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Acute care readmission reduction initiatives: An update on major programs in Michigan

Inpatient hospitalizations account for 32 percent of the total $2.9 trillion spent on health care in the United States. In the majority of cases, it is necessary and appropriate to admit a patient to the hospital. However, patients returning to the hospital soon (e.g., within 30 days) after their previous stay account for a substantial percentage of admissions. Research has shown that many factors—including a patient’s socioeconomic status, clinical conditions, and their communities’ characteristics—can influence acute care hospital readmissions.

In 2013, CHRT published an issue brief on the major programs aimed at reducing hospital readmissions, including the Hospital Readmissions Reduction Program (HRRP) established under the Affordable Care Act (ACA). This paper is an update on the HRRP and other programs previously highlighted.

The HRRP has spurred a significant amount of activity to curb acute care hospital readmissions. In 2013, CHRT identified 10 readmissions initiatives used by hospitals and health plans nationally. Six of these initiatives have been implemented in Michigan (Appendix A provides an update on the other four programs). Those programs implemented in Michigan included:

Care Transitions Intervention® (CTI): Transitions Coaches® (e.g. advance practice nurses, registered nurses, and social workers), trained through the CTI program, review a patient’s discharge plans at the hospital, visit the patient at home within 48 to 72 hours of discharge, and call the patient three times within the first 28 days after discharge.
Project Re-Engineered Discharge (RED): Nurses coordinate patients’ transitions home, while pharmacists call patients after discharge to review medications and communicate any problems to the primary care provider.
Transitional Care Model (TCM): Advanced practice nurses provide home visits to high-risk elderly patients for three months, and are available by phone seven days a week.
Hospital to Home (H2H): A central clearinghouse provides hospitals and cardiovascular care providers with information and tools for improving care transitions and reducing readmission rates among patients who experienced heart failure or a heart attack.
Project BOOST (Better Outcomes for Older adults through Safe Transitions): A toolkit that offers hospitals and primary care providers evidence-based clinical intervention tools for improving care transitions.
State Action on Avoidable Readmissions (STAAR): A pilot program that focuses on building community-based and state-based partnerships to improve care transitions.

Each of the six initiatives target one of three levels for intervention—patient, system, and community levels—and are supported by varying degrees of evidence. The following is a summary of their implementation in Michigan, and an introduction to BCBSM’s new initiative to help reduce hospital readmissions in the state.

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Care transitions: Best practices and evidence-based programs

Poorly coordinated care transitions from the hospital to other care settings cost an estimated $12 billion to $44 billion per year. Poor transitions also often result in poor health outcomes. The most common adverse effects associated with poor transitions are injuries due to medication errors, complications from procedures, infections, and falls.

Providers are focused on improving transitions, due in part to reimbursement changes under the Affordable Care Act. In October 2012, the Centers for Medicare and Medicaid Services (CMS) instituted penalties for facilities with high readmission rates within 30 days of discharge for three conditions: myocardial infarction (heart attack), heart failure, and pneumonia. Hospitals face reimbursement reductions of up to one percent of annual Medicare payments. New payment models, including bundled payments and shared savings programs for Accountable Care Organizations , also create incentives to coordinate transitions and provide care in less intensive settings. CMS is also encouraging outpatient providers to focus on safe transitions through new reimbursement codes issued in 2013. Providers may bill for care transitions services if they see patients within 14 days of discharge from a hospital, skilled nursing facilities (SNF), or rehabilitation facility. Improving care transitions for complex patients moving from hospitals to SNFs, to their own home, or to another setting can result in significant savings while improving patient safety.

Many providers are focused on improving transitions, due in part to reimbursement changes under the Affordable Care Act. This paper summarizes best practices in care transitions, including:

comprehensive discharge planning,
sending discharge summaries to outpatient providers,
assessing financial barriers to filling prescriptions,
using a “teach back” method to ensure patient understanding,
following up with outpatient providers, and more.

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Acute care readmission reduction initiatives: Major program highlights

Beginning October 1, 2012, the Centers for Medicare and Medicaid Services (CMS) began reducing hospitals’ Medicare payments based on 30-day hospital readmission rates. The reductions are based on hospitals’ 30-day risk-adjusted readmission rates relative to national averages. Penalties are imposed for each hospital’s percentage of potentially preventable Medicare readmissions for those conditions. Under the Patient Protection and Affordable Care Act (ACA), acute care hospitals with high readmission rates for acute myocardial infarction (AMI), heart failure (HF), and pneumonia may lose up to 1 percent of their Medicare payments for fiscal year (FY) 2013, up to 2 percent for FY 2014, and up to 3 percent for FY 2015.

In FY 2015, four additional conditions will be included under the Readmission Reductions Program: Chronic obstructive pulmonary disease (COPD), coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA) and “other vascular” surgical procedures.

Two-thirds of all applicable hospitals (2,213) nationally, including approximately one-third of Michigan hospitals (55), were penalized in FY 2013 as a result of this provision. Total penalties were approximately $280 million nationally and $14 million in Michigan.

Further information about the CMS acute care readmissions penalty may be found at http://www.cms.gov. Additional information about reducing unnecessary admissions may be found at http://www.pso.ahrq.gov.

A number of initiatives are under way across the country to try and reduce readmission rates. Some of those key programs, along with research results to date, are summarized in this report.

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