Blog | Medicare Compliance RAC OIG

Managing the 30-Day Readmissions Window

Blog | Medicare Compliance RAC OIG

Managing the 30-Day Readmissions Window

Mary Kay Thalken explains that ensuring continuity of care to reduce readmissions requires a current, comprehensive referral network. Automating the process can be helpful as well.

Avoiding hospital readmissions while ensuring patient safety and high-quality care is a critical concern for hospitals. To do so, hospitals must effectively manage care across the continuum—including the 30 days post-discharge during which a hospital can be penalized for a readmission, as defined for Medicare payment purposes—by building up strong post-acute care networks.

Pressure to Reduce Readmissions

As part of the Affordable Care Act, the Hospital Readmissions Reduction Program requires that the Centers for Medicare & Medicaid Services (CMS) reduce payments to hospitals by up to 3 percent per readmission occurring within 30 days of discharge. Therefore, as hospitals seek ways to decrease length of stay (LOS), they also are looking to reduce the number of 30-day readmissions. Reaching a balance is complex—shorter stays often lead to higher readmission rates that result in penalties. 

Hospitals have tried various approaches to effectively coordinate care and transition patients from the hospital setting to a post-acute care, skilled nursing, or home care setting. Many of those discharge planning options involve manual processes performed by clinicians and case workers whose time could be better spent with patients. Such practices are costly and impractical and have a negative financial impact.

Tracking and Decreasing LOS

Many facilities lack the capability to track LOS for patients waiting to go to skilled nursing, post-acute rehab, or home care, causing avoidable delays. Being unable to capture and track LOS data puts hospitals at a disadvantage because they cannot obtain the measures that can tell them how to improve LOS. To initiate and sustain change, discharge planners, case managers, and finance officers must identify the root causes of avoidable delays in relation to these patients.

Inefficiencies Undermine Productivity, Care Transitions, and Financial Performance

In today’s value-based care environment, organizations are pressed to improve quality, reduce costs, and promote patient satisfaction. Hospitals simply cannot afford the cost of poor care transitions.

Inefficiencies have a notable impact on overall productivity in a specific department and throughout the organization. For example, relying on social workers and registered nurse case managers to do clerical work takes time away from the patients whose cases are clinically, socially, and financially complex. Eliminating clerical inefficiencies translates to dollars saved.

Case Example

For discharge planners, referring patients after discharge for home care, hospice, rehab center, or other placement is an inherently challenging task, but the difficulties are compounded if they require an intermediate placement and cannot find one. Ensuring continuity of care to reduce readmissions requires a current, comprehensive referral network. When seeking the best placement, discharge planners can best help patients and their families if the process is automated and includes access to a list of facilities with appropriate questions to ask. 

By implementing process improvements and enabling technology, one Upper Midwest tertiary medical center was able to better manage post-discharge referrals, resulting in significant time and cost savings. The center began by studying the impact of inefficiencies and identifying the following challenges:

  • Low post-acute care provider participation under the previous discharge system (50 percent)
  • Providers deterred from joining post-acute referral network under pay-to-play model
  • Discharge staff tied to phone calls, faxing, and follow-up calls to post-acute providers
  • Stagnant LOS
  • Fragmented discharge process not conducive to increased efficiency

In preparation for value-based care and participation as an accountable care organization (ACO), the medical center reevaluated its discharge planning process with an eye to achieving five goals:

  • Reduce LOS index
  • Increase provider participation and satisfaction
  • Reduce provider response times
  • Improve staff adoption and satisfaction
  • Increase patient satisfaction

Achieving these goals would require more than implementing new technology. The facility took the following steps to improve processes:

  • Reexamined every process devoted to patient transfer and discharge to identify improvement opportunities.
  • Evaluated the existing post-acute network arrangement to promote provider participation for patient referral business, develop stronger post-acute care relationships, and provide the best options for each patient.
  • Undertook a complete workflow redesign to optimize existing processes. Many discharge planning staff were using disparate manual procedures to facilitate the discharge—leading to rework, missed steps, and frustration among staff.
  • Standardized procedures to improve efficiency for everyone involved. Using standardized forms, workflows, and processes saved time and enhanced the ability to efficiently move patients and improve throughput.
  • Evaluated technology-enabled analytics to focus on facilities that could benefit from improvement more than others. The organization wanted to determine, for example, which facilities were slower in responding to referrals, which had difficulty retrieving the delivered packets of patient information, and which were provided the best care focused on particular patient diagnoses compared to others. 

Through careful evaluation and planning prior to implementing new technology, the medical center was well positioned to improve bottom-line financial results and patient outcomes. After six months of using an automated referral system, the facility saw a 5 percent drop in the skilled nursing facility LOS index. Home health and acute rehab LOS dropped 12 and 8 percent respectively. Overall, increased efficiencies yielded net savings of $1.2 million annually—a significant ROI.

From hospital discharge to post-acute placement or recovery at home, the right people, processes, and care coordination technology help manage patient care transitions in a way that helps prevent avoidable readmissions. 

Mary Kay Thalken, RN, MBA, is chief clinical officer of Ensocare in Omaha, Neb. 

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Mary Kay Thalken

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