The Centers for Medicare & Medicaid Services have been focusing on reducing acute care readmissions within 30 days of discharge through its Hospital Readmissions Reduction Program. Hospitals with higher than expected 30-day readmission rates will incur penalties against their total Medicare payments beginning in federal fiscal 2013.


Commercial payers likely will follow suit, as organizations such as the Joint Commission, Partnership for Patients and the National Quality Forum support this program.

To meet the challenge, hospitals need to take a structured approach to reducing readmissions — an assessment of the organization's risk and a comprehensive strategy that transitions the patient from the hospital to post-hospital care.

Top Diagnoses and Penalties

The Hospital Readmissions Reduction Program levels penalties against hospitals with "excessive readmissions" after risk adjustments have been applied. The penalties will apply to all Medicare payments, not just payments associated with excessive readmissions. Currently, CMS is focused on the congestive heart failure, acute myocardial infarction and pneumonia Medicare severity-diagnosis related groups. Although the reimbursement reductions do not begin until 2013, these penalties will be determined by clinical outcomes monitored in federal fiscal 2012.

Understanding the Risk

Hospitals must assess the risk of individual patients as well as that of the organization.

Patient risk. The patient's readmission risk assessment should be completed by the registered nurse on admission and when the patient's clinical condition changes. Patient risk factors include:

  • age, socioeconomic level, education and comorbidities;
  • medications, literacy and culture;
  • patient readiness to change;
  • number of emergency department visits and hospitalizations within the last six months.  

The patient's risk should be reevaluated at designated intervals throughout the hospital stay. Key components of the readmission risk assessment include the setting from which the patient is admitted, previous readmissions, the specialty of the attending practitioner, and readmission for other diagnoses and significant comorbidities.

Hospital risk. Understanding the organization's specific patient population risks is key to developing an effective hospitalwide strategy. The organization's risk is assessed through quality and operational metrics such as:

  • Hospital Consumer Assessment of Healthcare Providers and Systems scores;
  • core measures for CHF, AMI and pneumonia;
  • readmission rates;
  • utilization of resources;
  • cost of care per case.

Senior managers should review their metrics on a monthly basis and adjust accordingly to improve performance. By performing a readmission risk assessment and understanding the gaps in clinical practice, the hospital can design strategies to help reduce its risk for readmissions.


Opening the Lines of Communication


Health care providers must use effective spoken and written communication methods to convey the patient's short- and long-term treatment and discharge plans. The communication flow begins in the clinic or ED, transitions to the acute care setting, and continues with the primary care provider and venues of care following hospital discharge. Communication handoffs involve numerous people: the PCP; the ED personnel; the inpatient care team, including hospitalists, nurses, case managers, social workers and pharmacists; and the post-acute care providers.

Continued development of electronic communication is an essential component of the tools necessary to care for patients.

Strategies to Prevent Readmissions

In the acute care setting, communication strategies include multidisciplinary care progression rounds, patient and family education, meetings for patients at high risk for readmission, medication reconciliation, and discharge planning with the post-acute venues of care. Hospitals will need to conduct these strategies electronically to be effective.

Patient education is essential for improving self-care and lowering readmission risk. Providers may use a variety of teaching tools such as teach-back, in which the patient demonstrates knowledge by teaching the clinician; computerized learning and testing; and group sessions to help improve self-care. Providing continued patient education throughout the inpatient stay helps patients retain knowledge and prevent confusion at home.

Medication reconciliation is comparing the medications the patient is taking at admission with the medications prescribed at discharge. Encouraging the patient to participate in medication reconciliation helps improve self-care, as it provides patients with a list of pre-hospital medications that should be discontinued when they leave the hospital, and reminds them of any changes in the dose or frequency. It also highlights the medications patients should continue as well as over-the-counter medications they should avoid.

It is critical that these instructions be provided in the language the patient speaks and in a format that can be provided to caregivers in the next venue of care.

Patient-friendly discharge plan. As the patient is being prepared for discharge from the acute care setting, the staff nurse should provide a clear, easy-to-follow plan that details the post-discharge plan of care. Key components of the plan should include:

  • the reason for hospitalization;
  • medication reconciliation;
  • pending tests and results;
  • post-discharge services needed;
  • reference to post-discharge resources to support health improvement and maintenance;
  • symptoms that indicate the patient should contact the PCP;
  • the post-hospitalization appointment with the PCP; and
  • important contacts and phone numbers.

Post-discharge intervention. Patients in a high-risk category for readmission need an intensive post-discharge intervention plan to minimize recidivism. The care manager or primary nurse should schedule a home visit in the first 48 hours of discharge, followed by a PCP office visit within the first two to four days post-discharge. Patients at moderate or low risk require a home phone call within 48 hours and an office visit five to seven days post-discharge. These initial home calls or visits are used to confirm that the patient:

  • has filled the prescriptions and understands how to use the medications;
  • is able to identify worsening symptoms;
  • knows when and whom to call;
  • identifies specific self-care actions to improve health;
  • knows the time and date of the next office appointment.

Responsibility for home calls can be assigned to the care manager, primary nurse or advanced practice clinician working with the PCP.

Financial Penalties for Readmission

The Agency for Healthcare Research and Quality projects that, of the 3,100 hospitals expected to be included in the Readmissions Reduction Program, 2,300 of them are likely to experience reduced repayment due to readmission. Of those, 60 percent are projected to face payment reductions of $10,000 to $500,000.

Organizations in the best position to address their risk will review their current processes and workflows; engage the health care team to ensure an optimal patient experience; assess the staffing and processes used in care management; and measure and manage the quality outcomes, service standards and financial performance that will mitigate the organization's risk.

Patricia Hines, Ph.D, R.N., and Bonnie Barndt-Maglio, Ph.D., R.N., are vice presidents with the Camden Group in Los Angeles.