Readmissions and Adverse Events After Discharge For example, patients who are admitted under observation status are excluded. A classic study found that nearly 20% of patients experience adverse events within 3 weeks of discharge, nearly three-quarters of which could have been prevented or ameliorated. The HRRP is a start. government site. Talk to your care team if you or a loved one have questions during the transition home or after discharge. Nevertheless there are theoretical considerations whether a readmission is an indication of bad quality of care. Readmissions reduction program. We sought to characterize acute care hospital admissions and thirty-day readmissions in the Medicaid population through a retrospective Detailed review of outliersthose hospitals with high-high, high-low, low-high, and low-low risk-standardized mortality and readmission ratespromises to identify some drivers of variation in outcomes.60 Ultimately, a range of investigation is needed to develop more targeted, efficient, patient-centered interventions to improve transitions of care and patient outcomes. Risk-adjusted 30-day readmission measures are used to measure hospital performance. The excess readmission ratio, used to assign penalties to hospitals, adjusts for variation in hospitals volume and case mix. Early data suggest that HRRP implementation has been associated with a reduction in readmissions. In year two, 2,225 hospitals were penalized $227 million and represented 0.2% of total Medicare base payments to hospitals.17 In the second year 1,371 hospitals received lower penalties, whereas 1,074 hospitals received greater penalties; the average penalty decreased from 0.42% to 0.38%.17 The majority of hospitals penalized were large hospitals, teaching hospitals, and safety-net hospitals.18 In both years, the majority of hospitals receiving penalties served low-income patients. Hospital Readmissions Reduction Program - PMC - National Center for Review of draft national quality forum (NQF) report: risk adjustment for socioeconomic status or other sociodemographic factors. While specific attribution may be difficult to assess for individual cases, risk-standardized summary measures ideally should reflect comprehensive differences in care at the institutional level. In response, CMS instituted an algorithm to account for a wider range of planned readmissions starting in fiscal year 2014.9. This must include further inquiry into the nuanced relationship between readmission rates and socioeconomic factors, which are not currently included in risk adjustment methodology. Bradley EH, Curry L, Horwitz LI, Sipsma H, Wang Y, Walsh MN, Goldmann D, White N, Pina IL, Krumholz HM. [Accessed June 10, 2014]; Institute for Healthcare Improvement. FOIA Reducing Unnecessary Hospital Readmissions: The Role of the Patient Safety Organization Thirty-day readmissions--truth and consequences. A quality improvement approach to reducing hospital readmissions in official website and that any information you provide is encrypted The conditions initially included in the HRRP were acute myocardial infarction, heart failure, and pneumonia, which expanded in 2015 to include patients with acute exacerbation of chronic obstructive pulmonary disease and patients admitted for elective total hip arthroplasty and total knee arthroplasty.9 Conditions are identified based on primary discharge diagnosis, not the DRG assigned to the hospitalization. Centers for Medicare and Medicaid Services. In fact, the communication-focused dimension and process-of-care combo results in a 5-percentage-point reduction in 30-day readmission rates for an average U.S. hospital. The one thing I will never do is write a patient off. I love that I work as an advocate for my patients and can always customize or change and implement a new plan, if needed.. Reported here are results of a patient survey developed as part of regular hospital quality assurance activities. Much of the improvement was due to a new process comparing hospitals with similar socioeconomic demographics of their patients, rather than an average for all hospitals. Readmissions are costly, often doubling the cost of care for one of these episodes and that is why it is a key performance indicator. Let me end with someone I rarely quote, Dr. Ashish Jha of Harvards Global Health Institute, All of us as clinicians need to know that if policy makers are going to ask us to change how we practice medicine, it is helping us deliver better care to our patients.. The truth of the matter is that after eight years of this program, requiring significant effort by clinicians, hospitals and their staff, with penalties but no rewards, we do not know whether