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CMS released a statement on Thursday, July 9, saying that its Hospital Compare Web site will now contain data reporting how frequently patients return to a hospital after being discharged, “a possible indicator of how well the facility did the first time around,” says the statement.
The statement goes on to say that, on average, one in five Medicare beneficiaries discharged from a hospital is readmitted within a month. President Obama and Congress are focusing on reducing readmissions as a way to improve quality and achieve cost savings, according to the statement.
Hospital Compare data show that 19.9% of patients admitted to a hospital for heart attack treatment will return to the hospital within 30 days, 24.5% of patients admitted for heart failure will return to the hospital within 30 days, and 18.2% of patients admitted for pneumonia will return to the hospital within 30 days.
“Research has shown that hospital readmissions are reducing the quality of healthcare while increasing hospital costs,” the statement reports.
“Providing readmission rates by hospital will give consumers even better information with which to compare local providers,” said Charlene Frizzera, CMS Acting Administrator. “Readmission rates will help consumers identify those providers in the community who are furnishing high-value healthcare with the best results.”
CMS has also changed the way it calculates mortality rates. In past years, it used only one year of claims data to compute mortality, while now it will use three years of claims data.
CMS says that reporting three-year mortality data will also help inform the public about hospital quality. Using the three-year data method, CMS estimates that the national 30-day mortality rate for patients originally admitted for heart attack care is 16.6%. For heart failure patients, the national 30-day mortality rate is 11.1%, and for pneumonia patients, the national rate is 11.5%.
The Hospital Compare Web site will show whether a hospital’s mortality or readmissions rate is “better than,” “no different from,” or “worse than” the U.S. national rate.
Hospital Compare also includes 10 measures that capture patient satisfaction with hospital care, 25 process of care measures, and two children’s asthma care measures. The site also features information about the number of selected elective hospital procedures provided to patients and what Medicare pays for those services.
The Hospital Compare Web site can be found at www.hospitalcompare.hhs.gov.
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The spotlight’s shining on readmission rates. A Commonwealth Fund–supported study published in the April New England Journal of Medicine found that one-fifth of Medicare beneficiaries return to the hospital within 30 days of discharge and one-third return within 90 days. The study stated that unplanned readmissions cost Medicare $17.4 billion in 2004.
Developed by Timothy Bickmore, PhD, assistant professor of computer and information science at Northeastern University in Boston, the virtual patient advocate is on clinical trial at Boston Medical Center to increase patient understanding of postdischarge self-care regimens. Bickmore and his team of researchers hope the system can decrease patient readmissions within 30 days of hospital discharge.
“Nationally, it’s been shown that about 20% of patients get readmitted within 30 days,” says Bickmore, who adds that one-third of those readmissions are preventable. “There is a lot of information patients need to know before they go home. The typical discharge in the [United States] lasts about eight minutes and it’s like, ‘Here are your prescriptions and a pat on the back.’ ”
Check out the July 2009 issue of Case Management Monthly to read the full article.
Patients typically arrive at the hospital as planned, urgent, or emergent admissions, and are registered in different ways. Errors made during the registration process can have a negative impact all the way to throughput and discharge planning. For this reason, the hospital may want to consider a performance improvement project to identify if there are registration errors, the types and frequency of these errors, and when they occur. For example, do errors occur more often on emergency admission on the night shift? What types of errors are they? Are they duplicate medical record numbers, errors in Social Security numbers, or the spelling of patient names? Any of these issues will have an impact on patient safety, discharge planning, and even billing or denials.
Editor’s note: This tip comes from HCPro’s newest training resource for hospital case managers—Core Skills for Hospital Case Managers: A Training Toolkit for Effective Outcomes by Beverly Cunningham, MS, RN, and Toni Cesta PhD, RN, FAAN, available now at HCMarketplace.com.
Q: I am a case manager on a cardiac step-down unit. Our case managers’ work focuses primarily on l specific disease management and patient contact/education and nurse mentoring/chart reviewing, patient rounding, etc. We are very clinically focused.
