ERR for heart failure by state, 2014-2017. Data from CMS.

The introduction of the CMS Hospital Readmissions Reduction Program (HRRP) in October 2012 thrust readmission reduction into the mind of every health executive.

Defining readmissions

Readmissions are defined by CMS as an admission to a participating hospital within 30 days of a discharge from the same or another hospital.

CMS tracks these six conditions and procedures as part of HRRP:

• Heart Failure (HF)

• Acute Myocardial Infarction (AMI)

• Coronary Artery Bypass Graft (CABG) Surgery

• Chronic Obstructive Pulmonary Disease (COPD)

• Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA)

• Pneumonia

Each of these conditions is vital for healthcare organizations to measure-falling behind on only one can still result in penalties.

How readmissions penalties are calculated

For FY 2020, CMS will be examining hospital data based on hospitals’ performances during a three-year period from July 1, 2015 through June 30, 2018.

The payment adjustment factor (PAF) is the reduction applied to CMS payments. It is calculated using an excess readmission ratio (ERR), which CMS calculates by looking at a hospital’s expected readmission rate (based on other similar hospitals) and comparing it to a hospital’s actual readmission rate.

Related article: Nine Ways to Reduce Hospital Readmissions from Hospital Executives

Hospitals that perform better than average will have an ERR less than 1.0 (and are not penalized), while hospitals performing worse than average will have an ERR of greater than 1.0 (and are penalized). The PAF is generated using ERR and a complicated formula. The minimum PAF is 0.97 (which would account for a 3% penalty, the maximum penalty allowed).

Payment reductions are calculated by subtracting the PAF from 1.0 and multiplying by 100. So for example, a hospital with a PAF of 0.975 would have a payment reduction of 2.5%:

1.0 - 0.9750 = 0.025 x 100 = 2.5% reduction

Since the program began, CMS has doled out $2.5 billion in penalties, with an estimated $564 million in fiscal year 2018 alone, up from the $528 million in 2017. Even though there are signs that readmission rates in a variety of condition types are improving, of the 3,241 hospitals evaluated for readmissions between October 2017 and September 2018, 2,573 (80%) were penalized.

The maximum penalty for hospitals is 3%. However, very few hospitals have penalties this high levied against them-in FY 2017, just 1.8% of hospitals paid the highest penalties.

In this special three-part series, Managed Healthcare Executive will be bringing you the ultimate guide on reducing readmissions for each of the six conditions CMS tracks. This first part will take an in-depth look at how hospitals can prevent heart-failure readmissions.

Reduce heart failure readmissions

To help your organization successfully reduce heart failure readmissions, here is the complete guide to heart failure, including:

• Heart failure rates by region (see map)

• Causes of heart failure readmission

• Reimbursement trends

• Real-world strategies for reducing readmissions.

Causes of heart failure readmission

The reasons for readmission are multifactorial and it is difficult to predict individual causes for readmission. 

Catherine J. Ryan, PhD, clinical associate professor, college of nursing, University of Illinois at Chicago Department of Biobehavioral Health Science, Chicago, says one way that readmissions have been categorized is simply as preventable or unpreventable. Others have categorized reasons for readmission as clinical, behavioral, and patient-centric, recognizing that the responsibility of readmission may reside with the patient, provider, hospital system, or any combination thereof. 

“Heart failure readmissions have been associated with a variety of factors or characteristics,” she says, adding that the most common include advanced age, history of renal disease, history of diabetes, or a heart failure admission within the past year. Other factors include admission to a teaching hospital, discharge against medical advice or discharge to home, receiving Medicaid, and being of African American ancestry.

Related article: The SDOH Factor That Impacts Heart Disease

A study by the Harvard School of Public Health (HSPH) found that elderly black patients were more likely to be readmitted to the hospital after a prior hospital stay for heart failure due to disparities related to both race and the hospitals where patients were treated.

Another study, “The Prevention of Hospital Readmissions in Heart Failure” by the David Geffen School of Medicine at UCLA, Los Angeles, showed that among readmitted Medicare patients with HF, the five most common primary diagnoses-HF, renal disorders, pneumonia, arrhythmias, and sepsis-account for 56% of the readmissions with no other diagnoses accounting for more than 5%.

“Readmission potentially reflects a failure of the discharge process; thus, discharge planning should start at the time of admission,” says Karen M. Vuckovic, PhD, advanced practice registered nurse, division of cardiology, University of Illinois Hospital & Health Sciences System, Chicago. “Health-related quality of life, or an individual’s perceived physical and mental health over time, predicts readmissions in patients with heart failure.”

Reimbursement trends

“For the past several years, there has been a heightened national focus on reducing readmissions and thus identifying patients with the highest risk for readmission,” Ryan says. “Although there have been reductions, readmission rates remain high.”

In the skilled nursing market, Zachary Palace, MD, medical director of RiverSpring Health Hebrew Home at Riverdale in Bronx, New York, says the shift to patient-driven payment model (PDPM) provides facilities with higher reimbursement for more complex Medicare Part A patients, explaining the amount of care needed correlates more directly to the reimbursement received.

