The Great Plains QIN team strives to improve healthcare quality and patient outcomes. We work with partners and community coalitions to identify areas for improvement, which include reducing avoidable hospital admissions and readmissions, including those caused by high-risk medications related to adverse drug events, improving medication safety and overall better care coordination.
The Great Plains QIN team recently developed community-level reports to provide a snapshot of readmission data. These reports are intended to help identify opportunities for improvement, address gaps and lend to a reduction in avoidable hospital admissions/re-admissions. Our team of data analysts created a report for North Dakota and South Dakota and included community-level data sets.
“If you cannot measure it, you cannot improve it,”
- Access the North Dakota Report
- Access the South Dakota Report
Community-level measures included are:
- 30-day Hospital Readmission Rate and Trends: The percentage of hospital readmissions within 30 days of discharge
- Acute Care Utilization Rate: Admissions and Emergency Department (ED) Visits (without admission)
- Hospital Discharge Rate per Location: Home (Community), Home Health, Hospice, and Skilled Nursing Facility
- 30-Day Hospital Readmission Rate per Discharge Location: As Above
- Top Five DRG Bundles for Admissions: DRG bundles designated by Great Plains QIN
- Top Five DRG Bundles for 30-Day Readmissions: DRG bundles designated by Great Plains QIN
- ED Visits among Super-Utilizers Rate: Rate of emergency department visits per 1,000 Medicare Fee-for-Service beneficiary-years among Super-Utilizers. One beneficiary-year is comprised of 12 months of original Medicare enrollment. “Super-Utilizers” are Medicare Beneficiaries who have at least 4 inpatient discharges or at least 5 ED visits, observation stays, and inpatient discharges combined in the 12-month period immediately preceding the performance period.
- 30-Day Readmissions Rate: Rate of all-cause inpatient readmissions within 30 days after inpatient discharge per 1,000 Medicare Fee-for-Service beneficiary-years. One beneficiary-year is comprised of 12 months of original Medicare enrollment.
* Medicare claims fee-for-service data (Q4 2022) is the data source. These measures are not risk adjusted.
“There is so much useful information in this report. If I had to highlight a couple of areas I find the most valuable, I would say readmission rates among discharge locations is top on that list. To be able to see in a community the organization type that might have a higher rate of readmission and be able to drill down and find the root cause is invaluable. Also, the top admission and readmission DRG bundle for each community is valuable to understand where education efforts in the community might be needed,” shared Tammy Wagner, Great Plains QIN Quality Improvement Advisor.
Great Plains had developed similar reports that were very popular with communities in prior work that assisted those communities to drive their readmission improvement work through a better understanding of their data. Great Plains wanted to reinvigorate these reports to show our partners the data and work being done on hospital utilization, such as ED visits, readmissions, top admission and readmission diagnosis.
For questions on this report, please contact a member of our Great Plains Quality Innovation Network team; visit the Who We Are page for a listing of team members and contact information.