Post-acute providers must reduce readmissions. They could use some help.
About 20% – or one in five – Medicare beneficiaries who are sent to a skilled nursing facility from a hospital are readmitted to the hospital within 30 days, points out Dr. David Gifford, senior vice president of quality and regulatory affairs and chief medical officer for the American Health Care Association. That’s too many, according to Medicare and, no doubt, to SNFs and their residents as well.
Sales reps can help their post-acute-care customers by trying to understand the causes of excessive readmissions and the ways in which SNFs are trying to address the problem.
Value-Based Purchasing
Medicare’s SNF Value-Based Purchasing (VBP) Program rewards – or penalizes – skilled nursing facilities based on the quality of care they provide to Medicare beneficiaries as measured by a hospital readmissions measure.
“In today’s healthcare market, rehospitalizations from nursing centers is one of the most common metrics that hospitals, managed care organizations, and nursing centers themselves focus on,” says Gifford. “The measure is used by hospitals for referral decisions, managed care for network selection, and CMS for SNF Part A payments and its Five-Star rating system. Families and residents want to avoid rehospitalizations as well.”
The CMS SNF VBP program adjusts a center’s Part A payment based on its 30-day rehospitalization rate, he explains. The adjustment can range from a cut of 2% to an increase of about 1%, which is applied for all claims submitted during a fiscal year, he says. Each year, the facility is assigned a new adjustment factor for the next fiscal year. The 30-day rehospitalization rates are converted into a score based on the facility’s ranking on their risk-adjusted rate or the amount of improvement over the prior two years. Centers are then ranked on their score, and their ranking is converted into a payment adjustment factor as described above.
Payment adjustments were first applied to post-acute-care providers for FY19, which started Oct. 1, 2018. The program is expected to last 10 years.
Cause and effect
“Reasons for rehospitalizations are complex,” says Gifford. Many residents who are sent to skilled nursing facilities have very complex conditions, with most taking over 10 medications and having over 10 different diagnoses, he points out. A lack of information during transfers exacerbates the problem.
“[P]roviding better information at the time of transfers, better access to nurse practitioners and physicians to avoid sending residents to the emergency room, and any way to more effectively monitor a resident’s condition will be important to help lower the risk of rehospitalization.”
Skilled nursing facilities are doing what they can to improve the way they receive incoming residents’ information – including equipment and medications – before they arrive from the hospital, says Gifford. “Facilities are also looking at how they monitor residents’ conditions, and they are contacting physicians if there are any early changes in their conditions. Many are also using nurse practitioners to see residents more frequently, rather than sending them to the hospital.”
Says Shawn Scott, vice president of strategic business development for Medline, “Our skilled nursing customers as a whole have always delivered good care and will continue to do so under VBP and [the patient-driven payment model, or] PDPM. The difference we are seeing is more attention being placed on better monitoring of their residents to catch acute changes of conditions before they need to be readmitted to a hospital. They are investing in IT and training so they can handle higher acuity residents. This added attention, along with better communication with the hospital, has helped reduce readmissions over the last couple of years.”
Future
The Value-Based Program will last at least 10 years, but will probably be tweaked between now and then. Already, the Centers for Medicare & Medicaid Services is preparing to change the rehospitalization incentives and penalties from an “all-cause” measure to “potentially preventable” ones, says Gifford.
“They have not yet specified when that migration will occur, but they have specified how the potentially preventable rehospitalization measure will be calculated,” he says. “They will use the diagnosis on the hospital claim from the readmission to determine if a readmission was potentially preventable. The list of diagnoses and ICD codes captures about two-thirds of all hospital admissions, and includes diagnoses such as hypertension, diabetes, asthma and congestive heart failure.”
Says Scott, “Readmissions is one of many things long-term care providers are concerned about. Although it’s an indicator of quality care, and is something referral sources are looking at, they must also look closely at their length of stay, discharge to community, staffing ratios, turnover, five star, and many other indicators that are driving quality results at their building. At the end of the day, to be successful in the skilled nursing arena, you have to be able to measure all quality metrics and to be able to move quickly to correct areas where you might be deficient, because the reimbursement dollars depend on it.”
A closer relationship between acute-care providers and post-acute providers will help.
Bob Miller, vice president of Gericare Medical Supply, points to data showing that increased cooperation between acute-care providers and post-acute providers not only can maximize reimbursement, but cut down on readmissions.
“The challenge is to get more hospitals and post-acute facilities working more closely together to make a difference in readmissions,” he says.
The new PDPM payment program could also have an effect. “The record-keeping and the attitude of accountability when it comes to measuring success should all help in the readmission challenge – especially the initial assessment of a resident when they are taken in by the post-acute facility.
“This will be a crucial part of the process.”
Can primary care providers help reduce readmissions?
The 30-day period immediately following hospital discharge is a particularly vulnerable time for patients.
According to the Agency for Healthcare Research and Quality, each year in the United States more than 35 million patients are discharged from the hospital. Among the Medicare fee-for-service population, approximately 18 percent of discharged patients are readmitted to a hospital facility within 30 days, and among the adult Medicaid population, the rate is even higher.
To date, most efforts to reduce readmissions have focused on hospital-based interventions. Yet hospital providers have only a limited ability to affect what occurs once the patient has left the hospital. In fact, despite concerted national efforts from such programs as the Hospital Readmissions Reduction Program, an estimated 27 percent of hospital readmissions may still be avoidable.
Less attention and study has been paid to the role of primary care providers in reducing readmissions, despite the fact that primary care is increasingly being called on to play a key role in integrating care across the continuum. To address this gap, AHRQ funded research on what is currently known about reducing readmissions from the primary care perspective.
Challenges and opportunities
According to AHRQ, the literature suggests that primary care providers face several challenges to caring appropriately for their patients at the time of, and immediately after, hospital discharge. They include:
- A lack of compensation for peri-discharge care coordination.
- Organizational challenges, including poor communication between the hospital and ambulatory environments.
- A lack of time and support to communicate with inpatient providers and understand medication and other changes that occurred during hospitalization.
- Patients’ difficulty in financing post-discharge care, inadequate physical and emotional support to comply with the post-discharge care plan, and lack of social support to address nonmedical needs, such as housing and transportation.
Independent community primary-care practices face particular challenges coordinating care for patients following hospitalization because they are not affiliated with hospitals or other networks that can assist with coordination efforts during care transitions.
Further, many of the primary care-based interventions reviewed by AHRQ were funded by grants or other temporary funding mechanisms. Many staff members used in these interventions – nurses, pharmacists, and care managers – did not provide directly reimbursable services. Thus, additional clinics could not initiate similar programs without external support, raising concerns about the sustainability of these programs.
AHRQ found that coordinated, or bundled, interventions by hospitals, primary care providers and post-acute providers offer the best shot at reducing readmissions. They include coordinated medication management, post-discharge telephonic outreach, and patient education. In addition, transition efforts can be facilitated by clinical and financial integration of clinics and hospitals. Primary care clinics that lack the scale to hire their own dedicated care coordination staff may attempt to leverage community resources, such as those available through third-party payers or hospitals, to support their patients.
Source: Environmental Scan of Primary Care-Based Efforts to Reduce Readmissions, Agency for Healthcare Research and Quality, March 2019,