there are any beneficial effects for patients. Hospital readmission measures have been touted not only as a quality measure, but also as a means to bend the healthcare cost curve. Hospital Readmissions: Necessary Evil or Preventable Target For Quality For Medicare beneficiaries with inpatient stays, hospitals receive payment using the inpatient prospective payment system (IPPS). That means handling stress, getting good women's health care, and nurturing yourself. Reduce Avoidable Readmissions | IHI - Institute for Healthcare Improvement Last, but not least, it helps realign financial incentives to better reward the entire process of care; until 30-day bundled payments or ACOs replace the existing fee-for-service structure, the readmission metrics provide a necessary complement to the IPPS-DRG-based system. Eapen ZJ, Reed SD, Li Y, Kociol RD, Armstrong PW, Starling RC, McMurray JJ, Massie BM, Swedberg K, Ezekowitz JA, Fonarow GC, Teerlink JR, Metra M, Whellan DJ, O'Connor CM, Califf RM, Hernandez AF. 1 procedure in index admission: 78%. However, the retrospective nature of diagnosis ascertainment, the relatively poor performance of readmission risk models,20 and the wide-range of causes of readmission has limited the ability of hospitals to target patients at highest risk with tailored interventions. Unplanned hospital readmission is not always related to the previous visit. The .gov means its official. If incentivized appropriately, care systems can theoretically identify and ameliorate many of these contributing factors, thereby avoiding some unnecessary readmissions. are in effect starting April 24. Programs like the H2H Initiative,29 TARGET:HF,30 and Aligning Forces for Quality Network,59 which aim to share best practices between institutions and improve transitions of care, represent one important approach. Johns Hopkins Medicine hospitals track the number of patients with unplanned readmissions to the hospital within the 30 days after being discharged. The average penalty increased from 0.38% to 0.63% with 39 hospitals receiving the maximum 3% penalty.19 One reason for the increased and extensive penalties is the addition of two conditions. Rather than choosing a handful of care processes from the thousands that occur during a hospitalization, outcomes measuresif carefully constructed and fairly adjusted for case mixcan better reflect the overall performance of a health system. National patterns of use and effectiveness of angiotensin-converting enzyme inhibitors in older patients with heart failure and left ventricular systolic dysfunction. Unweighted, this database contains data from approximately 15 million discharges each year. the contents by NLM or the National Institutes of Health. Address for Correspondence: Larry A. Allen, MD, MHS, University of Colorado, School of Medicine, 12631 East 17, The publisher's final edited version of this article is available at, patient readmission, heart failure, health care, health policy. An acquired post-hospital syndrome has been described as a period of transient vulnerability, and a time of generalized risk of adverse health outcomes among patients who were recently hospitalized.57 During hospitalization, patients experience substantial stress in addition to disruption of their normal physiologic systems. Reducing hospital readmissionsespecially those that result from poor inpatient or outpatient carehas long been a health policy goal because it represents an opportunity to lower health care costs, improve quality, and increase patient satisfaction at once. AHRQ contracted with Boston University Medical Center to develop this toolkit to assist hospitals, particularly those that serve diverse populations, to re-engineer their discharge process. [Accessed May 25, 2014]; Medicare Payment Advisory Commission. On July 3, 2014, CMS issued a proposed rule that would add new quality reporting measures for the Medicare Shared Savings Program, including all-cause unplanned admissions for patients with heart failure and all-cause unplanned admissions for patients with multiple chronic conditions. September 7, 2019 Background Being discharged from the hospital can be dangerous. [Accessed June 20, 2014]; Eapen ZJ, McCoy LA, Fonarow GC, Yancy CW, Miranda ML, Peterson ED, Califf RM, Hernandez AF. This takes into account the hospital-specific effect, the probability of readmission for each patient, and the probability of readmission based on patient risk factors (age, gender, and selected clinical comorbidities). However, many events, including hip fracture, may be preventable. PDF Guide to Reducing Disparities in Readmissions - Centers for Medicare 1. Similarly, the American Heart Associations