Potentially Preventable Readmissions: Overview of Definitions and Clinical Logic HSCRC April 6, 2010 Elizabeth McCullough, 3M Health Information Systems 6 April 2010

2 PPR-Potentially Preventable Readmissions PPR Definition: A Potentially Preventable Readmission (PPR) is a readmission that is clinically-related to the initial hospital admission that may have resulted from a deficiency in the process of care and treatment or lack of post discharge follow-up rather than unrelated events that occur post discharge (broken leg due to trauma), or readmissions that were planned at the time of the discharge from the initial admission. Clinically-related: Clinically-related is defined as a requirement that the underlying reason for following a prior hospital readmission be plausibly related to the care rendered during or immediately following a prior hospital admission.

3 Why PPRs What might cause a PPR to happen? A readmission is considered to be clinically related to a prior admission and potentially preventable if there was a reasonable expectation that it could have been prevented by one or more of the following: –The provision of quality care in the initial hospitalization –Adequate discharge planning –Adequate post-discharge follow up –Improved coordination between inpatient and outpatient Health Care Teams **Identifying Potential Preventable Readmission Article, Health Care Financing Review Fall 2008

4 The Identification of Potentially Preventable Readmissions (PPRs) Three Phases Phase I: Identify Excluded Admissions and Non Events Phase II: Determine Preliminary Classification of Remaining Admissions Phase III: Identify PPRs and Determine Final Classification of Admissions

5 Phase I : Identify Excluded Admissions and Non-events

6 Exclusions from the readmission methodology No possible clinical relation to the index admission (cholecsytectomy two weeks after total hip replacement); Not clearly related to improvement opportunities in either hospital or outpatient care (e.g. readmissions for malignancy care or a motor vehicle accident) If any of the following conditions apply to the initial admission, a subsequent readmission is globally excluded from consideration as a PPR –Admissions for which follow-up care is intrinsically extensive and complex Major or metastatic malignancies treated medically Multiple trauma, burns –Discharge status indicates limited hospital & provider control Left against medical advice Transferred to another acute care hospital –Neonates –Other exclusions Specific eye procedures and infections Cystic fibrosis with pulmonary diagnoses –Died – not included as candidate initial admissions (denominator) PPR Definition Manual Appendix E for List of Globally Excluded APR DRGs PPR Definition Manual Appendix G for List of Major and Metastatic Malignant Diagnoses

7 Non Event Admissions Admissions for certain non-acute care services during the interval between a prior admission and subsequent admission do not affect the classification of the subsequent admission List of Non Event APR DRGs 860 Rehabilitiation, 862 Other Aftercare & Convalescense, 863 Neonatal Aftercare List of Non Event Discharge Status Codes

8 Phase II: Determine Preliminary Classification of Remaining Admissions

9 Example Readmission

10 Examples of a Non Events Admissions that get “ignored”

11 Transfer Example Transfer To Another facility: Transferred from To Another facility:

12 Excluded and Only Admissions Example

13 Phase III: Identify PPRs and Determine Final Classification of Admissions

14 Clinically Related Medical Readmissions Medical readmission for a continuation or recurrence of the reason for the initial admission, or for a closely related condition. Medical readmission for an acute decompensation of a chronic problem that was not the principal reason for the initial admission, but may be related to care either during or after the initial admission. Medical readmission for an acute medical condition or complication that may be related to or may have resulted from care during the initial admission or in the post- discharge period after the initial admission.

15 Clinically Related Surgical Readmissions Readmission for a surgical procedure to address a continuation or a recurrence of the problem causing the initial admission. Readmission for surgical procedure to address a complication that may be related to or may have resulted from care during the initial admission.

16 Methodology for Selecting Potentially Preventable Readmissions (PPRs)

17 PPR Matrix v27 98,596 cells in 314 Initial Admission (IA) APR DRG x 314 Readmission (RA) APR DRG Matrix 22% clinically related IA by RA APR DRG combination 37% globally excluded IA by RA APR DRG combination 41% DRG specific clinical exclusion IA by RA APR DRG combination

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19 Phase III- Identify PPRs and Determine Final Classification of Admission

20 Determine if a Readmission Chain is Terminated Reasons for terminating a readmission chain –Admissions with a discharge status of “died” Still classified as PPR, but PPR terminates the readmission chain –Excluded admissions Any subsequent admission may be classified as an initial admission and start a new chain –Transfers to another acute care facility Considered a PPR Transfer readmission will terminate the readmission chain and no subsequent admission will be part of the readmission chain Phase III- Identify PPRs and Determine Final Classification of Admission

21 Re-classify Readmission when not Clinically Related to Initial Admission Phase III- Identify PPRs and Determine Final Classification of Admission

22 Re-classify Initial Admission when Readmission not Clinically Related Phase III- Identify PPRs and Determine Final Classification of Admission

23 Reasons for Readmission Florida, All Patients, ReasonReason DescriptionCountPercent 1Medical – continuation of initial problem57, A Medical – decompensation of chronic problem (ambulatory care sensitive condition)39, BMedical – other decompensation18, Medical – complication of previous admission76, Surgical – continuation of initial problem8, Surgical – complication of initial admission6, AMental health, non-MH initial admission6, BSubstance abuse, non SA initial admission1, C Mental health or substance abuse readmission, initial admission for MH or SA18, Total233,

24 Top 15 represents 35% of all initial admissions followed by PPRs Top 15 Initial Admissions followed by one or more PPR

25 Top 15 PPRs represents 42% of charges on PPRs for a 30 day readmission time window Top 15 Reasons for PPRs

26 Top Five PPR Reasons for an Initial Admission of Heart Failure

27 Summary of PPRs Determines if there is a probable clinical relationship between an initial hospitalization and a readmission Identify admissions that are potentially preventable Identify admissions that are “at risk” for being followed by a potentially preventable readmission Identify chains of readmissions that are all related to the same prior admission Determine numerator and denominator for computing readmission rates (dependent variable)