The Physical Therapist and Readmission

Hospital Readmission,
the Penalties, and the
Physical Therapist role
in Reduction
The Objectives
Identify the specific regulatory reform involving the focus on
prevention of readmission and the penalties on acute care
Identify key factors that contribute to the avoidable readmission
Discuss the best practices identified in the reduction of
preventable readmissions
Discuss the role of the physical therapist in various strategies to
improve care coordination, enhance discharge planning, educate
patients in self-care, and prompting follow-up care
Discuss the clinical and financial application of strategies along
with the opportunities for physical therapist in the current
regulatory environment
The Reform
Affordable Care Act includes Medicare reforms:
A key strategy is improving the quality of care and cost
Centers for Medicare and Medicaid Services (CMS) determined that
higher hospital readmission rates are linked to higher costs and
results in lower quality of care to Medicare beneficiaries
One of the key provisions is to reduce the number of unplanned
hospital readmissions
The projected savings over 10 years = 8.2 Billion
Key Drivers of this Reform
CMS reduced Medicare payments to hospitals with relatively high preventable
readmissions beginning in Oct 2012.
Initially 3 key conditions will be monitored:
Possible future readmission measures for FY 2015:
Heart failure
Additional conditions identified in 2007 MedPAC report: COPD, CABG, PTCA
Other conditions determined to be appropriate by the Secretary—possibilities include TKR
and THR
CMS is making public the 30 day admission rates for
hospitals on its Hospital Compare Website. 30 day
readmission rates are shown for heart attack, heart
failure, and pneumonia.
Other Reform factors to consider:
CMS will begin requiring reporting for 30 day Comprehensive
All-Cause-Risk Standardized Readmission Measure in FY-2014 in
the Inpatient Rehab Setting. This setting is the first for “allcause” readmission measure requirement.
Hospitals can actually lose money by decreasing hospital
readmissions. Hospitals not functioning at capacity can
generate revenue via increased patient days.
Planned Readmission are not considered in current criteria.
These admissions are intentional readmissions scheduled within
30 days of discharge as a planned part of the patients plan of
care (i.e. –planned revision procedures).
The Facts:
While the rate of hospital readmissions may vary significantly–
the rate of avoidable admissions do not (Joynt KE, 2011).
The growing body of evidence suggests that the primary drivers
for variability in hospital readmission rates are the composition
of a hospitals patient population and the resources of the
community. Just 27% of readmissions were deemed preventable
in a recent systematic literature review (van Walraven, 2011).
Hospitals with a low mortality rate among patients with heart
failure have higher readmission rates (Gorodeski, 2010).
Improved access to primary care and improved care
coordination has been linked to increased rates of readmission
and increased patient satisfaction (Weinberger, 1996).
The causes for readmission occurring within 3-7 days after
discharge are much more under the hospitals control than those
within 30 days (van Walraven,2011)
Direct Correlations
Specifically sighted:
The presence of a primary care physician
The presence of follow-up visits
Spouse and/or family support
Insurance Coverage
Longer Hospital stays
What works?
Individual strategies have been found to have modest affects (less than
half a percent) on readmission, but facilities utilizing a multi-faceted
approach saw statically significant increases with each additional
strategy (Bradley, 2013).
Strategies that were associated with lower hospital 30 day readmission
rates included the following:
Partnering with community physicians or physician groups to reduce
Partnering with local hospitals to reduce readmissions
Having nurses responsible for medication reconciliation
Arranging follow-up appointments before discharge
Having a process in place to send all discharge paper or electronic
summaries directly to the patient’s primary physician.
Assigning staff to follow up on test results that return after the patient is
The Road to Reduced Readmissions
Home Health
•Coordinated Hospital Discharge Information Exchange
•Detailed Discharge Instructions
•Education regarding medications and self-monitoring
•Schedule follow-up visit with primary care physician
•Day 1 Rehabilitation Evaluations
•Staffing RN, Dietary, Pharmacist
•QI Project Requirement for Re-admission Prevention
•EMR Requirement
•“Call Us First” Patient Education Requirement
• Tele-monitoring
•“Front Loading” concepts initiative
• EMR requirement
•QI Project Requirement for Re-admission Prevention
The goal of reducing re-admissions is
difficult to achieve without the
participation of those outside the
hospitals provider number. Along
with vender management there has
been an accompanying decline in the
access provided to step-down
The ACO type model that has been
on the forefront of discussions and in
the initial development would give
added control to the hospital system.
Programs that include remote
monitoring and structured telephone
support are an affective measure in
the management of chronic heart
failure (Robyn A Clark, 2007).
Where do the Therapist fit in?
In the hospital DRG based system
therapy plays a primary role in the
assessment and appropriate triage
of a patient by need…not just
Therapy is the central driver in
RUG based payment system in
skilled nursing facilities.
The HHRG score in home health
utilizes therapy and nursing
components in determination of
home health reimbursement.
These factors allow Physical
Therapist to participate in the
discussions at every level of care.
The Hospital Role
Appropriate Discharge: Something we
do very well!!
• Patients were 2.9 times more likely to be
readmitted when the discharge
recommendations were not implemented.
(Smith B.A. et al 2010)
Communication: Appropriate handoff by the physical therapist of record
has been established as a Standards
of Practice for Physical Therapy.
• HOD P06-08-16-16
• HOD S06-10-09-07
• Joint Commission has also sighted this as an
area of need for improvement
Important Steps:
 Plan for discharge initiates day
 Plan of care is communicated
to other providers and is
patient centered.
 Equipment order and delivery
in adequate time.
 Advising the patient on
prognosis of function,
participation, and discharge
 Insure the proper discharge
information is relayed to the
next provider. Call Report
Skilled Nursing Specifics
Clinical Consideration
Day 1, Day 1, Day 1
Promote both staff and
patient involvement in care.
Learn the signs and
symptoms: dyspnea, crackles,
peripheral edema, cardiac
response to therex.
Identify and focus: Dietary,
Pharmacy, Nursing, Treatment
Rx (resistance training)
Call Report
On the Horizon:
The US Department of Health and Human
Services cites analysis by the Medicare
Payment Advisory Commission which
indicates that nearly 14 percent of individuals
on Medicare discharged from a hospital to a
skilled nursing setting are readmitted to the
hospital for conditions that could potentially
have been avoided. The HHS 2014 budget
proposal recommends reducing payments by
up to three percent for skilled nursing
facilities that are determined to have high
rates of preventable hospital readmissions.
The proposed penalties would take effect in
2017, with an estimated $2.2 billion in savings
over 10 years.
Home Health Specifics
Clinical Considerations
Front Loading--- remember
the 3-7 day window
Call—ask for report
Ask the right questions—
church + hair appoint=danger,
How does weight and blood
pressure fit into the day?
Who is helping?
At Risk Patients are easy to
The presence of a primary care
The presence of follow-up visits
Spouse and/or family support
Insurance Coverage
Choice Rehab, A Division of Nathan Jackson, PLLC, is a rehab management, staffing, and consulting firm. We specialize in
providing custom solutions for our clients and improved integration of services through the healthcare system. Our focus is
on improved patient outcomes through multi-level cooperative program development. Choice provides care solutions at
the acute, sub-acute, home health, and outpatient level. We believe that rehabilitative management throughout the
patient continuum is a vital component for a health care providers success.
p(855) 485-8273
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