Providing excellent care during the first hospitalization; and
Putting into place the best possible coordination plans with the outpatient setting – including both the outpatient health professional team and the patient/family/caregiver.
Determining the Potentially Preventability of a Readmission – a General Rule
If for a specific type of discharge (e.g., coronary bypass surgery) a hospital that has a statistically significant higher rate of specific types of readmissions than comparable hospitals, the health care team will believe that opportunities to improve exist for either quality of care during the initial discharge and/or the coordination process and discharge planning in the outpatient sector.
Clinical Criteria for Determining Potentially Preventable Readmissions
The reason for the readmission can be a consequence of the prior discharge.
Poor quality during the prior hospitalization
Poor coordination between the inpatient and outpatient health care team
The reason for readmission can be a consequence of inadequate post discharge outpatient follow-up
If the reason for readmission is unrelated to the prior hospitalization, it is not considered a potentially preventable readmission (e.g., admission for trauma) and is not designated as a PPR
General Guidelines for PPRs Default: Potentially Preventable Example: Admission for diabetes following discharge for AMI Exception: Unrelated acute events Example: Admission for trauma following discharge for AMI Default: Potentially Preventable Example: Admission for angina following discharge for PTCA Exception: Unrelated acute events Example: Admission for eye infections following discharge for PTCA Default: Not Potentially Preventable Example: Admission for appendectomy following discharge for pneumonia Exception: Prior discharge diagnosis was reason for surgery Example: Admission for appendectomy following discharge for abdominal pain Default: Not Potentially Preventable Example: Admission for cholecystectomy following discharge for CABG Example: Admission for PTCA following discharge for CABG Surgical Medical Surgical Medical Initial Discharge Readmission
Three other factors make a readmission not potentially preventable
Discharge status of prior discharge
AMA and transferred to another acute care hospital
Type of prior discharge
Follow-up care is intrinsically complex and extensive
Length of time interval between discharge and readmission
Long time intervals (>30 days) reduce confidence that readmission is causally linked to the prior discharge
“For discharges occurring on or after October 1, 2008, the diagnosis-related group to be assigned under this paragraph for a discharge described in clause (ii) shall be a diagnosis-related group that does not result in higher payment based on the presence of a secondary diagnosis code described in clause (iv).”
Clause (iv) specifies high cost on high volume infections that were not present at the time of admission and would “reasonably have been prevented through the applications of evidence based guidelines”
PPR Payment Adjustment would have the Following Benefits
Provides a payment increase to hospitals that have low PPR rates
Provides a payment decrease to hospitals that have high PPR rates
Introduces an explicit pay for performance component in the IPPS
By altering payment on case by case basis the incentive to reduce the occurrence PPRs is reinforced for each patient, thereby, strengthening the effectiveness of the incentive to improve quality as it relates to PPCs and PPRs.