FutureFocus May 15 2019: Where Do The Highest Risk Of Readmissions Come From?

Lisa Remington

Our FutureFocus identifies where the highest risk of readmissions come from. The pressure is mounting for skilled nursing facilities (SNFs). For 2019, SNF's value-based purchasing program has a 2% withhold on performance. One of their key measurements is hospital readmissions. Learn how your organization can gain insight about changes to the SNF's value-based purchasing program and new opportunities to collaborate.

Lisa Remington, President, Remington Health Strategy Group

By: Lisa Remington, President, Remington Health Strategy Group, Publisher, The Remington Report

Approximately one in five Medicare beneficiaries are discharged from hospital’s to skilled nursing facilities (SNFs). Patients discharged from a skilled nursing facility to home face the highest risk of readmission in the first two days after SNF discharge.

Pressure is mounting for SNFs. 2020 marks the implementation of the new SNF Patient-Driven Payment Model (PDPM). The update to the Medicare payment rates and quality programs aligns payment rates for SNFs to the cost of providing care.

The SNF Value-based Purchasing Program adjusts Medicare reimbursements based on SNF's performance on the program's hospital readmissions measure. For FY 2019, the withholding percentage is 2%.

"The rate of readmissions increased on days 0 to 2 after SNF discharge."

If SNFs lower their readmission rates, providers can earn the two percent. CMS reports almost three-quarters of the providers in the country will receive a cut under VBP. Only 27 percent earn the “bonus”

The SNF Value-Based Purchasing Program

The key metric for the readmission program is SNF 30-Day All-Cause Readmission Measure (SNFRM). This measure was designed to identify outcomes of unplanned all-cause hospital readmissions within 30 days of discharge from their prior acute hospital discharge.

Under the SNFRM, hospital readmissions are identified through Medicare claims. Readmissions within the 30-day window are counted regardless of whether the beneficiary is readmitted. Rates will be risk-adjusted based on patient demographics, principal diagnosis during prior hospitalization, comorbidities, and other health status variables that affect the probability of readmission.

SNF Penalties Continue To Be High

The majority of skilled nursing facilities will receive a penalty on their Medicare payments for fiscal 2019 for poor 30-day readmission rates back to hospitals, according to CMS data. Of the 14,959 skilled nursing facilities subject to the CMS' Skilled Nursing Facility Value-based Purchasing Program, 73% received a penalty while 27% got a bonus. CMS data also shows that the SNFs on average got worse at managing readmissions the longer they were in the program. 

Case Study – SNF Heart Failure Discharged To Home

A recent study published in The Journal of Post-Acute and Long-Term Care Medicine included 67,585 Heart Failure hospitalizations discharged to SNF and subsequently discharged home. The objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with  heart failure (HF) who had subsequent SNF stays of 30 days or less.

Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The rate of readmissions increased on days 0 to 2 after SNF discharge.

Highlights from the study of heart failure patients:

  • 24.2% of patients discharged from SNF to home were readmitted to a hospital within 30 days of SNF discharges.
  • Risk for readmission was 2 to 4 times higher immediately after SNF to home discharge compared to later time periods.
  • Early readmission risk dropped by half for patients with SNF stays of 1 to 2 weeks compared to those with shorter stays.

Why Do Readmissions From SNFs Create The Need For Collaborative PAC Provider Management?

  • One in four nursing home residents on Medicare was hospitalized in 2011, costing the program $14.3 billion.
  • One in four nursing home residents on Medicare was hospitalized in 2011, costing the program $14.3 billion, according to a report from the Department of Health and Human Services Office of Inspector General (OIG).
  • Of the 3.3 million Medicare residents who stayed in nursing homes for at least 1 day in FY 2011, 825,765 (24.8 percent) experienced hospitalizations. The majority of hospitalized residents (67.8 percent) transferred from nursing homes to hospitals only once. Twenty percent transferred two times, 7.2 percent transferred three times, and the remaining 5 percent transferred four or more times.

Top Five Diagnoses on Claims of All Hospitalized Medicare Nursing Home Residents in FY 2011

CCS Primary Diagnosis Category

Percentage of Hospitalizations

Five Most Frequent CCS Categories

Septicemia

13.4%

Pneumonia

7.0%

Congestive heart failure, non-hypertensive

5.8%

Urinary tract infections

5.3%