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Hospital Readmission Penalties

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Hospital Readmission Penalties

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unplanned hospital readmissionStewart Miller is treated for congestive heart failure. After 4 days in the hospital, he is sent home by the physician. Two weeks later, he is worse and has to be readmitted to the hospital in acute congestive heart failure. When questioned by the nurse who completes the admission assessment, he says he could not get his prescription for Lasix (a water pill) filled because he had no transportation. Stewart did not realize it was important. His doctor just handed him the prescription and left the room without discussing the medication. He did not see a nurse before leaving, just a transport aide who took him to the curb.

Readmission Costs
Before attention was paid to the issue of unplanned readmissions, it made good financial sense for a hospital to welcome a patient for admission even if the patient was recently discharged. The hospital was paid for that second admission, just as it was for the first one. But the U.S. government decided the bill for readmissions got too high. Unplanned readmissions within 30 days of discharge cost Medicare billions of dollars.

Just five medical diagnoses account for almost half a million 30 day hospital readmissions, at a cost of more than $6 billion:

  • congestive heart failure
  • cardiac dysrhythmia (irregular heart beat)
  • septicemia (blood infection – except for patients in labor)
  • pneumonia and
  • chronic obstructive pulmonary disease.

The Centers for Medicare and Medicaid Services (CMS) are targeting hospitals through the Hospital Readmissions Reduction Program. Uncle Sam is fighting back since many hospital readmissions are potentially avoidable.

Medical malpractice attorneys may see these cases when the readmission occurred due to

  • quality of care concerns
  • poor communication between the provider and family or family
  • lack of follow up appointments with providers
  • inadequate discharge instructions
  • poor compliance by the patient with medication regimens

Congress looked at the issue of hospital readmissions and concluded that quality of care issues emerge from three phases of a hospitalization: the hospital stay, the discharge process and the post discharge follow up. Not all readmissions are associated with failures in the system. Some patients’ readmissions relate to the severity of underlying chronic conditions. But many can be avoided.

woman inwheelchair being discharged from hospitalHigh Rate of Readmission Medical Diagnoses
CMS started cracking down on facilities with high rates of potentially preventable readmissions by lowering their Medicare payments. First, in 2013, they focused on three high rate medical diagnoses:

  • Congestive heart failure
  • Acute myocardial infarction (heart attack)
  • Pneumonia

Beginning in October 2014, they added three more:

  • Chronic obstructive pulmonary disease
  • Elective hip arthoplasty (replacement)
  • Elective knee arthroplasty

Coronary artery bypass graft is next in line for 2017. Hospitals with excessive readmission rates are penalized; they are taking note and addressing the concnerns.

Readmissions and Systems Issues
What does a readmission within 30 days mean to a medical or nursing malpractice case? Research suggests that there is a correlation between the care environment and readmission. The researchers evaluated nurse staffing level, nurse education and the nurses’ evaluation of their work environment. The poorly staffed, high workload nursing environment led to a higher probability of readmission. The nurses’ education level significantly affected readmissions for pneumonia but not for acute myocardial infarction or heart failure.

Nurses have an important role in patient teaching, discharge planning, communication with the health care team, and post discharge care management. A nurse should have seen Mr. Miller before he left the building to ensure he understood the importance of taking Lasix and had a plan to get his prescription filled.

Inadequate medical management also plays a role in readmissions. Those who manage patients – hospitalists, physicians assistants, nurse practitioners – need to function as part of a team to achieve optimal outcomes for patients. They need to address the individual’s specific needs, listen to concerns about management after discharge, and sometimes find creative solutions to help patients follow instructions for self care.

Medical malpractice attorneys may find themselves involved in a case of an unplanned readmission which resulted in the serious deterioration or death of a patient. In many cases these outcomes can and should be prevented. It makes good financial sense for hospitals not to pay millions in fines. It makes good medical sense for healthcare providers to work together to avoid readmissions.

Med League nurses help attorney understand the medical issues associated with a case involving an unplanned readmission. Let us help you with your next case.

Brooks, J. Reducing Hospital Readmissions, American Journal of Nursing January 2015 Vol 115 No. 1, 62-65
McHugh MD, Ma, C. Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Aff (Millwood) 2013: 32 (10): 1740-7

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