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Avoiding the Readmissions Penalty Zone: Population Health Management for High-Risk Populations
Avoiding the Readmissions Penalty Zone: Population Health Management for High-Risk Populations
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Still smarting from $280 million in penalties levied by CMS in FY 2013, hospitals and health systems can't afford to take time out from efforts to reduce avoidable hospital readmissions in the Medicare population.

Avoiding the Readmissions Penalty Zone: Population Health Management for High-Risk Populations delivers winning process improvements and interventions that can help organizations make measurable progress toward reducing readmissions in high-risk populations, including a look at a health system-SNF network that has curbed rehospitalizations and length of stay for participants.

In 2012, CMS reduced reimbursement for 2,217 hospitals for excess 30-day readmission ratios related to AMI, heart failure and pneumonia. CMS plans to expand not only the list of target conditions but also its focus on the quality of hospitals' transitional care — the handoff of patients from one care site to another.

This 40-page resource opens with cross-continuum tactics to lessen the financial impact of the CMS Readmission Penalty program from Amy Boutwell, MD, MPP, president of Collaborative Healthcare Strategies, who draws on her experience as co-founder of the IHI STAAR (State Action on Avoidable Rehospitalizations) Initiative. She is also senior physician consultant to the National Coordinating Center for the CMS QIO Care Transitions Theme.

Dr. Boutwell covers these areas:

  • Creating a diversified and stratified approach to reducing readmissions;
  • Developing a practice change culture to respond to clinical conditions that ensures patients are treated at the right site of care;
  • Staying ahead of readmissions data and projected CMS penalties (a 2 percent increase is planned for FY 2014 and a 3 percent increase in fiscal 2015);
  • Reviewing care processes, readmissions and enabling testing and implementing practice improvements to reduce readmissions;
  • Making the improvements needed in reducing readmission while incurring penalties;
and much more.

Dr. Boutwell advises hospitals to monitor what goes on across its care continuum and to partner with facilities it discharges to most often to reduce 30-day readmissions. Summa Health System has done just that with the development of its Care Coordination Network, a community partnership with skilled nursing facilities (SNFs), that is reducing hospital readmission rates and average length of stay for patients transferred to these SNFs.

Avoiding the Readmissions Penalty Zone: Population Health Management for High-Risk Populations presents this case study in reducing SNF-to-hospital readmissions. Carolyn Holder, manager of transitional care for Summa Health System and Michael Demagall, administrator of Bath Manor & Windsong Care Center, two SNFs participating in the network, describe the partnership:

  • Three key areas that improved care transitions between Summa's hospitals and SNFs in its community;
  • Strategies implemented by Summa to address the key hospital-to-SNF transition challenges;
  • Steps in developing a QI process that monitors transitions to identify weaknesses in the care transition process; and
  • Development and enhancement of the partnership as the hospital system works toward development of an ACO.

Table of Contents

  • Cross-Continuum Strategies to Lessen the Financial Impact
    • CMS Sliding Scale Penalties
    • 2015 Condition List Expansion
    • Considerations for Transitional Care
    • STAAR Readmissions Toolkit
    • Four Domains of Process Improvement
    • Cross-Setting Portfolio of Strategies
    • 5 Recommendations to Reduce Readmissions Penalties
    • Moving from Pilot to Portfolio
  • Case Study: SNF Care Coordination Network Reduces SNF-Hospital Readmissions
    • Developing a Care Coordination Network
    • Decision to Developing a Care Coordination Network
    • Staffing and Implementing a Care Coordination Network
    • What Does the Care Coordination Network Accomplish?
    • Barriers to Patient Care
    • Formulating Solutions to Barriers
    • Transfer Form for Post-Acute to the ED
    • Measuring Outcomes Between Facilities
    • Calculating Readmission Rate
    • Formation and Development of an ACO
  • Q&A: Ask the Experts
    • Can Home Visits Help to Reduce Readmissions?
    • Community Providers and Partnerships
    • High-Risk Diagnoses Requiring Population Health Management
    • Evidence for Clinical Pharmacists
    • Transitioning Patients Between Care Sites
    • Sharing Information between SNF and Hospital
    • Physician Interaction with Patients in SNFs
    • Sharing Preferred Provider Information with Patients
    • Giving Patients a Provider Choice
    • SNF Specializations
    • CHF Transition Protocol
    • Future Program Enhancements
  • Glossary
  • For More Information
  • About the Speakers
Publication Date: February 2013
Number of Pages: 40
ISBN 10: 1-939167-08-6 (Print version); 1-939167-09-4 (PDF version)
ISBN 13: 978-1-939167-08-8 (Print version); 978-1-939167-09-5 (PDF version)
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