30 Day readmissions for CHF patients David Herbetko Thomas Jefferson University 30 Day readmissions for CHF patients Abstract Hospital readmissions are a prominent healthcare issue today. The Centers for Medicare and Medicaid Services are experiencing financial losses in the billions in regards to this patient population. Within the Patient Protection and Affordable Care Act, Section 3025 passed the Hospital Readmissions Reduction Program. This program identifies hospitals with large-scale readmission rates for patients within thirty days of discharge related to congestive heart failure, heart attack, and pneumonia, and marked them liable for the penalties of the program.
According to the Centers for Medicare and Medicaid Services (2012) readmission is defined as an admission into the hospital within 30 days of a discharge from the same hospital or another sub-section hospital. Reducing the rates of unnecessary readmission into acute care facilities has now become the focus on healthcare quality improvement efforts through the use of the transitional care model. Readmissions are expensive. In 2011, the Healthcare Cost and Utilization Project estimated that 30-day adult all-cause hospital readmissions were associated with around $41.3 billion in hospital costs (2011). To reduce the relatively high rates of readmissions, especially for Medicaid/Medicare patients who encompass a total estimate of 130 million beneficiaries (CMS 2017), the Affordable Care Act implemented the Hospital Readmission Reduction Program abbreviated as HRRP, which financially penalizes hospitals with relatively high rates of Medicare readmissions.
Introduction For several decades, government officials and healthcare experts have been discussing the broken and dysfunctional US healthcare system. The US ranks highest for cost and lowest for outcomes. Healthcare accounted for 17.4 percent of the gross domestic product in 2013 (CMS.gov). The Institute for Healthcare Improvement highlighted the quality of healthcare in the US or lack of quality with the 100,000 lives campaign. The Institute for Healthcare Improvement brought national attention and awareness to the epidemic of hospital errors and the loss of life related to those errors.
With this knowledge for these populations, it is essential to include FCC components in the hospital-school transition program. FCC components include the following core concepts: information sharing, dignity and respect, collaboration, and involvement. Information sharing is important to include in this school-reentry program because it is important to communicate between the entire unit in useful ways while providing complete and accurate details, and including families in the decision-making process. Dignity and respect are important for this transition program because the healthcare team should support and honor patient/family ideas to individualize the reentry process. Collaboration is a key concept of FCC that should be included in the school-reentry program because it invites everyone to work together to develop the most effective and customized plan for the patient.
Working in a renal/urology medical-surgical unit, it is a challenge for both the nursing staff and nursing administration to have readmissions due to fluid and electrolyte imbalance from patients with ESRD and CHF. In my own experience, patients who have been in and out of the hospital for the past six months to a year are at a higher risk of acquiring nosocomial infections resulting in a weaker immune system to an already compromised one, as well as longer hospital stay. Readmissions from these patients pose as a physical, emotional and financial strain to both patients and/or their families. Additionally, readmissions within 30 days for patients with CHF poses as an additional cost for hospitals as there is reduced Medicare payments for Inpatient
Although, due to the recent presidential election, it is currently uncertain how HF readmissions may affect our future economic standpoint. Therefore, the healthcare environment must continue to review processes to be incoherent with possible upcoming changes.
This act led to changes within hospitals and workplaces across the nation. One change is the way hospitals are run. According to Roper, "That means hospitals are focusing on what happens after a patient is released-- are they getting follow-up care, seeing their primary physician, taking necessary medications? And hospital care is being even more closely documented" (2). Because
Medicare reimbursement is partially based on a facility’s Star Rating. A critical component to this is patient surveys and HCAHPS. I have seen a push toward the customer service experience. Indeed, I feel strongly that every healthcare worker including nurses should treat each of their patients with respect, equality and do the absolute best to meet their needs.
