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QIS System Addresses Hospital Readmissions

Dr. Andy Kramer
Provider Magazine – June 2011

Q. 

Does QIS address readmissions to hospitals?

A.

In 2012 the provisions in the Patient Protection and Affordable Care Act for hospitals, where there is already public reporting of readmissions, will have financial risk for readmissions related to selected conditions. In addition, payment incentives in the Centers for Medicare & Medicaid Services (CMS) Nursing Home Value-Based Purchasing demo will be tied to hospitalization.

Fortunately, QIS does address hospitalization of nursing facility admissions. The admission sample chart review that is conducted on a sample of 30 admissions to the nursing facility generates a properly calculated readmission rate for one of the Stage 1 Quality of Care and Quality of Life Indicators—QP058 Hospitalization within 30 Days. The numerator is the number of residents in the randomly selected admission sample that are readmitted in 30 days, and the denominator is the total number of residents in that sample.

‘Payment incentives will be tied to hospitalization.’

If the threshold of 15 percent is exceeded, then a Stage 2 investigation is triggered for the care area of Hospitalization. This triggers review of the Stage 2 Critical Elements for Hospitalization or Death, which is used to assess compliance with the following CMS F-tags:

F272: Comprehensive Assessment; F274: Resident Assessment When Required; F279: Comprehensive Care Plan; F282:Care Plan Implementation by Qualified Persons; F309: Provision of Care and Services; F157: Notification of Changes; F241: Dignity; F271: Admission Orders; F278: Accuracy of Assessments; F281: Professional Standards of Quality; F242: Self-Determination and Participation; F353: Nursing Services; F385: Physician Supervision; F501: Medical Director; and F514: Clinical Records.

Thus, the Stage 2 Critical Element Pathway covers a broad range of issues that are relevant to hospitalizations that surveyors will be investigating. It is important to conduct Stage 1 assessments on a large enough admission sample to obtain information on hospital readmission that is useful.

Given that, on average, about 17 percent of admissions are readmitted to a hospital, the average will be about 5 readmissions with a sample of 30. This is not an adequate number of readmissions to thoroughly assess care related to preventing readmissions. Hence, a skilled unit with large numbers of admissions should conduct the Stage 1 admission assessment on all admissions.

To conduct the calculations correctly, managers should track the readmission rate and analyze issues like the units from where readmissions occur and how soon after admission the readmissions occur. Using the readmission rate and data in conjunction with a broader-based review of quality of care can help shed light on ways to reduce readmissions.


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