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Readmissions Are Down, Penalties Are Up — What Do You Do Now?
Abstract:
The Medicare readmission reduction program has been in place for five years but, despite decreasing readmissions, hospitals are still receiving penalties — $528 million in fiscal 2017 alone. The program has been criticized for basing penalties on a tiered structure so hospitals may be penalized despite cutting readmissions, and for not taking into account socioeconomic issues and other factors beyond hospitals' control that result in patients getting sicker. To help hospitals succeed, and to provide better care, case managers should work to prevent readmissions for all patients, including the Medicaid population, and adapt readmission prevention initiatives to meet the specific needs of patients in different demographic groups or with different conditions. Case managers should work closely with their counterparts at other levels of care to develop consistent educational tools and share information via the electronic medical record or nurse-to nurse calls to ensure smooth transitions and provide follow-up education and medication reconciliation for patients discharged to home. Case managers in the ED are essential to begin the discharge planning assessment while the family is still present and to prevent readmissions by lining up services in the community when appropriate.
Insights
Hospitals face penalties from the Medicare Readmission Reduction Program despite reducing readmissions. Case managers can prevent readmissions by tailoring strategies and improving care transitions for all patients.
Area of Science:
- Healthcare Management
- Patient Care Coordination
- Public Health Policy
Background:
- The Medicare Readmission Reduction Program (HRRP) has been active for five years, aiming to decrease hospital readmissions.
- Despite decreasing readmissions, hospitals incurred significant financial penalties ($528 million in fiscal year 2017).
- Criticisms include penalties for hospitals reducing readmissions and failure to account for socioeconomic factors influencing patient health.
Purpose of the Study:
- To identify strategies for hospitals to succeed within the HRRP and improve patient care.
- To emphasize the role of case managers in readmission prevention across diverse patient populations.
- To advocate for tailored readmission prevention initiatives based on patient demographics and conditions.
Main Methods:
- Case managers should proactively prevent readmissions for all patients, including the Medicaid population.
- Adapt readmission prevention initiatives to meet the specific needs of patients in different demographic groups or with different conditions.
- Enhance collaboration between case managers and healthcare providers across different care settings for seamless patient transitions.
Main Results:
- Consistent educational tools and information sharing via electronic medical records or nurse-to-nurse calls are crucial.
- Follow-up education and medication reconciliation are essential for patients discharged home.
- Early discharge planning assessments by case managers in the Emergency Department (ED) are vital.
Conclusions:
- Case managers play a critical role in preventing readmissions by initiating discharge planning early and coordinating community services.
- Tailoring interventions and improving inter-level care coordination are key to mitigating penalties and enhancing patient outcomes.
- Addressing socioeconomic factors and ensuring consistent patient education are essential for effective readmission reduction strategies.
