In order to qualify for the quality point in the hospital readmission category, each facility will be evaluated on their number of preventable hospital readmissions. This point is one of the five points that each facility has the potential to earn.

Qualifying for the Hospital Readmission Quality Point

Facilities will earn one point if their facility’s actual hospital readmission rate is at or below the risk-adjusted expected rate calculated for the facility. Another notable aspect in the calculation of this point is the fact that all of the data will be obtained from the actual hospital claims. Each claim submitted from the hospital that has a Medicaid number on it will be included in the calculation. This includes crossover claims even if Medicaid is not the primary payer. There are some specifics that bear mention:

• The resident must be an inpatient in your facility for at least 14 days in order to be included in the hospital readmission rate.
• Residents with catastrophic conditions and dominant, metastatic and complicated malignancies will be excluded from the calculation.
• Residents having resided in your facility during the past two days prior to hospital readmission will be included in the calculation. This means that if a resident is discharged home and then readmits to the hospital within 48 hours, that resident will be included in the calculation.

Facility Expected Admission Rate

The facility Expected Admission Rate(EAR) “will be calculated using Medicaid hospital claims (including crossover claims) for nursing facility residents who meet specific criteria as noted below for the 12 month period prior to the measurement period. The DRG determined by the hospital will be used to assign each resident to one of 26 Aggregate Clinical Risk Groups (ACRG). The EAR will be calculated and risk adjusted for each of the ACRGs using claims data for all of the residents in each of the CRGs during the time period.” The implication of this being that the facility has very little control over the calculation of the EAR.

In an effort to manage your hospital readmissions at the facility level, education should be your primary focus. The more aware your staff is, the more likely it is that your staff will identify issues.

• Educate physicians, nurse practitioners, and physician assistants on the specific interventions that are available to your facility. Some examples may be: stat labs, IV fluids, or IV antibiotics.
• Educate your nursing staff on the appropriate identification of resident changes of condition. This should include symptom management and facility nursing policy on change in condition.

Hospital Readmission Educational Tools

There are some great tools available to help in fostering this education. There is the e-Interact Situation, Background, Assessment, Recommendation, most often referred to as the SBAR tool. The SBAR will allow the nurses to gather the appropriate information to prepare for calling the physician regarding a resident change in condition. This will help to ensure the complete resident condition is relayed to the physician in a timely and organized manner. Another tool that is available for use is the e-Interact Stop and Watch form. This form can be used by all staff in the LTPAC setting. By implementing this form and process you will be able to identify resident changes in condition more readily because you are including more staff members. Stop and Watch forms can be initiated by housekeeping, dietary, activities, social service, therapy as well as nursing. The more people watching the residents for those subtle changes the better chance you will have to identify changes sooner.

The last piece to include in your hospital readmissions puzzle will be to include these metrics in your facility Quality Assurance (QA) and Performance Improvement (PI), or the QAPI process. This is an excellent way to monitor for trends and identify opportunities for additional education. The QAPI team will also be able to introduce Performance Improvement Plans in an effort to enhance facility’s overall processes and policies.

For more information on the 5 Quality Add-On Points for 2016, please contact the experts at Richter Healthcare Consultants today!