The Nursing Leadership Dilemma with 30 Day Readmissions of Medicare Patients

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Over 2000 hospitals in the United States received some very bad news last week about their future reimbursement from Medicare. They will be penalized by the government on Medicare reimbursement during 2013 because many of their patients are being readmitted to the hospital within 30 days of discharge. These penalties have been authorized as part of the recently passed Affordable Care Act. With health-care costs skyrocketing, the readmission of 20% of Medicare within 30 days of discharge from hospitals has captured national attention as a symbol of uncoordinated and expensive health-care. The penalties in reimbursement are an attempt by Medicare to both reduce costs and force improvements in hospital quality. Nurses in a wide range of health settings are being called on to provide their expertise in the development of strategies to reduce hospital readmissions.

The 30 Day Readmission Rate Dilemma

Bob Johansen, a leadership futurist, defines a dilemma as a problem that cannot be easily solved and won’t go away. The problem of 30 day readmission rates can be viewed as a dilemma. Many hospitals over the past year have put considerable effort into reducing their 30 readmission rates with only partial success. The penalties were based on the frequency that three groups of Medicare patients (heart failure, heart attack and pneumonia) were admitted within 30 days from 2008 to 2011. Hospital care is just one piece of a complicated health-care puzzle in the United States. There are still many gaps in providing care for chronically ill patients across the continuum. More coordinated discharge planning will solve some but not all the problems. Readmission rates alone may not be an indicator of poor care. In fact, some patients may have problems identified early and be readmitted with shorter lengths of stays than they would have had if their admissions had been delayed.

Dilemma Flipping

Dilemma flipping is a way of viewing unsolvable challenges as both a threat and an opportunity. The threat is obvious for the 2211 hospitals who will have their base Medicare payments reduced in 2013 by up to 1% based on an evaluation of their performance during the past year. The maximum penalty will increase to 2% in 2013 and 3% in 2014. This could mean a substantial reduction in needed reimbursement especially for hospitals who treat a large population of Medicare patients. Some of the hospitals who are losing reimbursement this year are public, safety net hospitals that are already in financial trouble.

There are opportunities for nurse leaders to view the problem of 30 day readmissions in a different way with a different nursing mindset. Although we have always understood that more effective care coordination could improve care, there has never been a strong drive in many organizations to require this of their interdisciplinary team members. Discharge planning is often fragmented and not begun early enough in the hospitalization. A quick fix such as creating new discharge planning sheets with more check boxes is not likely to solve an issue that is far more complex.

This new dilemma presents an ideal opportunity to push for a different care delivery model that emphasizes interdisciplinary care coordination. In a recent study on Collaborating to Improve Care and Cut Costs published by the Health Leaders Media Council, 69% of health care organizations surveyed indicated that adopting care coordination across the continuum was the top intervention that could be implemented to reduce the costs of health care. This is one initiative that nurse leaders can be instrumental in taking the lead. This is a complex problem. Every organization will have unique challenges given their surrounding community, availability of resources and patient case mix. There is no one size fits all solution but there are best practices that have been published by organizations like the Commonwealth foundation’s Reducing Hospital Re-admissions: Best Practices from Top Performing Hospitals.

Value-Based Care Initiatives Are Here to Stay

Are hospitals being unfairly targeted with this new initiative? Perhaps, but a key piece of information in putting together the health-care financing puzzle is to look at how dollars are currently being spent. Hospital care is the single biggest spending category at 31% of the health-care dollar pie. Not surprisingly, when cuts are proposed, this big ticket item is looked at first. Payment incentives are quickly moving away from volume toward a greater focus on value of services and health outcomes, including fewer hospitalizations. This is the future of health care and nurse leaders are in a unique position, with the right skill sets to promote better care coordination.

Read to Lead

Commonwealth Foundation (April 2011). Reducing Hospital Readmissions: Best Practices from Top Performing Hospitals 1473_SilowCarroll_readmissions_synthesis_web_version

Rau, J. Medicare to penalize 2,211 hospitals for excess admissions. Kaiser Health News. (August 13, 2012). http://www.kaiserhealthnews.org/Stories/2012/August/13/medicare-hospitals-readmissions-penalties.aspx