Reducing readmissions matters to both hospitals and nursing homes. With readmission measures that can impact the bottom line for both, strategic partnerships are paramount.
For the FY 2025 Program year, the Skilled Nursing Facility (SNF) Value Based Payment Program will award incentive payments to SNFs based on their performance on the SNF 30-Day All-Cause Readmission Measure (SNFRM). The SNFRM measures the rate of all-cause, unplanned hospital readmissions for SNF residents within 30 days of discharge from a prior hospital stay.
The SNFRM is risk adjusted for patient demographics, comorbidities, and other health status variables that affect the probability of a hospital readmission, including diagnoses of COVID-19. Each SNF receives a SNFRM result (i.e., a risk-standardized readmission rate) for a baseline period and a performance period.
Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that, for example, encourages PPS hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions. The program supports the national goal of improving health care for Americans by linking payment to the quality of hospital care.
CMS includes the following condition or procedure-specific 30-day risk-standardized unplanned readmission measures in the program:
- Acute myocardial infarction (AMI)
- Chronic obstructive pulmonary disease (COPD)
- Heart failure (HF)
- Pneumonia
- Coronary artery bypass graft (CABG) surgery
- Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA)
Critical Access Hospitals (CAHs) also have a MBQIP measure to improve the quality of care provided in critical access hospitals (CAHs) which includes care transitions and reducing readmissions. CAHs who wish to participate in any FLEX-funded activities must meet the MBQIP core measures. Access State Flex Program Key Resources.
It is important not only for residents/patients, but all healthcare organizations, hospitals, both PPS and CAHs, and nursing homes are working on this measure and either can receive incentives for reducing readmissions or penalties related to high readmission rates. It makes sense to be working closely together on communication, building relationships, using the same patient and family education tools, coordinating care with warm hand-offs, nursing home’s completing capabilities lists so the hospital better understands what the nursing home can do.
Collaboration & communication are key to reduce readmissions & improve patient/resident safety.
Great Plains QIN Tools & Resources:
- GPQIN: Readmissions Interview Tool
- GPQIN: Reducing Avoidable Emergency Department Visits & Hospitalization Toolkit
- GPQIN When to Call for Help Tool
- GPQIN When to Call for Help Tool Booklet Version (Print Setting: Print On Both Sides: Flip pages on short edge)
- GPQIN Checklist For When To Call For Help
Additional Tools:
- BOOST-Implementation Guide to Improve Care Transitions
- Re-Engineered Discharge (RED) Toolkit
- PRAPARE Implementation and Action Toolkit
- Ready-Set-Go Toolkit
- RHIhub-Rural Care Coordination Toolkit
Watch our Focus 4 Health Series!
TeamSTEPPS® – Improving Communication and Teamwork Skills
- Week One: Communication Tools | Recording
- Week Two: Team Leadership | Recording
- Week Three: Situation Monitoring | Recording
- Week Four: Mutual Support | Recording
Reducing Avoidable Emergency Department Visits
- Week One: Reducing Avoidable Emergency Department Visits: Recording
- Week Two: Communication During Hand-Off’s’: Recording
- Week Three: Communication Strategies: Recording
- Week Four: Infections, Falls, Medications, Success Measurement & Celebrating: Recording
Listen to our Podcast: Q-Tips For Your Ears!
How to Stay Out Of The Emergency Department: When should the Emergency Department (ED) be utilized and when should a person monitor their symptoms at home? When should someone visit the doctor’s office or an urgent care clinic? Why is ED overuse important and why does it matter? Take a few minutes to listen and learn more.