acute hospital stay, and who meet Medicare’s qualified diagnosis and comprehensive treatment

Reconcile medications and ensure that the patient has access to these medications at the time of discharge.

The dependent variables of patient satisfaction and patient expectations were clearly operationalized and their measures were clearly described. The authors gave samples of the questions asked to the patients surveyed. In addition, coefficient alphas were reported for patient satisfaction and patient exceptions (.92 and .83, respectively). The remaining two variables of interest, patient falls and medications errors were not quite as clearly operationalized. Reliability and validity statistics were not included in for the ORNA-II data. Medication errors were measured as the “total number of medication errors reported for the unit over 3 months” (Chang, Hughes, &Mark, 2006, pp. 376, para.5). However the authors did not state at which point the

This author’s point of view believes that determining the specific reason why readmissions occur is critical to put a strategy in place to start reducing these readmissions. The author felt that the study was a well-organized study and would provide valuable information to the hospitals who participated.