Readmission Rates To The Hospital: A Case Study

The overall process of discharging a patient from a hospital and the transition back home or to a care facility are critical advancements in the overall course of both acute and long-term care. It is important that the hospitals releasing these patients have ensured the proper overall course of care from beginning to end. The lack of consistency with both the discharge process and the quality of discharge planning has led to many avoidable readmissions. To reduce the amount of hospital readmissions, it is imperative that hospitals recognize the need for focused patient care and that programs are being implemented to assist in the care transition.

Readmissions is a basis for financial penalties to hospitals as a provision of the Affordable Care Act by reducing payments to hospitals with an” excess” 30-day readmissions. The data showed that patients living in high poverty neighborhoods were more likely to be readmitted, older and male patients were more likely to be readmitted as opposed to young and female patients. Lastly, patients with CHF, acute myocardial infarction, and those with certain diseases, such as diabetes, liver and kidney disease were at higher risk of being readmitted. The data also showed married patients were less likely to have a readmission because of more social support (Study Links Social, Community Factors with Hospital Readmissions,

Readmission to a hospital creates strain and added expense for the patient and hospital; in 2011, hospital costs due to readmission were almost $41.3 billion (Hines, Barrett, Jiang, & Steiner, 2014; Rau, 2014). There are many aspects of healthcare associated with readmission, such as lack of discharge planning and education, which need to be addressed i to decrease the amount of preventable re-hospitalizations.

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.

Hospital readmissions are potentially harmful, costly and often times an avoidable event. Between the provisions set forth under the Affordable Care Act and the penalties authorized by the Centers of Medicare and Medicaid Services, hospitals are forced to shift their focus towards the development of strategies to reduce and prevent avoidable hospital readmissions related to heart failure. It is estimated that of the 6 million individuals within the United States diagnosed with heart failure, 1 million of them are hospitalized each year with a primary diagnosis of heart failure, accounting for $17 billion dollars of Medicare expenditures (Sales et al, 2013). What is worse is the death rate associated with heart failure each year, accounting

This newer reimbursement system has been a topic of contention amongst a large portion of the professional medical community due to the perceived unfairness that it brings in certain situations where a patient must be readmitted and, as a consequence, the primary care providers may not be reimbursed for the readmission regardless if they were responsible. With the introduction of the Affordable Care Act in 2010, further criteria such as the Readmissions Reduction Program have been added that determines the eligibility of a primary care provider being reimbursed through the Medicare/Medicaid program. These new requirements have led to new avenues of contention amongst healthcare professionals and, in some cases, new avenues for fraud and patient discrimination.

In 2013 an average of one out of eight Medicare patients are readmitted within a 30-day period which lead to the estimated costs of around $18 billion a year for Medicare patients alone. Hospitals will either be penalized or receive bonuses for their performance with readmissions. This program will encourage hospitals to concentrate on ways to improve coordinating transitions of care while improving the safety and quality of care provided. In order to

The Affordable Care Act was enacted to improve health care and to lower health care cost in America. The ACA developed different strategies to meet these goals called the “pay for performance” programs. These strategies are aimed at the different providers to improve quality care. The strategy that I selected is the “Hospital Readmissions Reduction Program” this program/strategy is also known as the HRRP and was begun in October of 2012. HRRP is aimed at hospitals and penalizes hospitals that have a high 30 day readmission rate. The penalties are assessed and based on a number of comparisons, those such as, performance, patient demographics, comorbidities and frailty.

In a world of budget cut and layoffs, medical corporations face new and different challenges in addition to helping and healing patients. I used to work as a medical biller in a physician’s office for five years and I experienced how difficult for the health care providers to get reimbursed. The government and the insurance companies have been limiting the budget towards the health care services. This action also affects the hospitals greatly because Centers for Medicare & Medicaid Services (CMS) and some policymakers have requested the hospitals to reduce the

Under the ACA there is a new method of payment called value-based purchasing (Yuh et al., 2015). Value-based purchasing focuses on aspects of quality care such as: patient safety, efficient care, and customer satisfaction. By providing quality care, physicians and hospitals are offered incentives that deter them from providing avoidable and pricey care (Yuh et al., 2015). Another way that the ACA is enhancing quality care is through the Readmissions Reduction Program. This program will decrease the reimbursements that the hospital will receive if there are a surplus of readmissions within a 30 day period. Overall, this will also improve quality of care by making sure that the patient is really ready for discharge when leaving the hospital and also strengthen efforts to reduce nosocomial infections (Aoughsten et al.,

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.

CMS 30 day-readmission penalties have motivated hospital to reevaluate discharge planning in hopes to reduce 30-day readmissions. Lopes et al. (2015) used the CRUSADE registry to evaluate causes associated with 30-day readmissions. This study included 36,711 patients with non-ST segment elevation myocardial infarction, age > 65 enrolled February 15, 2003 – December 29, 2006. This study evaluated comorbidities and cumulative incidence of readmissions over one year and found that readmissions with the very elderly having 50% mortality rate at 1 year which was thought to be impacted by co-morbidities, deconditioning and avoidance of core measure post-MI medications for various reasons. The final conclusion was that

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).

For years, healthcare costs have continued to increase in the United States and policymakers are constantly trying to find ways to reduce spending. According to reports, in 2011, about $900 billion out of the $2.6 trillion annual health care spending was wasteful spending. In the following year, there was a reported $690 billion wasted annually on healthcare. This wasteful spending is attributed to ineffective health care delivery, cost of adverse events, and poor care coordination that has led to avoidable readmissions (Lallemand, 2012). In the United States, readmissions are the highest amongst patients with chronic diseases accounting for about 90% of avoidable readmissions in 30 days after discharge, and costing the industry an estimated $17 billion. These readmissions are a result of inadequate discharge planning, lack of follow-up, and lack of education on disease management (Jayakody et al., 2016). Policymakers on the federal and state level have developed and implemented several programs, some varying state to state, to help reduce wasteful spending while improving quality of care.

Silverstein et al. in [24] were to develop and validate predictors of 30 day hospital readmission using a dataset of more than 29,000 patient’s record over the age of 65 and to compare prediction models that used alternate comorbidity classifications. In these paper they were capable to identify the risk factors of hospital readmission and calculated the risk of all the attributes by using prediction model. An important limitation of their study was that it did not directly include information on patients’ abilities to perform activities of daily living or other measures of physical function.