Readmissions: The Final CMS Rule, Community Engagement

Initiatives, and CMS GrantsKim Streit, FACHE, MBA, MHS

VP/Healthcare Research and Information for FHA

Susan Stone, MSN, RNCare Transitions Project Director for FMQAI

August 23, 2011

Objectives

• Describe the new financial incentive systems designed to reduced avoidable readmissions

• Learn about CMS programs that focus on improving care transitions

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CMS Final Rule 2012

• Selection of applicable conditions• Definition of “readmission”• Measures for applicable conditions• Methodology for calculating the Excess

Readmission Ratio• Public reporting of readmission data• Definition of “applicable period”

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Applicable Conditions

• Acute Myocardial infarction• Congestive Heart Failure• Pneumonia

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Definition of “Readmission”

• “in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary (30 days) from the date of such discharge”

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Measures

• AMI – 30-day Risk Standardized Readmission Measure

(NQF #0505)• Heart Failure

– 30-day Risk Standardized Readmission Measure (NQF #0330)

• Pneumonia – 30-day Risk Standardized Readmission Measure

(#0506)6

Exclusions

• Planned procedures following AMI• Transfers to another acute care hospital• Hospitalizations for in-hospital death• Not in Medicare FFS for at least 30 days

post-discharge• Discharged AMA• Under age 65

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Methodology

• Index hospitalization– Identified based on the principal diagnosis &

the inclusion/exclusion criteria• Risk Adjustment

– Age, sex, chronic medical conditions, indicators of patient frailty for 12 months prior

• If no claim in prior 12 months, only comorbidities in index admission included

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Index Readmission

Jan 1 Jan 15 Jan 25 Feb 10

Does not count

Index

Example

Discharged: Admitted:Admitted:Admitted:

For Details on the Measures

• www.qualitynet.org

• 2011 Measures Maintenance Technical Report: Acute Myocardial Infarction, Heart Failure, and Pneumonia 30-Day Risk-Standardized Readmission Measures

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Applicable Period/Data for Calculation

• Will use 3 years of data to calculate the “Excess Readmission Ratios”

• July 1, 2008- June 30, 2011 • Minimum of 25 discharges

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Excess Readmission Ratio

Risk adjusted actual readmissions

Risk adjusted expected readmissions

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P/E less than 1 = P/E greater than 1 =

Public Reporting of Readmission data

• Required to calculate/publish readmission rates for all patients for all hospitals

• Did not finalize – asked for suggestions only

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CMS FY 2013 Rulemaking

• Payment adjustment– Based DRG payment amount – Policies for SCH & MDHs– Adjustment factor (ratio & floor)– Aggregate payments for excess readmissions– Applicable hospital

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Payment Impact

• Beginning in FY2013, hospitals with higher than expected risk-adjusted readmissions rates for 30-days post-discharge will receive reduced Medicare payments for every discharge (readmissions rate based on prior year’s data)

• Maximum payment reduction for individual facilities: 1.0% in FY2013, increasing to 3.0% in FY2015 and thereafter

• The Secretary is mandated to establish a quality improvement program for hospitals with high severity-adjusted readmissions rates to be carried out in conjunction with Patient Safety Organizations

Community Engagement

The most effective interventions to reduce avoidable readmissions will depend on changes in the processes of care at a community level and engage more than one provider (including hospitals, home health agencies, dialysis facilities, nursing homes, and physician offices), as well as patients, families, and community health care stakeholders.

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QIO: Coalition Building to Improve Care Transitions

• Expands the 2008-2011 Care Transitions Project from 14 states to a national program

• FMQAI is seeking to recruit 9+ communities to participate in Florida’s Care Transitions initiatives

• Two types of communities:– Did not apply for/not accepted into a Formal Care

Transitions Program (grant) – will receive ongoing QIO technical assistance

– Accepted into a formal Care Transitions Program (receives a grant) – will receive technical assistance through another CMS contractor

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Community Criteria• Includes two-five participating hospitals that are

close in proximity• Collaborates with post-acute care settings,

physicians, and community organizations that can impact readmissions

• Target population – Medicare fee-for service (including dual eligible)

• Unit of measure – community (based on overlap of hospitals’ discharges/beneficiary zip codes)

• Goal – 20% relative improvement in 30-day readmission rate over three years

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Provide Technical Assistance for Communities (Non-Grant)

• Support coalition building among providers, stakeholders, and beneficiary advocacy and service organizations

• Conduct root-cause analysis and provide results for each community

• Work with providers to select evidence-based interventions and develop the implementation plan

• Continued ongoing assistance– Measure development– Monitor the effectiveness of the interventions– Support ongoing root-cause analyses

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Data Support* (Non-Grant)

• Hospital- and community-specific readmission rates

• Post-acute care setting readmission rates

• Disease-specific readmission rates

• Emergency department rates

• Observational stay rates• Mortality rates

20*includes readmissions to all hospitals

Provide Application Assistance for Communities (Grant)

• Mandated by the Affordable Care Act (section 3026) Community-based Care Transitions Program (CCTP) http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313

• $500 million available in grants• Partnership between high readmission rate

(AMI/HF/PNE) hospitals and a community-based organization (CBO) that provide care transitions services

• CCTP application toolkit and assistance available from FMQAI

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CCTP Grant ApplicationGetting Started

• Do your homework – review the facts and create relationships

• Identify key stakeholders – Hospital CFO, CEO, COO, VPN, Director of Case Management, etc., CBO, skilled nursing facilities, home health agencies, and physician champions

• Create a Memorandum of Understanding – delineates the role, responsibilities, etc.

• Complete a root-cause analysis and determine best practice intervention(s)

• Define an operating and cost model (write proposal)22

Hospital Engagement Contract

1. Reduce harm caused to patients in hospitals. By end of 2013, reduce preventable HACs by 40% from 2010.

2. Improve care transitions. By end of 2013, decrease preventable complications during a transition from one care setting to another, resulting in a 20% reduction in readmissions.

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10 Focus Areas of the Initiative

1. Adverse drug events

2. Catheter associated urinary tract infection

3. Catheter associated bloodstream infections

4. Injury from falls and immobility

5. Obstetrical adverse events

6. Pressure ulcers

7. Surgical site infections

8. Venous thromboembolism

9. Ventilator associated pneumonia

10. Preventable readmissions

Statewide Quality Meetings

• Provide a mechanism for providers to participate in a large scale improvement effort to reduce readmissions in Florida

• Engage leaders around an action-based agenda• Share relevant state data to determine areas for

rapid cycle improvement• Identify additional affinity groups to address

special need areas• Provide a forum to share successes and lessons

learned25

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Florida Hospital AssociationKim Streit, FACHE, MBA, MHS

Email: kims@fha.org Telephone: 407.841.6230

FMQAISusan Stone, MSN, RN

Email: sstone@flqio.sdps.orgTelephone: 813-865-3435