TARGET-HF program aims to improve quality, care transitions and outcomes of patients with heart failure by providing healthcare professionals with resources and materials targeting heart failure awareness, prevention, and treatment.30 The State Action on Avoidable Rehospitalizations is a multi-state initiative that engages patients, families, payers, and policy-level leaders in an effort to reduce rehospitalizations.31 Other initiatives such as Interventions to Reduce Acute Care Transfers have focused on the post-discharge environment and have aimed to reduce readmissions from skilled nursing facilities.32 The interest in successful transitional care strategies continues to grow and collaboration on a national level will assist hospitals in finding solutions that are most practical and effective.33, Many quality measures used for public reporting and pay-for-performance have historically focused on individual processes of care. 8 Specifically, transparency through public reporting provides an incentive to reduce readmission rates, to avoid "shaming." 1 Hospitals that have high readmission rates might deter future patients from choosing them. Patients who are discharged from the hospital are often at a high risk of being readmitted. [Accessed September 3, 2014]; Krumholz HM, Normand SLT, Keenan PS, Lin Z, Drye EE, Bhat KR, Wang YF, Ross JS, Schuur JD, Stauffer BD, Bernheim SM, Epstein AJ, Herrin J, Federer JJ, Mattera JA, Wang Y, Mulvey GK, Schreiner GC. Contributions are fully tax-deductible. An outcome measure, like readmission, is patient-centered with focus on what matters to patients, caregivers, payers, and society. [Accessed September 5, 2014]; Kansagara D, Englander H, Salanitro A, Kagen D, Theobald C, Freeman M, Kripalani S. Risk prediction models for hospital readmission: a systematic review. Vaduganathan M, Bonow RO, Gheorghiade M. Thirty-day readmissions: the clock is ticking. Why are Hospital Readmissions Bad? Is the patient correctly taking their medications? The reliance on episode-based payments entrenched silos of care, where acute care hospitals were largely incentivized to get patients only well enough to leave the hospital. A high-risk patient who dies in the hospital is not eligible for the readmission measure, and a patient who dies at home shortly after discharge from the index episode of care can never be readmitted. Numerous care transition processes reduce readmissions in clinical trials. Rockville, MD 20857 [Accessed May 25, 2014]; Joynt KE, Jha AK. The organizations quality and safety performance may have been impacted by the COVID-19 pandemic. Fact sheets: proposed policy and payment changes to the Medicare physician fee schedule for calendar year 2015. Epstein AM, Jha AK, Orav EJ. Deciding how to prioritize these will require ACOs to balance those most in need versus those most likely to benefit. Bundled Payments For Medical Conditions Show No Savings, Hospitals Excel at 'Learning for the Test'. ratio >1.0) and any ratio above that will generate a penalty; the actual dollar amount of the penalty is then determined by calculating 1 minus the aggregate payments for excess readmissions divided by the aggregate payments for all discharges, and multiplying this readmissions adjustment factor by a hospitals base DRG payment.9. Hospital volume can play a significant role in the assessment of hospital performance. In a large retrospective cohort study conducted in the United States, patients with an AMA discharge were more likely to experience 30-day hospital readmission compared with routine discharge (25.6 versus 11.5 percent), and AMA discharge was an independent predictor of readmission across a wide range of diagnoses [ 97 ]. Longer index hospitalizations expend more resources and keep patients from being home; yet, there appears to be a trade off in terms of readmission rates. With most efforts focused on reducing readmissions, there is a potential to overlook the stress and vulnerability patients experience. Joe', A Conversation Between ACSH and Great.com, Date Rape Redux: Deadly Fentanyl Used for Robberies, 5 Interesting (But Ultimately Useless), Bizarre Chemistry Factoids, NPR Frets About 'Weight Stigma' As Doctors Fight Childhood Obesity, Ignore the News: Earth Is Getting Cleaner and Healthier, Another Lousy Anti-Vaping Study, Debunked, Insanity: Doctor Gives Teenage Son Cigarettes to Break Vaping Habit, Underwater Suicide? For example, Kaiser Permanente has shown a reduction in 30-day all-cause readmission rates with their transitional care programs and bundling elements.41 Similarly, Colorados Accountable Care Collaborative, which pilots health care payment and delivery reforms through Medicaid, was