Reducing Hospital Readmissions & The Affordable Care Act

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1 Reducing Hospital Readmissions & The Affordable Care Act The Game Has Changed Drastically Reducing MSPB Measures Chuck Bongiovanni, MSW, MBA, NCRP, CSA, CFE

2 Chuck Bongiovanni, MSW, MBA, NCRP, CSA, CFE Master in Administrative Social Work Master in Business Administration Nationally Certified Readmission Professional Certified Senior Advisor Certified Franchise Executive Recipient of The Innovator in Readmissions Award National Advisory Board National Readmissions Prevention Collaborative National Speaker on Readmissions and Medicare Spending Per Beneficiary Author of The Community Integration Model

3 What is a Hospital Readmission Who are Readmitted Identify Social Factors For Readmissions 6 Top Readmitting Diagnosis 8 Strategies To Reduce Readmissions Future ACA Penalties Think Outside The Walls Of The Continuum of Care

4 Source : The Centers For Medicare and Medicaid Services

5 What Is A Hospital Readmission? Readmission for any cause to any acute care hospital within 30 days of discharge. Include patients who were initially hospitalized with one of several primary diagnoses (heart attack, heart failure, and pneumonia), regardless of whether patients are readmitted to the same or to a different hospital. The measure includes patients discharged to a nursing home setting.

6 What Is A Hospital Readmission? Source: Examining the Drivers of Readmissions and Reducing Unnecessary Readmissions for Better Patient Care: TrendWatch.org

7 Who Is Being Readmitted? The average age of readmissions was 80.3 years for patients originally hospitalized for heart failure, 79.8 years for patients originally hospitalized for acute myocardial infarction and 80 years for patients originally hospitalized for pneumonia. Source:

8 When Is Being Readmitted? Among all readmissions, approximately one-third occurred from day 16 through day 30 post-hospitalization. The median time period between hospitalization and readmission was 12 days for heart failure patients, 10 days for acute myocardial infarction patients and 12 days for pneumonia patients. Source:

9 Social Factors That Increase Hospital Readmission? Being a male Coming from African American or Hispanic background Having a lower level of education Earning no or low Income Unemployment Status of Unmarried Living alone and having a lack of social support Living in a rural area or living far away from a hospital Medicaid insurance coverage Engaging in risky behaviors: smoking, drug use. 10 reasons for hospitalizations in 2010.html

10 Other Factors That Increase Hospital Readmission? Unplanned hospitalization in the past 6 to 12 months On high risk medication (narcotics, antiepileptic medication, antidepressants) Polypharmacy, or your parent is on five or more medications. More than six chronic conditions, or specific clinical conditions including advanced COPD, diabetes, heart failure, stroke, cancer, weight loss, depression, and palliative care. Limited social contact. Has not received a follow up call from a member of the health care team following discharge. 10 reasons for hospitalizations in 2010.html

11 6 Top Readmitting Diagnosis 1. Heart Failure Rehospitalization was 24.8 percent. 2. Acute Myocardial Infarction Rehospitalization was 19.9 percent. 3. Pneumonia Rehospitalization was 18.3 percent. 4. The majority of all readmissions occurred within 15 days of hospitalization. 5. Among all readmissions, approximately one-third occurred from day 16 through day 30 post-hospitalization. 6. The median time period between hospitalization and readmission was 12 days for heart failure patients, 10 days for acute myocardial infarction patients and 12 days for pneumonia patients. causes/leading causes of hospitalizations

12 8 Strategies To Reduce Readmissions 1) Educate the patient about his or her diagnosis throughout the hospital stay 2) Make appointments for clinician follow up, test result follow up, and post discharge testing 3) Organizes post discharge services 4) Confirm the medication plan /12 Ways to Reduce Hospital Readmissions

13 8 Strategies To Reduce Readmissions 5) Reconciles the discharge plan with national guidelines and clinical pathways 6) Gives the patient a written discharge plan and assess the patient s understanding of the plan 7) Tell the patient what to do if a problem arises 8) Expedites transmission of the Discharge Résumé (summary) to outpatient providers /12 Ways to Reduce Hospital Readmissions

14 The Cost of Readmission Penalties 250 Bed Hospital $50,000,000 Medicare Reimbursement Hospital Medicare Profit (9%) = $4,500,000 maximum penalty= $150,000 (-3%) maximum bonus= $386,871 (+8%)

15 After Discharge Tools Potential Readmissions Check List Change In Medications Medication Reminders Nutrition Food Program

16 What Is Next Focus Of The ACA? Medicare Spending Per Beneficiary Measures

17 Understanding M.S.P.B. MSPB Measure is Medicare s way of measuring Hospital Financial Efficiency MSPB Measure is the average amount a hospital spends (Part A & Part B) vs a risk adjusted average of all hospitals in the nation during a Medicare Spending Episode Medicare Spending Episode begins: 3 Days prior to hospital admission Continues through Hospitalization Ends 30 Days after Hospital Discharge Source Centers for Medicare and Medicaid Services

18 Understanding M.S.P.B. Hospital Actual Spend CMS Expects MSPB MEASURE Hospital Spends $18, $18, MSPB = 1.00 Hospital Spends $17, $18, MSPB = 0.96 Hospital Spends $19, $18, MSPB = 1.04 Financially Efficient Less Financially Efficient

19 What MSPB Measure Score Shows More Financial Efficiency? The LOWER the MSPB Measure, The MORE FINANCIALLY EFFICIENT The Hospital Is. MSPB Measure = 0.96 MSPB Measure = 1.00 MSPB Measure = 1.04

