REDUCING READMISSIONS FOR CHF PATIENTS

REDUCING READMISSIONS FOR CHF PATIENTSDO DIETITIANS HAVE A ROLE?Renee Wing, Sodexo Dietetic InternOrange Park Medical Center

January 22, 2013What the previous cartoons illustrate is some of the challenges we, as dietitians face. Providing education to patients and ensuring they understand the information, working against all of the myths and fad diets, helping patients adhere to dietary recommendations, and the lack of follow up we are able to provide.

With that, my presentation today is on reducing readmissions for CHF patients and looking at whether dietitians do and/or should have a role in these efforts.4AGENDAHighlights of the legislationStatisticsInterventions Dietitians role

This is the agenda for the presentation.

I will go over some details of the Readmission Reduction Program.I will highlight some statistics about CHFI will summarize a few interventions that have been shown effective in reducing readmissionsI will share what I found regarding the role of dietitians and then open it up for a little discussion to hear what you think about our role.5WHY NOW?Section 3025 of the Affordable Care Act - Readmission Reduction Program.

Starting October 1, 2012, payments to hospitals exceeding a formulated readmission ratio will be reduced.Up to 1% in 2013 Estimated savings of $300 millionUp to 2% in 2014Up to 3% in 2015Approximately 1 in 5 Medicare patients end up back in the hospital within 30 days. Estimated that only 10% of these readmissions are planned.

Each year the ratios will be recalculated based on 3 years of data. 2013 was based on data from 2008-2011; 2014 will be based on 2009-2012; and 2015 will be based on 2010-2013.

Up to 1% in 2013, up to 2% in 2014 and up to 3% in 2015. Estimated savings represent about 0.3% of total Medicare payments.

This refers to overall Medicare reimbursement. As an example, if a hospital received the maximum penalty of 1 percent and it submitted a claim for $20,000 for a stay, Medicare would reimburse it $19,800.

2,217 hospitals are receiving penalties; approximately 46%. 1,910 hospitals will receive penalties less than 1 percent; The smallest penalty is one hundredth of a percent, which49 hospitals will receive. 307 hospitals receive the maximum 1% penalty.

Just to illustrate the kind of impact this has, Massachusetts General Hospital in Boston, which U.S. News recently ranked as thebest hospital in the country, will lose 0.53 percent of its Medicare payments because of its readmission rates, the records show.http://www.kaiserhealthnews.org/Stories/2012/August/13/medicare-hospitals-readmissions-penalties.aspx

6CURRENT RULEDischarge diagnoses of CHF, AMI, and Pneumonia are used as measures to evaluate readmissions.

Additional discharges to be considered include: COPD, CABG, PTCA, and other vascular surgeries. To be reviewed in 2015.The current rule and calculations, as well as those for the next 2 years, are based on the readmissions of Congestive Heart Failure, Acute Myocardial Infarction, and Pneumonia.

In 2015, the program will be reviewed and additional diagnoses will be considered: Chronic Obstructive Pulmonary Disease, Coronary Artery Bypass Graft, Percutaneous Transluminal Coronary Angioplasty, and other vascular surgeries.

These are the 7 conditions associated with approximately 30% of preventable readmissions.

CHF and pneumonia have the highest volume and expenditure. Had National Quality Forum (NQF) endorsed criteria for readmission and exclusions.

While these are the conditions used as measures and for calculations, these are not the only diagnoses affected by the penalty. The penalty is across the board for all Medicare reimbursements.7WHAT COUNTS?Readmission admission to a hospital within 30 days of discharge from the same or other hospital.

Readmission does NOT need to be for the same condition or a related condition.Admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital.

For example, A Medicare patient is admitted to OPMC for SOB, is d/c after 3 days. 20 days later the patient is admitted to St. Vincents with abdominal pain; this would count as a readmission against OPMC.

The rule refers to all-cause readmission which means the readmission does not need to be for the same problem as the initial admission or even related to it.

According to CMS, all-cause readmission was used because for the patient, any readmission is an adverse event. They also wanted to eliminate the potential for hospitals to change the way they code in order to avoid being counted in readmission measures. So, if only certain diagnoses were to be counted, they thought there was a possibility that hospitals would avoid using those codes for readmitted patients in order to avoid penalty.8EXCLUSIONSTransfer to another acute care facility.Planned readmissions.Same day readmissions for the same condition.Discharged against medical advice.Patient without at least 30 days of post-discharge enrollment in FFS MedicareMarylandIf discharged to a long-term care facility and readmitted to the hospital within 30 days, this DOES count as a readmission.

Planned readmissions such as for scheduled surgeries.

Maryland hospitals are exempt due to a federal waiver concerning how Medicare pays hospitals there.9CHF STATISTICS1 million hospitalizations in 2010

Costs $34 billion annually

Among the conditions associated with 30% of preventable readmissions.

Highest volume and expenditure (along with pneumonia)http://www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_heart_failure.htmCHF #1 most frequently used discharge diagnosis for Medicare patients; pneumonia #2, AMI #8

Act also required that conditions have readmission measures endorsed by the National Quality Forumhttp://www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_heart_failure.htm

Hospital Readmissions Reduction Program Overview pdf in folder10

CHF STATISTICShttp://www.cdc.gov/nchs/data/databriefs/db108.htm

Total number is the same, but % of people 1 indicates excessive readmissions.

Penalty is what will affect all Medicare payments to the hospital for 2013. 9 FL hospitals receive full 1% penalty, 25 have 0%

Get with the Guidelines medications. Diet education (written instructions), diabetes education, diabetes treatment, daily weight, omega 3 supplement14WHAT CAUSES READMISSIONS? Factors beyond anyones control Disease Specific Factors Patient Factors Physician Factor System Factorshttp://www.capanet.org/uploadedFiles/Content/Conferences/2012_Handouts/1006-1600_Kersh-CausesOf30DayHospReadmissionInHeartFailurePatients.pdfhttp://www.capanet.org/uploadedFiles/Content/Conferences/2012_Handouts/1006-1600_Kersh-CausesOf30DayHospReadmissionInHeartFailurePatients.pdf

Examples:Geography varies among states; 2009 Illinois, Kentucky, Alabama had rates >20%; Idaho, Colorado