able to show 8.6% fewer hospital readmissions than non-participating Medicaid enrollees within its first year.42, ACOs are far from perfect. Frontiers | Factors Associated With Hospital Readmission of Heart He went on to point out that. Burwell SM. Zhang W, Watanabe-Galloway S. Ten-year secular trends for congestive heart failure hospitalizations: an analysis of regional differences in the United States. This suggests that the domains of readmission and mortality are largely unrelated and that mortality and readmission are the result of somewhat different causesthus responsive to different interventions. These additions to the quality reporting standard for the 2015 reporting period will further align the Medicare Shared Savings Program with the HRRP.43, Despite the above-mentioned successes, there has been considerable discussion regarding the methodology for calculating excess readmissions. There are plausible reasons that the quality domains of mortality and readmission are distinct. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. This guide provides evidence-based strategies to reduce readmissions and can be adapted or expanded to address the transitional care needs of the adult Medicaid population. The Nationwide Readmissions Database (NRD) is part of a family of databases and software tools developed for the Healthcare Cost and Utilization Project. And those improvements were in nearly every county in New York. Many planned readmissions, such as ICD placement, often represent high-quality care and should not be counted against hospitals. With limited resources, ACOs must determine which quality measures are most important. The key question for the outcome measure is not whether an individual readmission is appropriate, but whether hospital-level variations in readmission rates are driven by preventable events. Helping Smokers Quit: The Science Behind Tobacco Harm Reduction, Foods Are Not Cigarettes: Why Tobacco Lawsuits Are Not a Model for Obesity Lawsuits, The Prevention and Treatment of Osteoporosis: A Review. Telephone: (301) 427-1364, AHRQ Publishing and Communications Guidelines, Evidence-based Practice Center (EPC) Reports, Healthcare Cost and Utilization Project (HCUP), AHRQ Quality Indicator Tools for Data Analytics, United States Health Information Knowledgebase (USHIK), AHRQ Informed Consent & Authorization Toolkit for Minimal Risk Research, Grant Application, Review & Award Process, Study Sections for Scientific Peer Review, Getting Recognition for Your AHRQ-Funded Study, AHRQ Research Summit on Diagnostic Safety, AHRQ Research Summit on Learning Health Systems, National Action Alliance To Advance Patient Safety, Taking Care of Myself: A Guide for When I Leave the Hospital, Designing and Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions, Project BOOST (Better Outcomes for Older Adults through Safer Transitions), Readmissions and Adverse Events After Discharge, Reducing Unnecessary Hospital Readmissions: The Role of the Patient Safety Organization. Preventable readmissions to hospital are frequent, costly, and demanding on healthcare resources; they also represent threats to patients' safety such as preventable adverse drug events, healthcare associated infections, procedural complications, and avoidable exacerbations in disease states or functional declines. Countries with longer length of stay for heart failure hospitalizations appear to have lower rates of readmission within 30 days. Iterative improvements to the outcome measures are vital to their success. One article suggests methods to reduce the trauma experienced by patients in the hospital, with interventions such as ensuring the patient receives enough rest and nourishment, encouraging activity, eliminating unnecessary testing and procedures, and decreasing random medication modifications.58 A focus not only on transitional care, but the hospitalization itself may help reduce the post-discharge syndrome, and its potential to increase readmissions.58. A brief report looking at Hospital Compare heart failure data revealed a statistically significant inverse correlation between higher risk-standardized hospital 30-day readmission rates with lower risk-standardized hospital 30-day mortality rates.48 A subsequent and more detailed analysis of hospital-level risk-standardized readmission and mortality rates demonstrated a modest inverse association between mortality and readmission rates in heart failure (correlation coefficient -0.14) and not throughout the entire range of performance; there was no relationship in the acute myocardial infarction and pneumonia rates.49. Officials estimate $17 billion of that comes from potentially avoidable readmissions.2 