20 The Traditional Continuum of Care The Problem Medicare Dollars Are Spend At Every Phase Of The Continuum Hospitals Are Financially Responsible For ALL POST-ACUTE Spending 40.3% of all Medicare Spending

21 Medical Center MSPB Measures* Hospital Has No Readmission Problem *www.medicare.com Hospital Name Period Claim Type Hospital National MEDICAL CENTER 1 to 3 days Prior to Index Hospital Admission Home Health Agency $0 $13 MEDICAL CENTER 1 to 3 days Prior to Index Hospital Admission Hospice $1 $1 MEDICAL CENTER 1 to 3 days Prior to Index Hospital Admission Inpatient $4 $5 MEDICAL CENTER 1 to 3 days Prior to Index Hospital Admission Outpatient $40 $113 MEDICAL CENTER 1 to 3 days Prior to Index Hospital Admission Skilled Nursing Facility $3 $2 MEDICAL CENTER 1 to 3 days Prior to Index Hospital Admission Durable Medical Equipment $8 $9 MEDICAL CENTER 1 to 3 days Prior to Index Hospital Admission Carrier $424 $488 MEDICAL CENTER During Index Hospital Admission Home Health Agency $0 $0 MEDICAL CENTER During Index Hospital Admission Hospice $0 $0 MEDICAL CENTER During Index Hospital Admission Inpatient $7,913 $8,997 MEDICAL CENTER During Index Hospital Admission Outpatient $0 $0 MEDICAL CENTER During Index Hospital Admission Skilled Nursing Facility $0 $0 MEDICAL CENTER During Index Hospital Admission Durable Medical Equipment $6 $23 MEDICAL CENTER During Index Hospital Admission Carrier $1,463 $1,511 MEDICAL CENTER 1 through 30 days After Discharge from Index Hospital AHome Health Agency $274 $547 MEDICAL CENTER 1 through 30 days After Discharge from Index Hospital AHospice $84 $119 MEDICAL CENTER 1 through 30 days After Discharge from Index Hospital AInpatient $2,899 $2,249 MEDICAL CENTER 1 through 30 days After Discharge from Index Hospital AOutpatient $741 $664 MEDICAL CENTER 1 through 30 days After Discharge from Index Hospital ASkilled Nursing Facility $4,436 $2,742 MEDICAL CENTER 1 through 30 days After Discharge from Index Hospital ADurable Medical Equipment $101 $107 MEDICAL CENTER 1 through 30 days After Discharge from Index Hospital ACarrier $1,103 $1,078 MEDICAL CENTER Complete Episode Total $19,500 $18,668 MSPB=1.04

22 Where Can We Start Controlling Post-Acute Costs? Patient s Eligibility Does Not Equate To A Physician's Order Example Unnecessary SNF Admissions Tommy Olmstead, Commissioner, Georgia Department of Human Resources, et al, v. L.C; Supreme Court of the United States, June 22, 1999.

23 Unnecessary SNF & LTACH Admissions Taken from the official government booklet on Medicare Patients must require skilled care on a daily basis and the services must be ones that, as a practical matter, CAN ONLY BE PROVIDED in a SNF on an inpatient basis. * *http://www.medicare.gov/coverage/skilled nursing facility care.html Tommy Olmstead, Commissioner, Georgia Department of Human Resources, et al, v. L.C; Supreme Court of the United States, June 22, 1999.

24 Wisconsin Study *Uninsured, K.C.o.M.a.t., Private Long Term Care Insurance: A Viable Option for Low and Middle Income Seniors? Citing AHIP LTC Insurance Market Survey, 2002, 2006.

25 Key: Spend Less Public (Medicare $$) Experiencing the greatest transfer of wealth from one generation to another in world history Only A Small Percentage Of Patients Are Needed To Make A Large Impact On MSPB

26 Beyond The Walls Of The Continuum Rule Out All Non Medicare Post Acute Discharge Options First Rethink & Reinvent The Continuum Of Care

27 Case Study What Is Are Her Post Acute Options? 87 years old Female Patient Admitted For: Weakness / CHF Multiple Chronic Conditions including CHF Pneumonia High Blood Pressure Dementia Activities of Daily Living Needs Include: Bathing Dressing Toileting Transferring

28 What Are Our New Options Her Skilled Care Needs Include: Medication Management Physical Therapy Respiratory Therapist Registered Nurse

29 Nursing Home or Community? ADL Needs Rehab SNF Assisted Living Residential Care Home Or Home Skilled Medical Needs Rehab SNF Assisted Living Residential Care Home Or Home High Blood Pressure Medication Management Heart Disease Physical Therapy Dementia Respiratory Therapist Bathing Dressing Toileting Transferring Registered Nurse 44% Medicare Spending Savings Individual Medicare Spending SNF D/C Individual Medicare Spending AL/RES $ $10, $7,550 $925 = $19,500 $ $10, $0 $1850 = $12,875

30 The Big Question: But Who Can Afford Assisted Living? Most Social Workers & Discharge Planners Are Uncomfortable About Discussing Finances

31 What Does It Cost Medicare? Assisted Living Costs Medicare $0.00 In Home Care Costs Medicare $0.00 A Medicare Certified Home Health Agency costs about 25% of a SNF

32 Assisted Living Alone Is NOT The Solution!!! Predictive Software For Assisted Living

33 Contact: Medicare Spending Book Model To Reduce Medicare Spending For Hospitals ACO s Bundled Payments Healthcare Plans SNFs Thank You Contact Me At

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