Starting in 2012, the Centers for Medicare and Medicaid Services (CMS) will begin withholding payments for potentially avoidable readmissions. This presentation reviews these new regulations, what causes excessive readmissions, and how hospitals can positively impact patient health by reaching out 24-72 hours after discharge.

1. time
Why it’s
to focus on
hospital
readmissions
Bridging the gap
between hospital and home

2. Approx.
$2 trillion
is spent on healthcare
in the U.S. each year.
SOURCE: Fazzi R, Agoglia R, Mazza G, Glading-DiLorenzo J. The Briggs National QualityImprovement/Hospitalization Reduction Study. Caring:
National Association for HomeCare magazine. 2006; 25(2):70.

3. Flickr: Daquella manera
1/3 hospitalizations.
is spent on
SOURCE: Fazzi R, Agoglia R, Mazza G, Glading-DiLorenzo J.
The Briggs National QualityImprovement/Hospitalization Reduction Study. Caring:
National Association for HomeCare magazine. 2006; 25(2):70.

4. 20% readmissions.
of those hospitalizations are
SOURCE: Fazzi R, Agoglia R, Mazza G, Glading-DiLorenzo J. The Briggs National QualityImprovement/Hospitalization Reduction Study. Caring:
National Association for HomeCare magazine. 2006; 25(2):70.

5. Hospital Readmission (Definition)
A hospitalization that occurs within a specified
time frame after discharge from the first or
index admission.
SOURCE: American Journal of Medical Quality. Redefining Hospital Readmissions to Better Reflect Clinical Course of Care for Heart Failure
Patients.

6. “ I think readmissions are a
bellwether of whether we are really
doing the kind of support, education,
outreach, and coordination that really
can keep people as healthy as
they possibly can [be].”
Dr. Donald Berwick, Administrator of the
Centers for Medicare and Medicaid Services

7. Leaving the hospital
stressful.
can be

8. Patients may be tired.

9. Patients may be tired.
…uncertain about their
discharge instructions.

10. Patients may be tired.
…nervous about
transitioning home.
…uncertain about their
discharge instructions.

11. Patients may be tired.
…nervous about
transitioning home.
…uncertain about their
discharge instructions.
…concerned their
condition could worsen.

12. Patients may be tired.
…nervous about
transitioning home.
…uncertain about their
discharge instructions.
…concerned their
condition could worsen.
…unhappy with their
hospital experience.

13. …at risk of readmission.

14. This is
especially true
with Medicare
patients.

15.
18-20% of Medicare patients
are re-hospitalized within
30 days of discharge.
SOURCE: Jencks S, et al. Rehospitalizations among patients in the Medicare fee-for-service program.New England Journal of Medicine 2009.

16. 33% readmit within 90 days.
SOURCE: Jencks S, et al. Rehospitalizations among patients in the Medicare fee-for-service program.New England Journal of Medicine 2009.

17. However, many of these
readmissions are potentially
avoidable.

18. “ Readmissions are not
primarily about people being
re-hospitalized because of mistakes
made in the hospital. [Readmissions]
are about making
transitions effectively.”
Stephen Jencks, M.D., a former senior clinical adviser to CMS.

19. Avoidable Readmission (Definition)
A potentially preventable re-hospitalization… that in
many cases may be prevented with proven
standards of care.
SOURCE: MedPAC (June 2007) Report to the Congress: Promoting Greater Efficiency in Medicare

20. Avoidable
readmissions
are all
too common.

21. In fact, 13% of Medicare
re-hospitalizations are
potentially avoidable.
SOURCE: Hackbarth G, Reischauer R, Miller M. Report to Congress: Medicare Payment Policy. Washington, DC: Medicare Payment Advisory
Committee; March 2007.

22. That’s a cost of about
$12 billion! ($7,000 per person)
SOURCE: Recreated from Table 5-2 within: MedPAC (June 2007) Report to the Congress: Promoting Greater Efficiency in Medicare. P 107, from 3M
analysis of 2005 Medicare discharge claims.

23. What causes
potentially avoidable
these
readmissions?

24. Reason #1
Patients
don’t follow home
care instructions.

25. Which can
cause serious
complications with
their at home recovery.

26. Especially
when dealing with
medications.

27.
In fact, of 2/3
Medicare readmissions
are due to medication
non-compliance.
SOURCE: Jencks S, et al. Rehospitalizations among patients in the Medicare fee-for-service program.New England Journal of Medicine 2009.

28. Reason #2
There isn’t
adequate follow up
or monitoring.

29. Many patients
aren’t seen by
physicians promptly after discharge.

30. In fact, 50% of Medicare patients had
no interaction with a physician
between discharge and readmission.
SOURCE: Jencks S, et al. Rehospitalizations among patients in the Medicare fee-for-service program.New England Journal of Medicine 2009.

