Read­mits and post-acute care

New rules on read­mis­sions push hos­pi­tals, post-acute providers into closer col­lab­o­ra­tion

Modern Healthcare - - FRONT PAGE -

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.

Im­prov­ing re­la­tion­ships

“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.

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