Readmissions, Care Transitions, and Value-based Programs

If it seems that hospitals have been focused on readmission rates for years, they have. Starting in fiscal year 2013, hospitals have been penalized for readmission rates for Medicare beneficiaries with certain diagnoses. Those penalties have been increasing with each year until the penalty cap of 3% was reached.

Progress has been made, though, with readmission rates dropping as teams started to focus on this issue. The noticeable drop in 2012 corresponded with the run up to the initial penalty phase and has continued to improve. Recent changes in the program include consideration of the proportion of dual eligible stays in a given hospital to assign that hospital into a peer group for comparison. This stratified methodology is used to calculate the Payment Adjustment factor which is used for determining payment reductions.

Concurrent with hospitals working hard to reduce readmissions, skilled nursing facilities (SNFs) have been working to reduce rehospitalizations in their short-term residents and hospitalization in their long-term resident cohort. Not surprisingly, the SNF focus on these residents has increased as their own initial penalty phase has approached.

But it is not just hospitals and SNFs that are zoning in on managing patients in place. Home Health agencies (HHAs) have their own value-based purchasing system looming on their horizon. The program is being piloted in nine states across the country to determine the impact of financial incentives on agency behavior and the quality of care delivered.

Hospitals Should Care about Value-based Rehospitalization Programs


Why should hospitals care about value-based rehospitalization programs in the post-acute care space? It’s simple – now you have more willing partners to join in improving care in this area. All of these separate Centers for Medicare and Medicaid (CMS) programs coalesce on this point. Granted the definitions and program particulars are site specific, but the overarching goal is still the same: reduce the return of patients to the hospital after discharge from an acute care stay.

Now is the time to reinvigorate your efforts to reduce readmissions, especially if your results have started to stagnate. If you have a strong internal process and confidence that your teams have solid systems around readmissions, begin outreach to your SNFs and HHAs in earnest. Even if you have made unsuccessful attempts earlier, try again. Their incentives are aligned with yours more than ever before.

Start the Conversation with
Your Care Partners


A place to start the conversation is with transitions between care partners. When you read the literature or look at the data, it is clear that the likelihood of readmission increases when a patient transitions between one level of care to another.

One major challenge is communication. Even with technology, communication of important care information is difficult. Providers may use different software systems that are not compatible which requires manual effort to gather care data to send with the patient.  Many times, discharges are rushed, teaching is short, medication reconciliation hurried, and paperwork incomplete. Even if you manage to gather it all, the paperwork can get lost on transport or delivered at the next location to the wrong person.

We sometimes think of a care transition as moving from one level of care to a less restrictive level of care, but the reverse is also important to assess. If the patient returns to the hospital, the documentation from the discharging site needs to be clear, with explicit documentation as to the symptoms, condition, and reason the patient was sent. Successful communication in this scenario can mean the difference between a readmission or the return of a treated and stabilized patient to the prior provider.

Whether you start with care transitions or some other process, now is the time to invite your PAC partners to the table, decide on the quality metrics you will all use, identify target areas, be transparent about your challenges and celebrate your successes.  Remember that providers at every point in the care continuum have the same goals to reduce readmissions and improve the quality of patient care.


Pam Kaiser
Pam Kaiser, MSN, RN
Vice President, Provider Services
PointRight Inc.


About Pam Kaiser

Senior Healthcare Specialist Pam has enjoyed 27 years in the healthcare field. A second career for her, she worked her way from a certified nursing assistant through the long term care ranks to become a leader in clinical reimbursement and compliance for several large long term care providers. Pam has a B.A in Advertising from Michigan State University and an MSN in Community Health Nursing from the University of Southern Maine.