Linda Steffens BSN RN CCRN Stacy Jaeger MS APRNBC Susan Herrmann MSN RN Kimberly Thomas BSN RN MSM CCRN Katherine Barker MSN RN MSRN CPN Audrey Eggleston BSN RN Delnor Hospital Geneva IL The ID: 498522
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Hospital Readmissions: Suggested Strategies to Prepare for The Move Toward Pay for Performance
Linda Steffens BSN RN CCRN
Stacy Jaeger MS APRN-BC
Susan Herrmann MSN RN
Kimberly Thomas BSN RN MSM CCRN
Katherine Barker MSN RN MSRN CPN
Audrey Eggleston BSN RN
Delnor Hospital Geneva, ILSlide2
The trend of more stringent standards affecting healthcare reimbursement is accelerating. Decreased reimbursement for some readmitted patients as well as bundling payment to include the thirty day time period post discharge have been proposed by CMS and
gained
congressional and administrative interest. This PowerPoint suggests possible strategies that nurse leaders might employ to pro-actively prepare for the likely consideration of readmission as a pay for performance indicator.
OVERVIEWSlide3
History
Medicare and third party payers have traditionally reimbursed healthcare providers on the basis of services rendered
Only a few restrictions applied i.e., readmission on the same day as discharge could not be resubmitted as a new episode of careSlide4
Current Proposals
The Senate Finance Committee has identified readmission within 30 days as a potential source of avoidable government expenditure
CMS has expressed interest in bundling payment for episodes of care to include a hospitalization and the subsequent thirty day time period.Readmission within 30 days of discharge is likely to be a future reportable pay for performance indicatorSlide5
Suggested Proactive Strategies for Nursing
1. Obtain baseline information regarding readmission rate/reasons for your institution
2. Initiate real time evaluation of patients who are currently being readmittedSlide6
Strategy One
Obtain baseline information regarding readmission rate/reasons for your institutionSlide7
Establishing Your Baseline
Perform a retrospective chart review of records patients who have been readmitted within 30 days of discharge
Provides baseline to gauge improvement effortsProvides data gathering proficiency for possible mandatory reporting
Audit strategy should include enough months to allow for seasonal variationSlide8
Basic Audit of Identified Readmission Record
Diagnosis
Provider
Payment Type—Medicare, Insurance, Private Pay
Days between discharge and readmission**
Probable reason for readmission
**
It has been suggested by IHI that examining readmissions that occur within 7 days of discharge may provide insight into the effects of tighter patient flow management and reveal over aggressive attempts to decrease LOS and possible premature dischargeSlide9
Possible Reasons for Readmission
Planned or Unplanned
(
ex chemotherapy or staged surgeries/procedures are planned)
Unrelated problem?
Secondary Infection?
Misdiagnosed on first admission?
Non Compliance?
Poor understanding of discharge plan?
Original discharge plan inadequate?
Premature discharge?
Error or Omission in discharge instructions?
Deterioration in a chronic condition?
Social Issues—deficient home resources to allow successful transition of care ?
On-going substance abuse issues?
Failure of outpatient care provider to follow through on discharge instructions?
Adverse Medication Reaction?Slide10
Make sure to record all readmission reasons that you discover—you may see patterns in your results that are specific to your institution. For example, our institution found that social factors were the leading reason for unplanned readmissions while other hospitals have noted infection, premature discharge, medication reactions, etc. as their leading cause.Slide11
Baseline Data Useful to
Identify institutional problems in the discharge process
Provide statistical basis to project potential revenue impact of proposed bundled paymentsInitiate a Plan for ImprovementSlide12
Planning to Improve
The Institute for Healthcare Improvement ( IHI .org) has free on line education and improvement trackers to help hospitals improve their processes and quality
Their step by step Improvement Tracker shows leaders how to set aims, define measurements, and measure performance.Trackers can be maintained online, anonymously if you wish, and provide graphing of your hospital specific data (example tracker provided in this supplemental digital content)Slide13
Strategy Two
Real-time evaluation of current patients readmitted within 30 daysSlide14
Real Time Evaluation
When retrospective chart review has been completed, move identification of readmission within 30 days to a real time activity
Perform standardized review of previous discharge paperwork and evaluate reason for discharge using methodology devised when performing baseline metricsNote Readmission within Thirty Days in the patient individualized care plan and nurse to nurse handoffSlide15
Discharge Planning
Utilize information yielded from review to improve discharge planning
Encourage collaboration of patients, discharge planners, physicians, direct care nurses, familiesSlide16
Discharge Process
Evaluate daily discharge process in real time
Consider “second pair of eyes” for discharge medication reconciliation and discharge instructionsConsider collaboration with CNS for all dischargesConsider eliminating standardized discharge call backsConsider individualized discharge callback plan as part of the discharge process with identification of patients at risk for readmission