To address this issue, the Centers for Medicare & Medicaid Services (CMS)through Congressional direction and Administration initiativesimplemented the Hospital Readmission Reduction Program (HRRP) in 2012. Hospital readmissions are associated with unfavorable patient outcomes and high financial costs.1, 2 Causes of readmissions are multi-factorial and rates vary substantially by institution.3, 4 Historically, nearly 20% of all Medicare discharges had a readmission within 30 days.1 The Medicare Payment Advisory Commission (MedPAC) has estimated that 12% of readmissions are potentially avoidable. New masking guidelines There are several explanations as to why readmission and morality data are inversely related in heart failure. How Toxic Terrorists Scare You With Science Terms, Adult Immunization: The Need for Enhanced Utilization, IARC Diesel Exhaust & Lung Cancer: An Analysis. So this finding may represent a small sample size or regression to the mean over time rather than a change in outcomes. Evidence based processes to prevent readmissions: more is better, a ten Was she over-diuresed or over-sedated? Johns Hopkins Medicine attempts to fully prepare all patients before discharge and offers many programs for patients who need extra support after returning home. This initial algorithm penalized hospitals for any other planned admission including such procedures as implantable cardioverter-defibrillators (ICD) in heart failure patients. Frequently asked questions about billing Medicare for transitional care management services. Readmission rates at 7, 14, and 30 days were 2.2%, 3.7%, and 5.6%. The pivot to an outcome measure highlighting risk-standardized hospital readmission rates has a number of appealing characteristics. 6 Reasons Readmissions to Hospital Are Bad for Seniors Readmissions, Observation, and the Hospital Readmissions Reduction What is Johns Hopkins Medicine doing to continue to improve? Federal Register. Door-to-drug and door-to-balloon times: where can we improve? Bill Hammond writing on New York's hospital readmission inEmpire Centernoted: modestly improved grades for reducing avoidable admissionsbased on the newest release from Medicare. New HHS data shows major strides made in patient safety, leading to improved care and savings. To provide holistic care to . Only 17% of hospitals, groups 1 and 3, were getting worse (3% were unchanged). National Library of Medicine Conversely, not accounting for the socioeconomic environment disproportionately penalizes hospitals that care for disadvantaged populations, thereby widening disparities in care. Trends in hospitalizations and outcomes for acute cardiovascular disease and stroke, 1999-2011. Why did the patient fall? U.S. Department of Health & Human Services. However, CMS has provided additional funding for transitional care efforts through complementary programs. Did she undergo a physical therapy evaluation prior to discharge and have appropriate home support? Medicare to start paying doctors who coordinate care for patients. There was an inverse correlation between country-level mean length of stay and readmission (r=0.52).39 Similar trends were observed across U.S. study sites. The more than two-fold variability in risk-standardized readmission rates between institutions is at face value a strong argument that many readmissions are preventable. [Accessed May 25, 2014]; American Heart Association. Group 3 when compared solely with their peers demonstrated better than average improvement leaving only the highest socioeconomic group (Group 1) with a greater penalty compare to their peers. and transmitted securely. The Economic & Emotional Cost of Hospital Readmissions - HealthStream Rodin D, Silow-Carroll S. Medicaid payment and delivery reform in Colorado: ACOs at the regional level. Hospital readmission rates are increasingly used for both quality improvement and cost control. Under such a scheme, hospitals that care for sicker or more socioeconomically vulnerable populations would be more heavily rewarded for improvements in discharge planning and care coordination to prevent short-term readmissions, with decreased penalties for the fact that their patients may need additional hospital services over the long run.54, The HRRP includes all unplanned readmissions within 30 days of hospital discharge. A hospital readmission is a patient who is readmitted within 30 days of being originally discharged, according to the Center for Medicare and Medicaid Services (CMS). Quality and safety performance during COVID-19. Reducing hospital readmissions is a way to improve care and reduce avoidable costs. Healthcare Cost and Utilization Project Below are some factors that