Preventing re-hospitalization is a critical goal for healthcare systems worldwide, aiming to improve patient outcomes and reduce unnecessary healthcare costs. Central to achieving this objective is the presence of knowledgeable individuals who can effectively educate patients about their conditions, treatment plans, and necessary lifestyle adjustments.

Patient education is the Number #1 strategy in preventing re-hospitalization, emphasizing why having dedicated educators—whether healthcare professionals, family members, or caregivers—is the first and most important rule in this prevent hospitalizations.

Medicare's Hospital Readmission Reduction Program (HRRP) imposes financial penalties (as much as 3% of total annual Medicare inpatient operating expenses) on hospitals - and home health agencies - with rates above the national readmission-rate average. 

Who's Responsible for Preventing a Re-Hospitalization?

Provider making referral to Home Health (Physician, Hospital, Nursing Home etc): A provider refers a patient to home health because the patient is (1) stable enough to be at home without around-the-clock monitoring and (2) the patient or caregiver is capable of knowing when to call the doctor if there's an exacerbation

Home Health Provider: The home health provider continues with intermittent monitoring and teaching the patient/caregiver how to prevent & manage exacerbations - including when to call the doctor.

If everyone does their part, hospital readmissions can be avoided.

Preventing Re-Hospitalization Rule #1: Make sure the caregiver - or patient - is alert, oriented and available for teaching.

Its happened to all of us.

You've called ahead, spoken with the patient and scheduled the admission visit. You arrive and the patient is alone - a caregiver is not present for the admission visit - and the patient seems confused.

No procedures are ordered - its strictly an 'MMTA" patient requiring Medication Management, Teaching, and Assessment. The patient is recently discharged from a Short-stay acute hospital (IPPS) for pneumonia, and on three (3) new medications. A call to a caregiver - a grandson who lives 20 minutes away - goes unanswered.

You have a confused patient on 3 new medications - and a (possibly) unreliable caregiver.

If it were me?

I'd send this patient back to the hospital.

Medicare Seeks to Reduce Billions in Overspending on Hospital Re-Admissions

In the US specifically, the 2010 Affordable Care Act introduced an initiative to address the problem of excessive readmissions. The Hospital Readmission Reduction Program (HRRP) imposes financial penalties (as much as 3% of total annual Medicare inpatient operating expenses) on hospitals with rates above the national readmission-rate average. In 2017, 76% of US hospitals incurred an average fine of $227K.

While the announcement of these penalties in 2010 did result in a slight dip in readmission rates, the effectiveness of the policy to drive improvements quickly stagnated. From 2013 to 2017, the percent of hospitals penalized for readmission rose from 64% to 79%. During this same time, the total value of assessed penalties rose from $290 to $590 million per year. Meanwhile, despite the increased penalties, from 2013 to mid-2016, the readmission rate for Medicare beneficiaries fell by only 0.1%. In short, many hospitals have struggled to find cost effective ways to reduce readmission rates.

Four (4) Reasons You Must Prevent a Re-Hospitalization

1. In the eyes of the payer - Medicare, Medicaid, commercial payers included - a re-hospitalization SUGGESTS THE PATIENT RECEIVED SUB-STANDARD CARE. Why was the patient discharged in the first place if they now need to be re-hospitalized?

If a home health referral is not appropriate - the patient is unstable and/or there is no teachable patient or caregiver - its up to the home health agency to send the patient back to the facility from where the patient was discharged.

2. Medicare punishes your HHA with a lower ranking on Home Health COMPARE. A third (33%) of your quality ranking on home health COMPARE accounts for your HHA's re-hospitalization rate. A low ranking also affects your HHA's ability to get referrals.

3. Medicare punishes your HHA with reduced payments

4. You'll get less referrals. ACOs, PPOs - and referral sources like hospitals - want to work HHAs who have low hospitalization rates.

OASIS-E Start of Care Can Determine a Quality Admission

Using the OASIS-E Start of Care, the patient's mental status is documented on M1700 Cognitive Functioning, M1710 When Confused, and the caregiver's capability for teaching and available is recorded on M2102F Types and Sources of Assistance.