Helping patients stay out of the hospital once they’ve been discharged has been a longtime priority for many hospitals and health networks. Now it has become a financial imperative too, thanks to provisions of the Patient Protection and Affordable Care Act that set penalties for hospitals with higher-than-average rates of avoidable readmission for patients with specified conditions.

Beginning in October 2012, the Centers for Medicare and Medicaid Services (CMS) has the authority to withhold reimbursements from hospitals with excessive readmission rates. Because they are among the most prevalent reasons for readmission, CMS will initially focus on preventable readmissions for congestive heart failure (CHF), acute myocardial infarction (AMI) and pneumonia.

By 2015, penalties most likely will extend to all seven of the top conditions that accounted for 30% of Medicare readmission spending in 2008. Hospitals are not being tasked with reducing all readmissions, only those that could be prevented by taking steps during and following the inpatient stay. By targeting these readmissions to avoid penalties, however, organizations will likely use its resources more effectively and improve care for all patients.

Develop a Readmission Reduction Strategy

Developing a readmission reduction strategy that effectively coordinates both inpatient and ambulatory care is essential. Web2pro’s approach focuses on the coordination of handoffs and aligns with the criteria endorsed by the Agency for Healthcare Research and Quality (AHRQ) (Re-Engineered Discharge), which incorporates 11 “mutually reinforcing components” that define good coordination of care through all transitions that may occur.

  • Primary resources include inpatient and outpatient readmission reduction care teams (RRCTs), or their equivalent.
  • For the inpatient team, critical steps include an initial risk assessment, patient education, self-management training, post-admission and pre-discharge medication reconciliation and setting up post-discharge appointments.
  • Upon discharge, the Ambulatory-RRCT assumes responsibility for appointment coordination and ensuring the primary care physician receives the patient’s discharge summary and any outstanding test results.
  • Post-discharge contact enables monitoring of patient progress and medication adherence.

Technology and performance analytics can help identify, hard-wire and optimize process improvements and streamline workflow. also can help make the necessary connections with the patient and among caregivers for transitions and follow-ups across the settings of care.

Now is the Time

Identify Factors that Increase Risk

Because the factors that increase readmission risk for specific conditions are clinical, socioeconomic and environmental, developing a predictive model typically requires data from disparate sources across the care continuum. Accurate analysis of the data requires the ability to integrate claims and clinical encounter data to measure readmissions regardless of where they occurred. An automated solution that can integrate data, apply business logic and enable stakeholders to analyze critical aspects of the readmission management process is essential.

Regardless of tools used, it is imperative to determine patients who are at risk for readmission prior to their current hospital stay and to leverage relevant information at the point of care. By evaluating readmissions holistically, organizations can design care systems to support financial viability, improve outcomes and increase patient satisfaction.

Understand and Measure the Financial Implications of Readmission

To understand the financial implications of readmission, organizations must be able to evaluate total cost of care across the continuum and balance that with other factors that impact population health. This evaluation requires integration of data from the hospital encounter, physician practices, home care, long-term care and other settings, as well as the ability to analyze variable costs within each phase of care and to model revenues as care shifts to different settings.

Effectively managing readmissions may require a new set of measures. For example, as bundled payments become the norm, total cost of care becomes the critical measure rather than average daily census, and ratio of inpatient to outpatient days may become the benchmark. The contribution margin for aggressive case management may be low, but it can reduce the total cost of care. By evaluating readmissions holistically, organizations can design care systems to support financial viability, improve outcomes and increase patient satisfaction.

Support Reform’s Goal of Quality, Affordable Healthcare for All

Readmission management is a patient-centered initiative designed to also help hospitals use resources more effectively and avoid penalties. Of course, financial penalties aren’t the only reason to implement a plan to reduce preventable readmissions — most hospital leaders and clinicians agree it’s not even the best one. Reducing preventable readmissions is tied to the overarching goal of healthcare reform: quality, affordable healthcare for all Americans.

Web2pro believes health IT can help close the gaps between the healthcare providers that are part of the patient’s care continuum, assist them in proactively focusing on at-risk patients, and support patient education and engagement. By reducing these preventable readmissions, an organization will improve care for all patients, including those whose readmissions were necessary and unavoidable. At the same time, it will support the organization’s business health as it addresses the increasing quality and cost challenges over the next decade of health reform.

AHRQ’s Project Red – 11 Components to Reduce Readmissions

The Agency for Healthcare Research and Quality (AHRQ) Project RED (Re-Engineered Discharge) incorporates 11 “mutually reinforcing components” that define good coordination of care through all transitions that may occur. Hospitals need to map improvement efforts to these 11 components and dedicate the resources necessary to operationalize an effective readmission reduction program. Note that many of the components are complementary processes that apply at multiple times and places across the continuum.

Project RED Components

  • Reconcile medications
  • Reconcile the discharge plan with national guidelines
  • Schedule follow-up appointments
  • Report outstanding tests
  • Coordinate post-discharge services
  • Provide written discharge plan
  • Provide instructions for managing problems
  • Deliver patient education
  • Assess and document patient understanding
  • Communicate discharge summary to the PCP
  • Schedule and complete telephonic outreach within 24 hours of discharge
Fredric Leary

About the author

Dr. Fredric Leary is Senior Medical Director for Web2pro Health Solutions, having served in a leadership role with the company since 2007. He has 15 years of experience as a Family Physician, with practice experiences including private practice, rural health clinic, employed urban physician, and a Family Medicine residency teaching position. His professional interests and practice designs focus on continuous quality improvement and patient safety. Dr. Leary is the past president and Chair of the Board of the Illinois Academy of Family Physicians, and is a fellow of the American Academy of Family Physicians.