We don’t do utilization review (UR) or discharge planning. We face the issue of case manager documentation. Legally, what must we document?
A: In this model, not doing utilization review allows the case manager to really focus on clinical progressions, which should be the focus of his or her documentation. The case manager should document how sick the patient is, and how the patient is progressing clinically each day. There’s no legal requirement for the case manager in this position to document, but there is a professional requirement to document the clinical progression as well as what the case managers taught the patient prior to discharge and how the patient responded. Every time they see, touch, or talk to a patient, the case managers should document.
This question was answered by Karen Zander, RN, MS, CMAC, FAAN.
Q: Has anyone developed specialty-specific history and physical (H&P) forms, such as an H&P for an orthopedic admission, an H&P for a medical admission, or an H&P for general surgery? We use the same H&P for all admissions and day surgery visits; however, our surgeons have challenged these forms on the basis that there are many items that are irrelevant to surgery admissions. For example, they want to limit the physical exam to a general exam (i.e., heart, lungs, and chest). They do not want to examine the abdomen, back, head, ears, eyes, nose, throat, or any other areas that might be more relevant to a general admission.
A: There is no regulation that requires specialty-specific H&Ps. Medical staff members should identify—at a minimum—what the H&P should include. For example, our policy states that at a minimum, the H&P for both inpatient and outpatient visits must include:
- A history related to the admission/surgery
- Examination of the heart, lungs, and mental status
- A specific examination related to the condition for which the patient is being treated
It also includes a plan for anesthesia, when appropriate, and a plan of care.
Editor’s note: Jean S. Clark, RHIA, CSHA, service line director for health information management services at Roper Saint Francis Healthcare in Charleston, SC, answered this question.
Q: If my hospital is not using the latest InterQual criteria, could that chart be pulled by the RAC for fraud?
A: InterQual is merely a screening criteria—CMS doesn’t actually require hospitals to use it. Therefore, use of an older version or a different set of criteria such as Milliman is not inherently a problem. However, because outside entities such as RACs, MACs or QIOs will be reviewing cases, most hospitals choose to use the same version used by their contractors (presumably the version for the year applicable to the case). Additionally, outdated versions may not reflect advances in care and may cause inappropriate screening decisions.
Note that a patient may not meet InterQual inpatient criteria, but still be considered an inpatient upon physician review. InterQual is a screening criteria—it screens for the most likely inpatient and outpatient admissions, but can not take into account every medical circumstance. There are a percentage of patients, who will fail inpatient criteria due to factors not considered in the InterQual criteria that upon physician’s review will nevertheless be appropriate for inpatient admission.
For this reason, each permanent RAC will now have at least one physician medical director who will be involved in developing evidence for individual claims determinations and act as a resource for all reviewers making such individual claim determinations. Additionally, the provider has the opportunity to request that the medical director participate in discussions regarding individual claims denials.
In addition, RACs do not audit for fraud. Their only task is to look for overpayments and underpayments, either due to errors by the hospital or by CMS’ processing systems. RACs are simply looking for incorrect payments, no matter whose fault, and getting that money back to the Medicare Trust Fund after taking their cut. Of course, if a RAC believes it uncovers a fraudulent scheme or set of practices, it may make an appropriate referral to one of the contractors monitoring for fraud, but it is not a part of their scope of work.
Editor’s note: This question was answered by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.
The California Department of Public Health has collected approximately $1.2 million in fines from hospitals for “never events” and other serious mishaps.
“Never events” are 28 occurrences on a list of inexcusable outcomes in healthcare settings compiled by the National Quality Forum. These adverse events are serious, largely preventable, and of concern to healthcare providers and the public for the purpose of accountability.
The latest round of fines included penalties for incidents such as failure to use respiratory equipment correctly and failure to transfuse a patient. One hospital failed to promptly investigate the alleged sexual assault of a patient by a staff member.
The state plans to use the funds collected via fines for safety and error prevention educational programs.
Source: HealthLeaders Media
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