The ACA authorized the federal government to penalize hospitals for poor readmission rates for Medicare patients with heart failure, and this has caused many to rethink their strategies.

Managing heart failure risk factors: Successful strategies

David Majure, MD, medical director, mechanical circulatory support program, Sandra Atlas Bass Heart Hospital at North Shore University Hospital in Manhasset, New York, says reducing readmissions is about a strong system approach and doing good heart failure care.

At his hospital, a group known as Health Solutions targets patients subject to the Heart Failure HRRP umbrella and efforts are made to connect with them at home.

The way it works, he explains, involves calling the patients at home and ensuring they have adequate resources at home and following up appropriately. By doing this, it helps reduce readmissions and the hospital’s decreasing numbers have shown it’s a success.

“If they become readmitted, they help them identify factors to help minimize their readmission,” Majure says.

The American Heart Association’s Get With The Guidelines-Heart Failure program is a hospital-based quality improvement program that provides assistance for providers to maintain current practice guidelines.

The guidelines noted that scheduling an early follow-up visit (within seven to 14 days) and early telephone follow-up (within three days) of hospital discharge are reasonable. In response to this recommendation, most HF programs include a discharge follow-up phone call though data in response to this recommendation is mixed. Therefore, Vuckovic notes each program needs to evaluate what works for their population.

“Studies which have included follow-up phone calls usually include other interventions,” she says. “There is a handout for TARGET-HF which guides the process and scripts the call.”

For example, a clinician-initiated discharge phone call is a simple and cost-effective method that allows clinicians to connect to the patients after their hospital discharge to check on their well-being, review or reinforce discharge instructions, and address issues that may potentially lead to adverse outcomes.

“Dealing with heart failure patient’s basic needs is essential in helping them manage their disease,” Vuckovic says. “For example, one inner-city teaching hospital recognized that providing housing for those who are homeless during the transition phase led to patients being more likely to attend follow-up appointments.”

Hebrew Home utilizes the AMDA’s (The Society for Post-Acute and Long-Term Care Medicine) Heart Failure Clinical Practice Guide as its protocol for treating CHF patients. Palace explains the guidelines are in a small handbook, easy to read, and provide clinicians with key points to identify heart failure, assess it, and treat and monitor achievements. This keeps everyone on the same page with best practices and ensuring they are practicing the most current medicine.

“We also have full-time physicians on staff and provide comprehensive training to all of our clinical teams on what to look for and what steps to take,” he says. “Through these efforts, we are able to manage the majority of patients in our facility and thus have a low number of readmissions.”

Related article: How Health Systems Use Pharmacists to Reduce Readmissions

Anecdotally, he shares families often talk about how their mom or dad when at different facilities, would end up in ER every few weeks with heart failure, but since coming to Hebrew House, they haven’t gone out at all. It’s a credit, Palace says, to managing these patients in-house.

Hebrew Home has also invested in technology, such as contact-free continuous vital sign monitoring, to help it identify patients at risk for CHF exacerbation. This is a trend that others are following and Palace says it’s important because it acts as the eyes and ears when the nurse is not in the room, which is a large part of the time.

“In CHF patients, a key risk to look for is an increase in fluids. Fluid builds up and when patients lie down, this fluid moves from their legs and collects in their lungs. An indicator we look for is shortness of breath,” Palace says. “We also monitor weight, a quick increase in weight is another way to monitor for fluid retention. We are also seeing a lot of new technology coming to the market specifically designed to help identify changes.”

The facility has also embraced the ReDS Vest, a recently-approved technology. The technology is a vest a nurse applies a patient which has a built-in sensor that reads across the chest from front to back and can quantify total lung water volume. That is also significant in helping to identify heart failure patients.

Hospitals successful at reducing readmissions that were enrolled in the American College of Cardiology’s Hospital to Home initiative, a resource for hospitals and cardiovascular care providers committed to improving transitions from hospital to home and reduce their risk of federal penalties associated with high readmission rates, created a summary of 10 key practices. Of the 10 practices, three centered on medication management.

“Education about the purposes of each medication, changes in doses/frequency, which to stop, which are new, and how to take them correctly were identified as essential to self-management. Medication reconciliation is essential,” Vuckovic says.

Palace says medication compliance is much easier to manage in a skilled nursing facility where physicians are keeping a close eye, and the clinical staff is helping to ensure adherence.

Vuckovic says that culturally appropriate multidisciplinary discharge planning and education has been shown to facilitate compliance and decrease readmissions. Research has shown that self-care (e.g., diet, medication, and symptom management) is largely insufficient in ethnic minority populations, indicating an area where more emphasis is needed-especially as self-care can be a major component of reducing readmissions.

“We need to shift our approach from hospital care to providing self-care at home since the majority of the patients’ care takes place in the home, not the hospital,” she says. “Providers should seize every opportunity to reinforce self-care principles and education.”

Nicholas Hamm is an editor with Managed Healthcare Executive. Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.