Readmissions have become an increasingly urgent concern for skilled nursing facilities not only because they are traumatic for residents, but also because under the Affordable Care Act, hospitals’ Medicare reimbursements have been tied to readmission rates. For the past few years, skilled nursing facilities have tried to attract referrals by showing that they can help hospitals keep readmissions low.
The Protecting Access to Medicare Act of 2014 recently made the issue even more pressing. Under the law, skilled nursing facilities will have Medicare reimbursements linked to their own readmissions rates starting in 2018. The language of that law should guide SNFs’ readmission reduction efforts. The law ties Medicare payments to the number of “potentially preventable” readmissions. So, first providers need to understand what potentially preventable readmissions are, and then they need to target efforts on those. By focusing on preventable readmissions, operators can get maximum results with the greatest efficiency.
A basic definition of potentially preventable readmissions is that the rate at which they occur can be reduced through early recognition and appropriate treatment. This separates them from readmissions for elective procedures and acute events that are outside the scope of practice for SNFs. To get a clearer understanding of potentially preventable readmissions you can look at a February 2014 Office of the Inspector General report on adverse events in skilled nursing facilities. It stated that 22% of Medicare SNF residents experienced an adverse event in fiscal year 2011, and over half of those people were hospitalized. Almost 60% of the adverse conditions were deemed “clearly or likely preventable” by physicians who reviewed patient charts. The report listed these preventable conditions, which include medication-induced delirium, fluid and electrolyte disorders, and catheter-associated urinary tract infections.
Proper calculation of readmission rates and adjusting for resident risk of readmission is a starting point. The 2014 March MedPAC report to congress provides national risk-adjusted rates against which you can compare yourself.
So, how do SNFs reduce potentially preventable readmissions? Targeted performance improvement projects are the answer. Also, having the right software can make a huge difference. The abaqis® Quality Management System, for example, allows SNF leaders to see at-a-glance residents’ specific readmission risk factors, determined through sophisticated predictive models. These models beat the traditional assessment method, in which a clinician comes up with a relatively subjective risk categorization for residents. The abaqis resident risk profiles can be used to identify the clinical risks associated with potentially avoidable readmissions so that providers can proactively address these issues.
For example, an operator might discover a very high rate of readmission for sepsis that seems secondary to urinary tract infections. A root cause analysis should follow, which could start with the fact that UTIs often begin with indwelling catheters. Then, ask how aggressive are we at removing these catheters, which often can be done right at admission? What alternatives are we considering? How rapidly are we moving to reduce catheter-associated UTIs leading to sepsis?” A system such as abaqis includes a wide array of data to inform performance improvement projects. For example, facility leaders can use the program to quickly see whether a resident is being treated by an on-call or attending physician. If having an on-call doctor is associated with readmissions, the facility might intervene with the physicians.
The data-driven method described here follows the principles of Quality Assurance & Performance Improvement (QAPI). Nursing homes are preparing for a forthcoming Centers for Medicare & Medicaid Services rule that will formally replace current quality assurance regulations with QAPI. So, if you can become more data driven you will be ahead of the curve both for future readmissions penalties and the upcoming QAPI regulation.
Although skilled nursing operators are facing the important task of reducing readmissions, there is good news on achieving this goal: There is an alignment between policy and providing good clinical care to skilled nursing residents, and there are powerful software tools that can give providers a distinct advantage.
Earlier in the summer my colleague, Michael K. Lin, Ph.D., chief scientific officer of Providigm, and I conducted a webinar on this subject sponsored by Medline that McKnight’s presented. To listen to the full presentation click here.