1. 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, IL

2. 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. OVERVIEW

3. 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 care

4. 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 indicator

5. 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 readmitted

6. Obtain baseline information regarding readmission rate/reasons for your institution

7. 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 efforts Provides data gathering proficiency for possible mandatory reporting Audit strategy should include enough months to allow for seasonal variation

8. 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 discharge

9. 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?

10. 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.

11. Baseline Data Useful to Identify institutional problems in the discharge process Provide statistical basis to project potential revenue impact of proposed bundled payments Initiate a Plan for Improvement

12. 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)

13. Real-time evaluation of current patients readmitted within 30 days

14. 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 metrics Note Readmission within Thirty Days in the patient individualized care plan and nurse to nurse handoff

15. Discharge Planning Utilize information yielded from review to improve discharge planning Encourage collaboration of patients, discharge planners, physicians, direct care nurses, families

16. Discharge Process Evaluate daily discharge process in real time Consider “second pair of eyes” for discharge medication reconciliation and discharge instructions Consider collaboration with CNS for all discharges Consider eliminating standardized discharge call backs Consider individualized discharge callback plan as part of the discharge process with identification of patients at risk for readmission