What You Need to Know About Hospital Readmission QMs

By Caralyn Davis, Staff Writer - May 18, 2016

The Centers for Medicare and Medicaid Services is serious about reducing unplanned hospital readmissions, targeting rehospitalizations and other rocky care transitions via several different quality measures across three quality reporting programs. Spearheaded by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 and the Protecting Access to Medicare Act (PAMA) of 2014, CMS is making a historic push to link hospital readmissions, as well as other QMs and resource-use measures, to Medicare Part A fee-for-service (FFS) payment for skilled nursing facilities.

Under the SNF Quality Reporting Program (SNF QRP), SNFs that don’t submit required quality data to CMS will have their annual updates reduced by 2 percent effective with fiscal year (FY) 2018 beginning Oct. 1, 2017. Under the SNF Value-Based Purchasing (SNF VBP) program, CMS will withhold 2 percent of SNF Part A payments effective with FY 2019 beginning Oct. 1, 2018, that some SNFs then will be able to earn back as value-based incentive payments.

In addition, by posting new publicly reported rehospitalization and other care transition QMs on Nursing Home Compare, with plans to begin incorporating these measures into the Five Star Quality Rating System this July, CMS also is ensuring unplanned hospital readmissions and poor care transitions impact SNFs on the managed care side, says Diane Vaughn, RN, C-DONA/LTC, LNHA, vice president of clinical services for Volunteers of America in Minneapolis.

“Most Medicare Advantage plans and other managed care partners such as accountable care organizations (ACOs) won’t want to work with nursing homes that don’t have at least a three-star rating in the Five Star system,” she explains.

Here is some basic information about the readmission and other care transition QMs either finalized or proposed for these three programs:

The publicly reported QMs

* Percentage of Short-Stay Residents Who Were Rehospitalized After a Nursing Home Admission, which is primarily claims-based but includes multiple MDS-based exclusions and covariates. This measure determines the percentage of all new admissions or readmissions to a nursing home from a hospital where the resident was re-admitted to a hospital for an inpatient or observation stay within 30 days of entry or re-entry (excluding planned inpatient readmissions). This is one of five new publicly reported QMs that will affect Five Star starting in July.

* Percentage of Short-Stay Residents Who Were Successfully Discharged to the Community, which derives from a mix of claims and MDS data. Specifically, this measure determines the percentage of all new admissions to a nursing home from a hospital where the resident was discharged to the community within 100 calendar days of entry and for 30 subsequent days, they did not die, were not admitted to a hospital for an unplanned inpatient stay, and were not readmitted to a nursing home. This QM also will affect Five Star starting in July.

* Percentage of Short-Stay Residents Who Have had an Outpatient Emergency Department Visit. This claims- and MDS-based measure specifically targets critical non-hospitalization care transitions, determining the percentage of all new admissions or readmissions to a nursing home from a hospital where the resident had an outpatient ED visit (i.e., an ED visit not resulting in an inpatient hospital admission) within 30 days of entry or re-entry. This QM also will affect Five Star starting in July.

Note: The technical specifications for these three QMs are in the Nursing Home Compare Quality Measure Technical Specifications and Appendices, available here. CMS has not yet released an updated Five Star Quality Rating System Technical User’s Guide.


* Potentially Preventable 30-Day Post-Discharge Readmission Measure for SNF QRP. This is one of three new claims-based QMs proposed in the FY 2017 SNF PPS proposed rule for the SNF QRP effective with FY 2018 payment determinations. This measure would be based on Medicare eligibility files and inpatient claims data collected from Oct. 1 to Dec. 31, 2016, drawing nothing from MDS coding and creating no data collection burden for providers. The measure would estimate the risk-standardized rate of unplanned, potentially preventable readmissions for Medicare residents.

* Discharge to Community-Post Acute Care (PAC) SNF QRP. The FY 2017 proposed rule also recommends implementing this new claims-based QM for the SNF QRP effective with FY 2018 payment determinations. This measure also would be based on Medicare eligibility files and inpatient claims data collected from Oct. 1 to Dec. 31, 2016. It would report a SNF’s risk-standardized rate of Medicare residents who are discharged to the community following a SNF stay, and do not have an unplanned readmission to an acute-care hospital or long-term care hospital in the 31 days following discharge to community, and who remain alive during the 31 days following discharge to community.

The SNF VBP program

* The SNF 30-Day All-Cause Readmission Measure (SNFRM). The FY 2016 SNF PPS final rule finalized the SNFRM for the SNF VBP program effective with FY 2019 payment determinations. The SNFRM estimates the risk-standardized rate of all-cause, unplanned hospital readmissions for SNF Medicare FFS beneficiaries within 30 days of discharge from their prior proximal short-stay acute hospital discharge.

* The SNF 30-Day Potentially Preventable Readmission Measure (SNFPPR). In addition to laying out the proposed rules for implementing the SNF VBP program, the FY 2017 SNF PPS proposed rule seeks to eventually transition this program to the SNFPPR. This measure estimates the risk-standardized rate of unplanned, potentially preventable readmissions for Medicare residents within a 30-day window following discharge from the immediately prior acute-care hospital stay.

