Readmission's
So the Centers for Medicare & Medicaid Services plans to levy about $227 million in fines nationwide this year in its campaign to save costs and reduce the number of patients who are readmitted to hospitals in less than 30 days. The penalties, which apply to readmissions for MI,CHF and Pneumonia, began in October 2012.
While I understand Medicare's goal is to pay hospitals not simply for the number of patients they serve, but for quality of care, these calculations do not take into account the socioeconomic factors or risk levels of patients they serve. The facility I am currently working at as a CDIS is taking a “double hit†for taking care of not only the underserved, but also those patients who have been referred for advanced care. The message to this facility is that " for doing your part for taking on cases that no one else will touch you’re going to be penalized" by Medicare. The current risk models are not accurate enough to penalize the right hospitals with quality-of-care problems. I have witnessed numerous inappropriate readmissions in the past but not at this facility.
Is it now time to drill down the Real Reason in some of these cases for the readmission and document them in the record? For instance an unemployed not very well educated patient is discharged from the hospital after a bout of CHF. All core measures ,meds etc were met at time of discharge and he shows up in the ED in Acute on his now Chronic CHF. During questioning he admits to skipping a few doses of his medical regime and also admits to being a spokesperson for Stouffers frozen foods(love them). CXR shows pulmonary edema , BNP 3500 etc...
Can we get creative in documentation such as Acute Pulmonary Edema secondary to medical noncompliance and volume overload AND not worsening of or exacerbation of CHF to avoid the penalty? If the facility and providers did all the correct things but the patient did not why should a penalty be in play here? I'm sure all of you out there know the type of patient's that will be returning rather quickly. It is time for patient accountability to factor into the equation for this readmission dilemma!
While I understand Medicare's goal is to pay hospitals not simply for the number of patients they serve, but for quality of care, these calculations do not take into account the socioeconomic factors or risk levels of patients they serve. The facility I am currently working at as a CDIS is taking a “double hit†for taking care of not only the underserved, but also those patients who have been referred for advanced care. The message to this facility is that " for doing your part for taking on cases that no one else will touch you’re going to be penalized" by Medicare. The current risk models are not accurate enough to penalize the right hospitals with quality-of-care problems. I have witnessed numerous inappropriate readmissions in the past but not at this facility.
Is it now time to drill down the Real Reason in some of these cases for the readmission and document them in the record? For instance an unemployed not very well educated patient is discharged from the hospital after a bout of CHF. All core measures ,meds etc were met at time of discharge and he shows up in the ED in Acute on his now Chronic CHF. During questioning he admits to skipping a few doses of his medical regime and also admits to being a spokesperson for Stouffers frozen foods(love them). CXR shows pulmonary edema , BNP 3500 etc...
Can we get creative in documentation such as Acute Pulmonary Edema secondary to medical noncompliance and volume overload AND not worsening of or exacerbation of CHF to avoid the penalty? If the facility and providers did all the correct things but the patient did not why should a penalty be in play here? I'm sure all of you out there know the type of patient's that will be returning rather quickly. It is time for patient accountability to factor into the equation for this readmission dilemma!
Comments
Historically speaking, we have had an illness healthcare model that thrived on a higher census. There was no financial benefit to prevent readmissions, contrarily, organizations financially gained. We are transitioning to a wellness model. Although I do not appreciate financial penalty, I am excited to see the work that is underway and the stressed importance for case managers. I think that it is important that we are involved in the correct reporting of data so that CMS, the AHA, and hospitals can possibly identify why patients are readmitted.
I have never worked as a case manager. I simply appreciate the work they do. Back to work!
Thanks,
Kathy
Kathy Shumpert, RN, CCDS
Clinical Documentation Improvement Specialist
Community Howard Regional Health
3500 S Lafountain
PO Box 9011
Kokomo, IN 46902
Office 765-864-8754
Cell 765-431-0123
Fax 765-453-8447
Sandy Beatty, RN, BSN, CCDS
Director of Clinical Documentation Improvement
Community Health Network
1500 North Ritter Avenue
Indianapolis, IN 46219
317-355-2016
sbeatty@ecommunity.com
As I recall, the brief memo's for the proposed IPPS rule included
discussion about apply some sort of risk adjustment to the readmissions
... haven't looked at it in any detail. Hopefully this will help.
If there are risk adjustments applied and if CMS releases the details
... sounds like an area for CDI to constructively focus!!
Don