1. Hospital Readmission, the Penalties, and the Physical Therapist role in Reduction 

2. The Objectives
Identify the specific regulatory reform involving the focus on prevention of readmission and the penalties on acute care hospitals
Identify key factors that contribute to the avoidable readmission
Discuss the best practices identified in the reduction of preventable readmissions
Discuss the role of the physical therapist in various strategies to improve care coordination, enhance discharge planning, educate patients in self-care, and prompting follow-up care
Discuss the clinical and financial application of strategies along with the opportunities for physical therapist in the current regulatory environment

3. The Reform Affordable Care Act includes Medicare reforms:
A key strategy is improving the quality of care and cost containment
Centers for Medicare and Medicaid Services (CMS) determined that higher hospital readmission rates are linked to higher costs and results in lower quality of care to Medicare beneficiaries
One of the key provisions is to reduce the number of unplanned hospital readmissions
The projected savings over 10 years = 8.2 Billion

4. Key Drivers of this Reform
CMS reduced Medicare payments to hospitals with relatively high preventable readmissions beginning in Oct 2012.
Initially 3 key conditions will be monitored:
Heart failure
AMI
Pneumonia
Possible future readmission measures for FY 2015:
Additional conditions identified in 2007 MedPAC report: COPD, CABG, PTCA
Other conditions determined to be appropriate by the Secretary—possibilities include TKR and THR
CMS is making public the 30 day admission rates for hospitals on its Hospital Compare Website. 30 day readmission rates are shown for heart attack, heart failure, and pneumonia.

5. Other Reform factors to consider:
CMS will begin requiring reporting for 30 day Comprehensive All-Cause-Risk Standardized Readmission Measure in FY-2014 in the Inpatient Rehab Setting. This setting is the first for “all- cause” readmission measure requirement.
Hospitals can actually lose money by decreasing hospital readmissions. Hospitals not functioning at capacity can generate revenue via increased patient days.
Planned Readmission are not considered in current criteria. These admissions are intentional readmissions scheduled within 30 days of discharge as a planned part of the patients plan of care (i.e. –planned revision procedures).

6. The Facts:
While the rate of hospital readmissions may vary significantly– the rate of avoidable admissions do not (Joynt KE, 2011).
The growing body of evidence suggests that the primary drivers for variability in hospital readmission rates are the composition of a hospitals patient population and the resources of the community. Just 27% of readmissions were deemed preventable in a recent systematic literature review (van Walraven, 2011).
Hospitals with a low mortality rate among patients with heart failure have higher readmission rates (Gorodeski, 2010).
Improved access to primary care and improved care coordination has been linked to increased rates of readmission and increased patient satisfaction (Weinberger, 1996).
The causes for readmission occurring within 3-7 days after discharge are much more under the hospitals control than those within 30 days (van Walraven,2011)

7. Direct Correlations Specifically sighted:
The presence of a primary care physician
The presence of follow-up visits
Spouse and/or family support
Insurance Coverage
Longer Hospital stays

8. What works?
Individual strategies have been found to have modest affects (less than half a percent) on readmission, but facilities utilizing a multi-faceted approach saw statically significant increases with each additional strategy (Bradley, 2013).
Strategies that were associated with lower hospital 30 day readmission rates included the following:
Partnering with community physicians or physician groups to reduce readmission
Partnering with local hospitals to reduce readmissions
Having nurses responsible for medication reconciliation
Arranging follow-up appointments before discharge
Having a process in place to send all discharge paper or electronic summaries directly to the patient’s primary physician.
Assigning staff to follow up on test results that return after the patient is discharged

9. The Road to Reduced Readmissions
Hospital
Coordinated Hospital Discharge Information Exchange
Detailed Discharge Instructions
Education regarding medications and self-monitoring
Schedule follow-up visit with primary care physician
SNF
Day 1 Rehabilitation Evaluations
Staffing RN, Dietary, Pharmacist
QI Project Requirement for Re-admission Prevention
EMR Requirement
Home Health Agency
“Call Us First” Patient Education Requirement
Tele-monitoring
“Front Loading” concepts initiative
EMR requirement
The goal of reducing re-admissions is difficult to achieve without the participation of those outside the hospitals provider number. Along with vender management there has been an accompanying decline in the access provided to step-down providers.
The ACO type model that has been on the forefront of discussions and in the initial development would give added control to the hospital system.
Programs that include remote monitoring and structured telephone support are an affective measure in the management of chronic heart failure (Robyn A Clark, 2007).

10. Where do the Therapist fit in? EVERYWHERE!!
In the hospital DRG based system therapy plays a primary role in the assessment and appropriate triage of a patient by need…not just diagnosis.
Therapy is the central driver in RUG based payment system in skilled nursing facilities.
The HHRG score in home health utilizes therapy and nursing components in determination of home health reimbursement.
These factors allow Physical Therapist to participate in the discussions at every level of care.
Hospital System
SNF
Home Health

11. The Hospital Role Important Steps: Plan for discharge initiates day 1
Plan of care is communicated to other providers and is patient centered.
Equipment order and delivery in adequate time.
Advising the patient on prognosis of function, participation, and discharge locations.
Insure the proper discharge information is relayed to the next provider. Call Report
Appropriate Discharge: Something we do very well!!
Patients were 2.9 times more likely to be readmitted when the discharge recommendations were not implemented. (Smith B.A. et al 2010)
Communication: Appropriate hand-off by the physical therapist of record has been established as a Standards of Practice for Physical Therapy.
HOD P
HOD S
Joint Commission has also sighted this as an area of need for improvement

12. Skilled Nursing Specifics
Clinical Consideration
On the Horizon:
Day 1, Day 1, Day 1
Promote both staff and patient involvement in care.
Learn the signs and symptoms: dyspnea, crackles, peripheral edema, cardiac response to therex.
Identify and focus: Dietary, Pharmacy, Nursing, Treatment Rx (resistance training)
Call Report
The US Department of Health and Human Services cites analysis by the Medicare Payment Advisory Commission which indicates that nearly 14 percent of individuals on Medicare discharged from a hospital to a skilled nursing setting are readmitted to the hospital for conditions that could potentially have been avoided. The HHS 2014 budget proposal recommends reducing payments by up to three percent for skilled nursing facilities that are determined to have high rates of preventable hospital readmissions. The proposed penalties would take effect in 2017, with an estimated $2.2 billion in savings over 10 years.

13. Home Health Specifics Clinical Considerations REMEMBER!!!
At Risk Patients are easy to identify:
The presence of a primary care physician
The presence of follow-up visits
Spouse and/or family support
Insurance Coverage
Front Loading--- remember the 3-7 day window
Call—ask for report
Ask the right questions— church + hair appoint=danger, danger
How does weight and blood pressure fit into the day?
Who is helping?

14. Discussion

15. Choice Rehab, A Division of Nathan Jackson, PLLC, is a rehab management, staffing, and consulting firm. We specialize in providing custom solutions for our clients and improved integration of services through the healthcare system. Our focus is on improved patient outcomes through multi-level cooperative program development.  Choice provides care solutions at the acute, sub-acute, home health, and outpatient level.  We believe that rehabilitative management throughout the patient continuum is a vital component for a health care providers success.
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