Eli's Rehab Report

Hint: The biggest cause of readmissions is not related to the admitting Dx.

Did you know that the Affordable Care Act sets parameters for more than just health insurance? It established the Hospital Readmissions Reduction Program — which requires CMS to reduce payments to hospitals with excess readmissions effective for discharges beginning Oct. 1, 2012.

“Currently acute care hospitals are penalized for readmissions from myocardial infarctions, heart failure and pneumonia,” notes Fran Fowler, FAAHC, principal of Fowler Healthcare Affiliates in Marietta, GA. “Other diagnoses that have the CMS’s attention include amputations of the lower extremity, heart valve procedures and debridement of a wound, infection or burn; however, plans to include these diagnoses are not evident at this time.”

Payment penalties for readmissions are also steadily increasing. Once 2 percent in 2013, penalties are now 3 percent in 2014. Also, the Hospital Readmission Reduction Program will add two new measures in 2015 — COPD and total hip/total knee arthroplasty.

Plus: “Several post-acute care settings are implementing all-cause readmissions measures including inpatient rehabilitation facilities, home health, and long term care hospitals,” notes Heather Smith, PT, MPH, program director of quality for the American Physical Therapy Association (APTA).

Get to the Root of the Problem

There are many culprits to hospital readmission, but the biggest cause of readmissions is usually not related to the admitting diagnosis, Fowler points out. For example, a UTI might develop as a result of the acute care stay, or the patient may experience congestive heart failure secondary to intensive rehab.

“The most common diagnoses for readmission have been pneumonia, myocardial infarctions and heart failure,” reports Anita Bemis-Dougherty, PT, DPT, MAS, lead clinical practice specialist for the APTA.

"System issues” are also to blame, “such as the discharge planning process, failures in communication, transitions to post-acute care, and lack of clarity about who is responsible for the patient’s care after hospital discharge,” Bemis-Dougherty adds.

More obvious risk factors for readmission include older age, functional limitations, and multiple chronic conditions, but don’t underestimate, immobility during the hospital stay. “In an article by Brown (2009. J Am Geriatric Soc; 57, p. 1660), 83 percent of the measured hospital stay was spent lying in bed,” Bemis-Dougherty cites. “This loss of mobility and function can put patients at risk for falls post-discharge” — making therapy’s role in pushing early mobility absolutely crucial.

Use These 7 Tickets to Success

Therapists play a key role in reducing readmissions. The following is a checklist of ways to make a positive impact — and take the heat off your reimbursements.

• Good preadmission screening. “Review for any procedures that could lead to complications in the post acute care stay (e.g. catheterization) and any instance during that acute care stay that suggests instability,” Fowler suggests — for example, the number of consulting physicians, medication allergic reactions, fevers, etc.
• Stellar clinical decision-making skills. “If physical therapists are involved in the discharge planning process and if the PT’s discharge recommendations are followed, the patient is less likely to be readmitted,” says Bemis-Dougherty, referencing a study by B.A. Smith et al in Physical Therapy 2010.
• Discern the “high observation patient” right off the bat. Two to three days post admission, ensure all medical conditions are noted and are addressed in the plan of care, Fowler says. “As part of the high-observation period, proper therapy build-up and monitoring patient reaction and tolerance are keys to ensuring that patients are not overly fatigued.” For patients with known chronic conditions, such as COPD, consider 15-minute intervals of therapy or therapy at the bedside, she adds.
• Sufficient rest periods between therapies. Nurses are key to ensuring that rest is happening. On a related note, “check daily weights, and follow up with early dietary intervention if weight loss is occurring,” Fowler says.
• Vital sign monitoring pre- and post-therapy. “Do this for the first two days to set a benchmark, and do additional monitoring if the patient shows early signs of distress,” Fowler recommends.
• Ensure a medical physician is available (to early consult for patients showing signs of complications or distress.) “The key to preventing readmissions is early detection and intervention,” Fowler says.
• Nail the educational component. Remember, you can “provide extensive patient and caregiver education prior to discharge to ensure a safe transition to home,” Bemis-Dougherty says. Be sure to include “recommendations for follow-up and also to make sure that patients take a more active role in their care transitions.”