OIG and CMS Focus on Preventable Hospital Readmissions

eduTrax News Service - Nov. 11, 2009.

Preventing readmissions of patients within 30 days of discharge is now a major focus for the US Department of Health and Human Services (HHS). The OIG now targets readmissions in its 2010 Work Plan, and CMS has started posting all hospital readmission rates for three conditions. Fourteen Medicare quality improvement organizations (QIOs) are working with hospitals to reduce readmissions. And health reform measures pending in Congress include various readmission provisions, including potential to crackdown on payments for preventable readmissions of the same patient within 30 days.

A recent study published by The New England Journal of Medicine showed that only 10% of rehospitalizations in 2004 were planned, which consequently cost Medicare $17.4 billion that year alone. The study also showed that 20% of Medicare beneficiaries hospitalized from 2003 to 2004 were readmitted to the same hospital again within 30 days, and 56% within a year.

The OIG 2010 Work Plan makes clear that there are two areas of concern. Their first concern is same-day readmissions, when patients return within a 24-hour period -- considered by some to be a more subjective issue. Second, however, is a more clear cut issue: an edit was created by CMS in 2004 to ensure that no subsequent claim for a same-day readmission would be paid. The OIG plans to test the edit’s effectiveness this year, according to the Work Plan.

The more complex and challenging issue is a readmission within 30 days of discharge, since there could be multiple causes for such readmission. In such cases, determining “the extent of oversight of readmission cases” is one of OIGs goals. Because CMS contracts with QIOs to assess whether hospital services meet professional standards of care, it is expected that QIOs will become directly involved in these cases. Also, since OIG mentions same-day and 30-day readmissions in the same space in the Work Plan, it is possible that OIG believes the two are related in some way.

Readmission rates have become public record since July, when CMS began posting on its Web site the 30-day readmission rates for heart attack, heart failure and pneumonia for 4,000 hospitals, as part of Medicare’s Hospital Compare quality data reporting program. In addition to announcing readmission rates for every hospital, CMS publically notes whether the rates are better, worse or no different than the national rate. According to Hospital Compare data, the national 30-day readmission rate is 19.9% for heart attack, 24.5% for heart failure and 18.2% for pneumonia.

CMS also has other initiatives under way to reduce readmissions within 30 days of discharge. For example, there are now 14 Medicare QIOs assigned to implement “Care Transitions,” designed to improve coordination of care at 800 providers sites. The QIOs are using several different strategies to help hospitals reduce readmissions under Care Transitions.

Some recent examples are:

• Louisiana Health Care Review implemented a coaching model for preventing readmissions after realizing that conventional discharge planning isn’t adequate to prevent readmissions. The coaching to prevent readmissions was developed by Eric Coleman, M.D., of the University of Colorado Health Sciences Center. A recent interview with the project's Medical Director says that only 5% were readmitted within 30 days, compared with 19% before coaching was implemented.
• Georgia Medical Care Foundation created a toolkit called “Interact,” which stands for “interventions to reduce acute care transfers.” The main goal of the special study was to develop and implement strategies and tools that would reduce potentially avoidable acute care transfers (ACT) from nursing homes. The INTERACT Framework was developed and implemented using a Collaborative Framework similar to the model developed by the Institute for Healthcare Improvement (IHI).
• Quality Insights of Pennsylvania partnered with the state Administration on Aging to adopt Coleman’s coaching model. Five hospitals, two in-patient rehabilitation facilities, one in-patient psychiatric unit,  six home health agencies, 12 skilled nursing facilities have signed on to participate in the project. The project even has its own newsletter.
• Health Care Quality Strategies in New Jersey implemented a transitional-care model for reducing readmissions that was developed by Mary Naylor of the University of Pennsylvania. Similar to the coaching model, a transitional-care nurse accompanies the patient to the first physician visit to ensure he or she is informed of essential information, and also visits the patient 24 to 48 hours after discharge, and is available by phone. The model emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management.