cause hospital readmissions. United States Department of Health and Human Services. Patients are most at risk to return to the hospital immediately following discharge. This is often also known as readmission to the hospital and readmission rates are an important measure in the US healthcare system. HHS Vulnerability Disclosure, Help Johns Hopkins Medicine hospitals track the number of patients with unplanned readmissions to the hospital within the 30 days after being discharged. Readmission, for the purposes of Medicare, is a hospital stay that has inpatient orders and that happens within 30 days of another hospital admission. Affordable Care Act update: implementing Medicare cost savings. Because they only directly control some of the factors and have to coordinate the rest of the care with other institutions or individuals it is hard to improve quickly. Some say it is not. Benchmark Source: Readmission rates are compared by the Centers He has over 25 years of experience as a vascular surgeon. Readmission to the hospital could be for any cause, such as worsening of disease or new conditions. Hospital 30-Day pneumonia readmission measure: methodology. There are already examples of ACOs working to reduce readmissions. 1, 3, 4, 6-12 Finally, some have suggested t. Report to the Congress: promoting greater efficiency in Medicare. Do countries or hospitals with longer hospital stays for acute heart failure have lower readmission rates? All-cause admission rates have been found to be substantially associated with regional differences in all-cause readmission rates.50 An alternative explanation is that hospitals with higher mortality rates have fewer patients to readmit. Hence, if a hospital has a lower mortality rate, then a greater proportion of its discharged patients are eligible for readmission. Note: A higher score indicates a better performance. Additionally, hospitals must have at least 25 initial hospitalizations for a diagnosis to be measured. As such, a lower readmission rate could be a consequence of increased mortality. Since October 1, 2012, the HRRP has required CMS to reduce payments to IPPS-participating hospitals with excess readmissions.9 Excess readmissions are defined by measuring a hospitals readmission rates, adjusted for age, sex, and co-existing conditions, which are then compared to the national averages.10 The penalty is a percentage of total Medicare payments to the hospital; the maximum penalty has been set at 1% for 2013, 2% for 2014, and 3% for 2015. National Quality Forum. Post-hospital syndrome--an acquired, transient condition of generalized risk. Preventing hospital readmissions: the importance of considering Among the 14 published models that target all unplanned readmissions (rather than readmissions for specific patient groups), the 'C statistic' ranges from 0.55 to 0.80, meaning that, when presented with two patients, these models correctly identify the higher risk individual between 55% and 80% of the time. Starting January 2013, Transitional Care Management Services provided two new current procedural terminology (CPT) codes.23, 24 These CPT codes cover services provided to a patient whose medical or psychosocial problems require moderate or high-complexity medical decision making during transitions in care. Similarly, CMS will begin to pay physicians for the provision of chronic care management services, further incentivizing the coordination of inpatient and outpatient care.25, 26. In addition, there are other correlating factors, including socioeconomic . Predictors of 30-day readmissions have been primarily identified using medical claims data. While these codes provide a higher billing for post-discharge visits either within 7 or 14 days of dischargedepending on the codethey go to the outpatient provider and thus do not help offset HRRP penalties unless there is financial integration of inpatient and outpatient care. An official website of the United States government. Project BOOST offers a discharge bundle consisting of medication reconciliation forms, a checklist for patient-centered hospital discharge education, and a checklist for postdischarge continuity checks. AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. Endorsed by the National Quality Forum, the risk adjustment measures are based on hierarchical logistic regression models. van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Although most agree that preventable readmissions should be avoided for the patients' sake, many disagree on what constitutes "preventable," saying readmissions may not reflect quality and arguing reduced reimbursement actually might be unfair.

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