31. With no
one to help them
schedule
and keep those
appointments

32. …a significant
gap in care occurs.

33. …a significant
gap in care occurs.
And patient
health deteriorates.

34. Reason #3
Hospitals
and Physicians
aren’t good
at
sharing
patient care plans.

35. Quite often,
physicians
aren’t kept in the loop about
discharge plans.

36. In fact, one review found that
only 3%-20% of
hospitals communicate with the
primary care physician.
SOURCE: Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits incommunication and information transfer between hospital-based
and primary carephysicians: implications for patient safety and continuity of care. JAMA. Feb 282007; 297(8):831-841.

37. And only 12%-34% of
primary care physicians have access to
discharge summaries during the first post
discharge visit.
SOURCE: Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits incommunication and information transfer between hospital-based
and primary carephysicians: implications for patient safety and continuity of care. JAMA. Feb 282007; 297(8):831-841.

38. But change is on the horizon.

39. Medicare and
The Center for
Medicaid Services (CMS)
is beginning to hold
hospitals accountable.

40. Starting October 2012,
CMS will begin withholding payments for
excessive readmissions.

41. Focusing first on:
1. Congestive Heart Failure (CHF)
2. Acute Myocardial Infarction (AMI)
3. Pneumonia

42. then adding others in 2014 .
4. Chronic Obstructive Lung Disease
5. Coronary Bypass Grafting
6. Percutaneous Coronary Interventions
7. Vascular Procedures

43. CMS penalties are based on a
maximum percentage
of total inpatient operating
payments.

44. increase
Which will
over the next
three years.
2012 = 1% 2013 = 2% 2014 = 3%

45. Their goal is toincentivize
hospitals to improve patient health by
extending care services
beyond the hospital setting – thereby
reducing costs.

46. “ The incentives we're
putting into place have created a
whole new way to think
about hospital care.”
Jonathan Blum, deputy administrator of the federal
Centers for Medicare Medicaid Services, or CMS.

47. And it’s
not just
about the
numbers.

48. Patient Experience
will play a key role in measuring
the effectiveness of a hospital’s inpatient
and discharge planning.

49. In fact, higher have beenHCAHPS
associated with a lower 30-day risk of
hospital readmission for:
Congestive Heart Failure (CHF)
Acute Myocardial Infarction (AMI)
Pneumonia
SOURCE: The American Journal of Managed Care: Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days

50. To avoid
CMS penalties,
it will be critical for hospitals
to support patients using
aftercare services.

51. Aftercare (Definition)
The subsequent care or maintenance of a patient
after a stay in the hospital.
SOURCE: New Oxford American Dictionary

52. Hospitals need to
start thinking of themselves as
care managers.

53. And take a
leading role
in managing patient care
after discharge.

54. In other words…

55. Set clear
expectations
on what will happen.

56. Set clear
expectations
on what will happen.
contact
Stay in
with the patient after discharge.

57. Set clear
expectations
on what will happen.
contact
Stay in
with the patient after discharge.
Keep physicians
in-the-loop.

58. Set clear
expectations
on what will happen.
contact
Stay in
with the patient after discharge.
Keep physicians
in-the-loop.
Provide
24x7 access
to decision support services.

59. “While timely follow-up
is critical, that alone isn’t enough
to prevent readmissions. To be
effective, you need a care team that
can connect,evaluate,
and escalate patients
to appropriate care and/or
administrative resources.”
Jeff Forbes, President, SironaHealth

60. Post Discharge
Follow-up (Definition)
Outbound calling programs that rapidly assess a
patient's current health status, schedule follow-up care,
and gather feedback on their hospital experience.
SOURCE: SironaHealth

61. To be successful,
post discharge
calling programs
must…

62. Follow up
24-72 hours
after discharge

63. Review
patient discharge
instructions

64. Provide
decision support and
health coaching

65. Schedule
Follow Up
Facilitate Find a Doctor
appropriate
next steps Escalate to
Urgent or
Emergency
Care
Guide to
Other
Hospital
Services

66. Make it easy to
reconnect
with a
clinician*
*in case they develop
symptoms after initial call.

67. Keep all
members
informed
of the care team

68. feedback
Use
to improve the discharge
experience

69. “ smooth
If we are able to
the transitions [after
discharge], those people would stay
home where they want to be and
costs would fall because [the
patients] are not deteriorating.
We have a tremendous
possibility there.”
Dr. Donald Berwick, Administrator of the
Centers for Medicare and Medicaid Services

70. We Agree.

71. Post Discharge
Follow Up Services
Keep patients healthy, reduce readmissions, improve experiences
Learn more!
www.SironaHealth.com/post-discharge

72. About SironaHealth
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coordinate patient care across telephone, web, email, and mobile channels. SironaHealth programs
help your patients make the appropriate healthcare choices —whether it be choosing the proper
physician or knowing when they should seek emergency care.
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