These types of care are covered when deemed medically necessary during a benefit period that begins when a patient is admitted as an inpatient in a hospital or skilled nursing facility and ends when they haven’t received care for 60 consecutive days. Each time a patient receives care during a new benefit period, the beneficiary must pay the inpatient deductible and copayments for all services during that beneficiary period. The duration of the benefit period determines the amount of deductibles and copayments and is due by day 60. The benefit period provides coverage up to 90 days, after which, a beneficiary who still needs care can use their nonrenewable lifetime reserve of up to 60 additional days of inpatient hospital care. After a beneficiary has exhausted all of their care days, whether they use the covered 60 days or have exhausted their additional lifetime reserve, they are responsible for all costs associated with additional care for that benefit
A therapist may do this once again in order to continue to receive reimbursement from Medicare for their services in order to generate more revenue for the clinic. Prior to the Jimmo versus Sebelius case in 2013, Medicare would deny coverage to patients receiving maintenance care for their condition due to their inability to demonstrate improvement from the skilled therapy services that they received (“Jimmo v Sebelius Settlement Agreement Factsheet,” 2013). However after the Jimmo versus Sebelius case, the Centers for Medicare & Medicaid Services revised portions of the manual which now states that coverage “does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care” (“CMS Manual System,” 2014). The correct action for the therapist to take in order to be in compliance with the rules is to provide adequate documentation as to why the patient would need and benefit from maintenance care services in order to prevent or slow the deterioration of their condition. An alternative would be to discharge the patient if they no longer require skilled and medically necessary services (“Jimmo v Sebelius Settlement Agreement Factsheet,” 2013) (“CMS Manual System,”
The insurance companies are in charge of the length of patients stay, depending on what the patient's insurance is, they can be kicked out in two days. I have a very difficult time processing how these insurance companies feel that a couple days stay for a patient detoxing, attempting suicide, or trying to kill someone, can be rehabilitated. If I had the power to get in touch with insurance companies and formulate an educational program for these agencies and educate them on how long it should take to stabilize a patient and deem them healthy enough to be discharged, I would do so (Adams, LeCroy, & Matto, 2009). I have also noticed that free time is spent watching television. I am in the youth unit most of the time and the children are constantly watching television or playing video games.
Previously, majority of healthcare systems were driven by other goals such as ensuring enhanced care access, containing the costs of healthcare delivery, and promoting patient convenience/customer service in a bid to improve the efficiency and quality of healthcare. However, the financial collapse had far-reaching consequences for the healthcare systems as it
Hope is not lost for our nations veterans, there are initiatives that may be implemented in order to improve the quality of care. We have identified four key areas that we feel will improve the quality of care for our nations veterans. These areas are; Patient Aligned Care Teams (PACTS), the program of vocational rehab, positive media relations, and universal electronic medical records. PACTS are formed when a veteran works together with multiple care disciplines in order to achieve whole person care and sustain life long wellness (VHA, 2015). These teams focus on patient medical partnerships, access to care, coordinated care among disciplines, and team based care with the veteran as the focus (VHA, 2015).
In January 2014, CNN reported the death of nineteen veterans at a VA hospital due to delayed diagnosis and treatment (Singh, et al., 2010). On April 23, 2013, forty veterans died waiting to see a doctor at Phoenix VA health care system (Singh, et al., 2010). According to the CNN reporter, the patients were on a secret list meant to keep VA officials at Washington in the dark as a recently retired VA doctor disclosed. The Phoenix case is a representation of the trouble that the majority of veterans face while attempting to access medical services from VA hospitals. Since 1923, scandals have dominated the VA hospitals (Singh, et al., 2010).
Physicians and Hospitals go hand in hand when it comes to the medical care of patients, and it is this relationship that allows the patients to receive the care they need and deserve. It is also this relationship that we as health care administrators need to understand. In order to fully understand this relationship we need to define the concept of the integrated physician model. We also need to explain the importance of clinical integration in the strategic planning process, and the dynamics of and controversies surrounding accountable care organizations and alternative approaches to the current health system. I will also explain the advantages and disadvantages for hospitals and physician’s models.