Readmissions: The Final CMS Rule, Community Engagement Initiatives, and CMS Grants

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Readmissions The Final CMS Rule, Community
Engagement Initiatives, and CMS Grants

• Kim Streit, FACHE, MBA, MHS
• VP/Healthcare Research and Information for FHA
• Susan Stone, MSN, RNCare Transitions Project
  Director for FMQAI
• August 23, 2011

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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)

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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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Example
Admitted
Discharged
Admitted
Admitted
Jan 1
Jan 15
Jan 25
Feb 10
Does not count
Index
Index
Readmission
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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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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 years 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

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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 Floridas 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

includes readmissions to all hospitals
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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?itemIDCMS1239313
• 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)

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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

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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
  learned

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Florida Hospital Association Kim Streit, FACHE, MBA, MHS Email kims_at_fha.org Telephone [phone] FMQAI Susan Stone, MSN, RN Email sstone_at_flqio.sdps.org Telephone [phone]