Payment Reduction Initiatives from Medicare
Ranae N. Beeker, RN,MSN,CCM,ACM
Admissions Coordinator/RN Case Manager
Sue Noyes, RN,BSN,CCM
Manager Case Management/Social Services
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Definition: A readmission is a return
hospitalization after an earlier hospital
admission.
◦ Medicare is reviewing “all cause” readmissions for
30 days post hospitalization
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Exception: Same-day readmissions for the
same condition to the same hospital
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Current focus of Center for Medicare and Medicaid
Services (CMS) with goal to achieve three-part aim
outcomes:
1) Better Care
2) Better Health
3) Lower Costs
Readmissions national cost $17 billion annually.
76% considered avoidable
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Affordable Care Act directed by Medicare
(CMS) will financially penalize hospitals
July 2012 Readmission data publicly reported
Readmissions are expensive, adverse events
for patients
Indicator for level of quality of care received
Effective October 1, 2012 (FFY 2013).
Medicare payment reductions under this
program will be capped at 1.0% in FFY
2013. The capped reduction amount will
increase over time.
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Identified Acute Myocardial Infarction ( AMI)
Heart Failure (HF) and Pneumonia (PN)
readmissions as common, costly and often
preventable.
These conditions impose a substantial burden
on patients and the healthcare system and
there is marked variation in outcomes by
institution.
Measure
CTMC Rate
Readmission
National
Rate
AMI
19.6%
19.2%
Heart Failure
24.6%
24.7%
Pneumonia
17.0%
18.5%
Based on discharges from July 2008-June 2011
Data from Hospital Compare website.
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Working to promote transitions of care are
smooth, seamless (Transitions of Care
Committee)
Identifying patients with readmission
potential on admission
Working with area nursing homes/skilled
nursing facilities
Working with our Home Health
(as well as other Home Health agencies that
service our area).
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Sepsis
Altered Mental Status related to infection or
encephalopathy
Acute Kidney Failure
Anemia, Gastrointestinal Bleed
Dehydration related to diarrhea or N/V
Pneumonia
Cardiac Dysrhythmias
Chronic Obstructive Pulmonary Disease
Acute on Chronic Congestive Heart Failure
Acute Myocardial Infarction
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Evaluate the spectrum of care for patients
Identify systemic or condition-specific changes
to make care safer and more effective
Invest in interventions that reduce complications
of care
Improve process for assessing the readiness of
patients for discharge
Improve discharge instructions
Reconcile medications
More carefully transition patients to next level of
care i.e outpatient care or other institutional care
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End of Life Care Planning opportunity
Partner with Home Health Agencies
Partner with Nursing Homes
Promote smooth transition of care (regardless of
disposition)
Establish high-risk criteria for discharge staff (i.e.
Social Workers, Case Managers and nursing staff)
Create readmission evaluation tool
New concept idea: Huddle (5min) with identified
readmission (team approach)
Promote f/u appt for all discharge patients within
5-7 days of discharge
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CTMC will be providing
information as Medicare
continues to move forward
on budget reduction
initiatives.
Work collaboratively with
physicians & health care
community .
Mode of contact: via your
office staff, email, &
Medical Staff office.
Do not hesitate to call Case
Management or
Administration with
questions…
This is definitely a work in
progress for all hospital
systems.
 http://www.hret.org/care/projects/resources
/Readmission_Guide.pdf
 www.rarereadmissions.org/documents/RARE_
Discharge_Observation.doc ·
 21st
Annual Midas+User Symposium:
Potentially Preventable Readmissions
 Wagonhurst, Patrice “Tools to Successfully
Apply for the CMS Community-Based Care
Transitions Program
 2012.Nikiforakis,K. Cheshire Medical Center.
Keene, NH
 http://www.qualitynet.org/dcs/ContentServer
?cid=1219069855273&pagename=QnetPubli
c%2FPage%2FQnetTier2&c=Page
 http://www.hospitalcompare.hhs.gov/hospita
lcompare.aspx#vwgrph=1&cmprTab=3&cmprI
D=450272%2C670056&stsltd=%20TX&loc=S
an%20Marcos%2C%20TX&lat=29.8832749&ln
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