Readmits and post-acute care
New rules on readmissions push hospitals, post-acute providers into closer collaboration
Do financial penalties in healthcare actually change behavior to a degree that leads to positive change? When it comes to hospital readmissions, an answer to that question is emerging: the threat of such penalties can— and has—done so for the relationship between acute-care and post-acute providers that care for the same patients.
Beginning Oct. 1, the Hospital Readmissions Reduction Program—included in the Patient Protection and Affordable Care Act—will kick in, which means hospitals will face a penalty for excessive readmissions of as much as 1% of their total Medicare billings next year. That fine will increase to 2% in 2014 and 3% in 2015.
“CMS is implementing the Readmissions Reduction Program through two IPPS (inpatient prospective payment system) cycles—fy 2012 and FY 2013,” a CMS official says in an e-mail, noting that the proposed rule for fiscal 2013 will be issued this spring and made final by Aug. 1. “Initially, CMS will be looking at readmissions rates for acute myocardial infarction (AMI), or heart attack, heart failure and pneumonia.”
For this fiscal year—which began Oct. 1, 2011—the agency implemented certain provisions, such as the definition of “readmission,” measures for the applicable conditions and public reporting of the readmission data. But the new program won’t affect payments to hos- pitals until fiscal 2013, which starts in October.
Although hospital patients are often discharged to post-acute settings such as skillednursing facilities, long-term acute-care hospitals and inpatient rehabilitation facilities, if they are readmitted to a hospital, it’s the acute-care facility that will take the financial hit. One might think this would place a great strain on the relationship between the acute-care and post-acute providers and generate an endless blame game.
Not so, it seems. The looming penalty is having the opposite effect. Instead of adding tension to the relationship between hospitals and post-acute providers, it’s prompting the groups to work together and communicate more effectively, strengthening those partnerships.
“In the net, it helps improve the relationship,” says Dr. David Gifford, senior vice president of quality and regulatory affairs for the American Health Care Association and the National Center for Assisted Living, the assisted-living arm of the AHCA. “It’s always existed because hospitals need a place to send patients—and one out of five go to a skilled-nursing facility. So a lot of them have relationships there,” he adds. “This is going to improve that relationship even further because now there is an incentive at both ends to coordinate the care.”
As Gifford explains, hospitals are the first providers to be subjected to such a penalty.
Gifford says that Medicare Payment Advisory Commission data show that of all Medicare hospital discharges that need post-acute services, regardless of where they go, 18% receive care in a skilled-nursing facility. But of those who are discharged to an institutional setting or home with healthcare services, about one-third end up going to a SNF.
“So if a hospital is looking to reduce rehospitalization, we’re a fifth of the discharges and a lot of those do come back to the hospital,” Gifford says.
The AHCA has made working with acutecare providers a priority in the past year, says Gifford, who adds that his group’s members are working to improve communication, given that many readmissions occur because of inadequate information—from either setting.
“Right now, the only ‘penalty’ to a SNF is a hospital deciding not to refer a patient to them,” Gifford says. “But it’s clear that all providers, not just SNFS, will have a similar penalty structure that hospitals have—so everyone is trying to get ahead of the curve.”
Catherine Koppelman, chief nursing officer for the University Hospitals health system and 703-bed University Hospitals Case Medical Center in Cleveland, also emphasizes the need for strong communication among acute and post-acute providers. The Ohio system established its own hospital readmission reduction program in the fall of 2008, well more than a year before the health reform law passed.
“I think that hospitals have more of an incentive to work with the post-acute providers in terms of collaborating in ways to prevent readmissions,” Koppelman says, adding that communication often means educating staff in postacute facilities beyond basic care measures. Consequently, they are “more tuned in to” the signs and symptoms of different diseases and can care for those problems in the post-acute facility.
“What we did is set up an infrastructure of a steering committee and subcommittees, and they were assigned to examine the root causes of readmissions for heart failure, MI (myocardial infarction) and pneumonia patients,” she says. “Then with those root causes, you have the programmatic changes you have to make in the care of those patients.”
For University Hospitals, those “programmatic changes” meant modifying how caregivers collect patient medical histories. Now they ask more questions on topics such as a patient’s
University Hospitals in Cleveland emphasizes the need for strong communication between acute and post-acute providers, including personal discharge planning.