Both the finalized measure and the proposed measure would be based on solely on Medicare eligibility files and inpatient claims data, so there would be no provider burden. For FY 2019 implementation, CMS will use a performance period of calendar year (CY) 2017 claims to compute the scoring, and the comparison base year will be CY 2015 claims.

The highest-ranked facilities will receive the highest payments, and the lowest-ranked 40 percent of facilities will receive payments that are less than what they would otherwise have received without the program. By statute, CMS is required to pay the better of achievement or improvement for each SNF.

Did you know?

All of the hospital readmission QMs in the publicly reported QMs, the SNF QRP, and the SNF VBP program are based on slightly different calculations, but they share one defining characteristic that some providers overlook, says Ann Spenard, MSN, RN-BC, vice president /principal at Qualidigm in Wethersfield, Conn. “Many providers are tracking 30-day readmissions just from their facility, meaning they track whether a resident has a 30-day readmission while the resident remains in their facility.”

However, CMS is assessing whether hospital readmissions occur within the target window irrespective of the resident’s location at the time of readmission, she notes. “For example, if a short-stay resident is discharged from your facility and goes home on day 15 of the readmission window for the SNF QRP Readmission QM, you can still get ‘dinged’ if that resident is readmitted to the hospital within those 15 days after discharge.”

Here are some tips for navigating care transitions:

* Adopt a strong care management program.

Care management is essential to reducing rehospitalizations and other care transition issues such as ED visits, says Gail Harris, RN, BSN, clinical risk manager and quality assurance nursing consultant at Preferred Care Partners Management Group in Plano, Texas. “One of the best things that providers can do is adopt a quality improvement program such as INTERACT (Interventions to Reduce Acute-Care Transfers) to identify early changes in condition.”

Providers also can develop their own programs using such resources as the Agency for Healthcare Research and Quality’s Improving Patient Safety in Long-term Care Facilities training modules, which can be used to train front-line staff to identify and communicate changes in resident condition. However, the benefit of using INTERACT is that it’s a free, nationally recognized, and systematic program, advises Harris. “The INTERACT team only asks that you use the system in its entirety.”

In addition to helping providers track hospitalization rates and conduct root-cause analyses of readmissions, the INTERACT system promotes better communication about early changes of condition among nursing facility staff and with physicians, as well as strengthening communication about care transitions between the nursing facility and the hospital.

“For example, you can teach nurse aides to use the Stop and Watch Early Warning Tool to alert the charge nurse when something a little different is occurring with a resident,” explains Harris. “Then the nurse can assess the resident using the SBAR Communication Form and Progress Note prior to speaking with the physician to ensure relevant information is properly communicated.”

* Re-think discharge planning.

SNFs need to take a similar approach to what hospitals did when they began being penalized for readmissions, suggests Spenard. “From the day that you admit a Part A resident, you need to start a really strong discharge plan so that you have everything in place by the time the resident is discharged from their short stay if it’s less than the 30 days. For example, if the resident needs home care, you will need to make sure that you have the home care arranged and that you follow up.”

According to Spenard, questions that providers might want to ask in this scenario include:

  • If you use three different home health agencies, and two of them will see the patient within 24 hours of discharge and the third one won’t get out there for 48 to 72 hours later, how will you handle that high-risk time for that particular patient if they choose that third agency?
  • Do you use a durable medical equipment vendor that will make sure necessary DME equipment is available for that patient timely?
  • Are you engaging with families?
  • Are you making sure that the patient has the meds that they need, or they can get the medications that they need?
  • Does the patient or family understand all of their medications?
  • Does the patient have a follow-up appointment with their physician?
  • Does the patient understand any restrictions they may have when they go home?

“So it’s not just about caring for patients while they are in the nursing facility,” says Spenard. “It is making sure we have a good solid plan in place and understanding those drivers: How are you tracking your patients once they leave? What kind of quality processes do you have in place? For example, are you doing follow-up phone calls to make sure that whatever you set in place is happening and to find out if patients are having any difficulties? If a discharged patient is starting to have difficulties in those first few days (e.g., five days) postdischarge, do they need to be readmitted to the SNF to avoid going back into the hospital? This represents a completely different way of thinking for nursing homes—it’s a game changer.”

* Don’t rest on your laurels.

Excellence on hospital readmissions will be an ever-moving target, particularly for the SNF VBP program, says Vaughn. “Last November, the American Health Care Association suggested that if providers had higher than a 14 percent rehospitalization rate, all-cause, then you probably wouldn’t get any of that 2 percent back for the SNFRM under the SNF VBP program,” she notes.

However, many SNFs are actively working to reduce hospital readmissions. Just since the passage of PAMA in 2014, SNFs have reduced readmissions by 2 percent, according to CMS. “Since the SNF VBP program is performance-based, that 14 percent bar could be even lower currently,” stresses Vaughn.

“Perhaps you now need a rehospitalization rate of below 10 or 12 percent to get those SNF VBP incentive payments. So as competitors and colleagues improve, you still are at risk for not getting any of that 2 percent back if your rehospitalization rate isn’t competitive,” she explains. “A trusted colleague taught me: It doesn’t matter if your rehospitalization rate is risk-adjusted or all-cause, just get it lower.” Note: CMS will begin providing quarterly SNF VBP program confidential feedback reports by Oct. 1.

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