Treat and Release: Transitions of Care Planning Should Include Medical Decision-making

Shorter ALOS was associated with increased readmissions.

Recently a fellow RAC Relief community member wrote that while 30-day inpatient readmissions had deceased under the HRRP (Hospital Readmission Reduction Program), the number of total hospital encounters, which include ED and observation revisits, have increased. Providers seek to treat and release patients from observation units or the ED for the targeted conditions. The community member referenced a study found online here: https://www.bmj.com/content/366/bmj.l4563.

He further wrote, in summary of the article, that “although reductions in readmissions have been attributed to improvements in discharge planning and transitional care, as intended by the HRRP, these declines instead appear to be due to intensified efforts to manage patients who return within 30 days of discharge in emergency departments and observation units.”

Frankly, I never bought into the concept that improvements in transitions of care planning were going to be any savior. My departments have been performing aggressive anticipatory case management for years. Handoffs to primary care providers are strong. Post-acute providers have their own readmission issues; primary care providers (PCPs) can handle patients only so early in the recovery curve.

Until a year ago, our readmission numbers looked good, and then they wandered into penalty territory.

In in an effort to find anything actionable, I looked at the role of medical decision-making, specifically the average length of stay (ALOS), for the index hospitalization. Both inpatient and observation encounters were included in the data, without differentiation as to status at index discharge or upon return. Also considered were days between index and return. A look back at the previous six months of hospital encounters was also accounted for. I was searching for anything that would inform how to view and attack the issue. The days between hospitalizations was further broken down to increments of three, seven, and 14 days, figuring these would be more revealing. They were.

What I found was that shorter ALOS was associated with increased readmissions. The margin was not wide. A decrease in ALOS of 0.5 days resulted in a disproportionate increase in readmission rate, and vice versa.

Interestingly, the ALOS of the return hospitalization was comparable to the index. A second 30-day readmission was rare. Targeted conditions were nearly matched by another: severe sepsis.

The utilization management (UM) committee, in an effort to derive actionable items, made the following informed assumption: returns within three days were completely avoidable. Since around 25 percent of readmissions occur within three days, we decided to look no further than this narrow time frame.

Drilling down on the data pointed in the direction of too much being asked of post-acute providers, expecting too much from the primary care provider (and their ability to fit hospital follow-ups into an already overburdened schedule), or the result of incomplete medical care before index discharge.

Because the return encounter ALOS is comparable to the index and subsequent 30-day hospitalization is rare, the idea that a patient can be discharged too early in their recovery curve was reinforced.

Success with HRRP is a success with individual patients, driven by adequate preparedness for discharge: this means good, early, and comprehensive transitions of care planning, which includes medical decision-making.

Facebook
Twitter
LinkedIn

Marvin D. Mitchell, RN, BSN, MBA

Marvin D. Mitchell, RN, BSN, MBA, is the director of case management and social work at San Gorgonio Memorial Hospital, east of Los Angeles. Building programs from the ground up has been his passion in every venue where case management is practiced. Mitchell is a member of the RACmonitor editorial board and makes frequent appearances on Monitor Mondays.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Heart Failure Coding Essentials: Ensuring Compliance and Optimal Reimbursement

Heart Failure Coding Essentials: Ensuring Compliance and Optimal Reimbursement

Master the complexities of heart failure coding with this expert-led webcast by Emily Montemayor, CCS, CMBCS, COC, CPC, CPMA. Discover strategies to ensure compliance with ICD-10-CM guidelines, documentation integrity, and capture comorbidities like CKD and hypertension. Learn how to resolve coding challenges, improve documentation practices, and submit clean claims to minimize denials and safeguard your organization’s financial health. With practical insights and real-world examples, this session equips you to prevent revenue leakage, enhance compliance, and secure optimal reimbursement—all while supporting better patient outcomes.

February 26, 2025
Decoding 2025 OPPS Charge Capture and Coding Complexities: Strategies for Success

Decoding 2025 OPPS Charge Capture and Coding Complexities: Strategies for Success

Prepare your organization for the 2025 OPPS updates with expert insights from Tiffani Bouchard, CCS, CRCR, a Revenue Integrity Professional with over 30 years of experience. This webcast will address critical challenges in charge capture and coding, providing clarity on APC policies, C-APC packaging, exclusions, and payer-specific requirements. Attendees will learn actionable strategies to ensure compliance, optimize reimbursement, and mitigate risks of claim denials. Gain the knowledge needed to implement updates effectively, educate your team, and maintain seamless revenue cycle operations in the face of evolving OPPS complexities.

January 29, 2025
Enhancing Outcomes with CDI-Coding-Quality Collaboration in Acute Care Hospitals

Enhancing Outcomes with CDI-Coding-Quality Collaboration in Acute Care Hospitals

Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.

November 21, 2024

Trending News

Featured Webcasts

Navigating the 2025 Medicare Physician Fee Schedule: Key Changes and Strategies for Success

Navigating the 2025 Medicare Physician Fee Schedule: Key Changes and Strategies for Success

The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.

January 21, 2025
Patient Notifications and Rights: What You Need to Know

Patient Notifications and Rights: What You Need to Know

Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.

December 5, 2024
Navigating the No Surprises Act & Price Transparency: Essential Insights for Compliance

Navigating the No Surprises Act & Price Transparency: Essential Insights for Compliance

Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks.  Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.

November 19, 2024
Post Operative Pain Blocks: Guidelines, Documentation, and Billing to Protect Your Facility

Post Operative Pain Blocks: Guidelines, Documentation, and Billing to Protect Your Facility

Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.

October 24, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24