Patients Reimbursement within Thirty Day Readmission

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Patients Reimbursement within Thirty Day Readmission
Patients Reimbursement within Thirty Day Readmission

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The rest pages she didn’t reviewed, I am also attaching her requirements.


CHF Patients Reimbursement within Thirty-Day Readmission Introduction


Reducing the rates of readmission is a national priority.  It is estimated that readmissions cost the American Health care more than $ 15 billion annually (McIlvennan et al., 2015). The National Quality Forum initiated hospital readmissions reduction program (HRRP) aimed at reducing rehospitalization rates for three highly prevalent conditions: Heart Failure (HF), Acute Myocardial Infarction (AMI) and Pneumonia (Joynt & Jha, 2013). This is being implemented by providing incentives to hospitals that do not exceed a predetermined readmission rates (limit of 3%) while penalizing those that exceed (Bradley et al., 2013).

Significance of Healthcare problem and Patients Reimbursement within Thirty Day Readmission

One indicator used by Centers for Medicare and Medicaid Services (CMS) to check health facility’s quality of care is readmission rates. If a healthcare facility has high proportion of the patients readmitted within 30 days for any disease or condition, then this could be an indicator of inadequate care delivery (McIlvennan et al., 2015). CHF (congestive heart failure) patient care is estimated to consume a staggering 17 percent of the total national health expenditures and has this has called for reduction of CHF patient readmissions so as to cut down costs (Yanez et al., 2013).

Purpose of the study Patients Reimbursement within Thirty Day Readmission

HF (heart failure) is a chronic condition often accompanied by downstream complications collectively referred to as Congestive Heart Failure (CHF). The purpose of this study was to explore whether the reimbursement within thirty-day readmission is justifiable in case of CHF patients.

Patients Reimbursement within Thirty Day Readmission Review of the Evidence

The primary function of the heart is to pump blood to the rest of the body.  When the heart has a defect, it does not circulate blood sufficiently and hence the kidney receives less blood and filters less fluid out of the circulation. As a result, fluid accumulates in major organs such as around the eyes, legs, the lungs and the liver, a condition technically referred to as congestive heart failure. (CHF).  CHF is chronic disease with symptoms such as fatigue, sweating, swelling of the feet and around the eyes, and fast breeding. The disease alternates between stability and worsening and such unpredictable nature has an impact on the patient’s use of healthcare services and can often lead to preventable hospital readmissions and reimbursements (Yanez, 2013).

CHF is the leading cause of hospitalization especially in geriatric population in the USA (Vinson et al., 1990). It affects about 5.8 million people. The issue of high readmission rates of CHF patients has high implication cost to the individual, family and the society. For instance, readmission rates for patients diagnosed with Congestive Heart Failure (CHF) accounts for $17.4 billion direct cost of care (Centers for Medicare and Medicaid, 2014). Although there is some progress in reducing mortality in patients diagnosed with CHF, readmission rates continues to rise with approximately 50% of the patients getting readmitted within 6 months of discharge (Committee of Presidents of Statistical Societies, 2012(Joynt & Jha, 2013)). Worse off, CHF accounts for about 17 percent of total USA national health expenditures (Yanez et al., 2013). This trend is projected to increase by five fold in the next decade if no interventions are put in place to manage the disease (Dearholt &Dang, 2012).

The USA hospitals are committed to improve the quality of care using innovative programs to strengthen linkage between the various stakeholders. However, most CHF patients are treated under inpatient option, and in addition to the many challenges involved when providing CHF patient care, CMS has placed a big burden on the hospitals by introducing an inappropriate one day length of stay admission and readmission within thirty days. CHF has a very high readmission rate in the USA which makes healthcare facilities prone to losses due to potential of becoming fully financially responsible for the CHF patients. AS a result health care facilities have re-engineered their sytems to avoid readmission costs (Mcllvennan et al., 2015)

For instance, Project RED (Re-engineered Discharge) is a research group at Boston University Medical Center that develops strategies used by healthcare facilities to reduce readmission rates. The aim of Project RED is to develop effective strategies in order to promote patient safety and to reduce readmission rates.  The project RED re-engineered intervention is based on 12 mutually discrete components that reinforce on patient safety and patient satisfaction. Examples of these components include Visiting Nurse Services, Tele-Health services, and other community health programs. An intervention study conducted by project RED reported that patients in the intervention (i.e. Project RED) were less likely to return to hospital within thirty days of discharge (Jessup, 2014).

Replication of project RED in two separate studies was shown to significantly reduce the number of CHF patients readmitted hence reducing the cost of healthcare. The Duke University health system, led by Dr. Christoper O’connor was the first to provide the path to accountable CHF patient care in the 1990s. Dr. O’connor noted that there was poor coordination /communication between CHF patients and physicians and there was no access to primary heathcare for CHF patients. These two challenges, coupled with limited knowledge of CHF management at that time often led to unnecessary hospital visits. To address these challenges, Duke University began a program of CHF patient care improvement with three major initiatives, including the Duke Heart Failure Program, the Heart@home initiative, and Same Day access clinic (Hernandez et al., 2010).

The Duke Heart Failure Program used a strategy involving multidisplinary CHF care teams involving cardiologists, nurses, therapists, dieticians and pharmacists and well defined guidelines (Hernandez et al., 2010; Smith et al., 2014). The study reported that for patients enrolled in the program from July 1998 to April hospitalization decreased from 1.5 to 0 per patient .per year hence saving £8571 per patient per year as a result of reduced readmissions (Hernandez et al., 2010). In 2012, the Duke began another study after making some changes such as putting in place a healthcare team for each patient, improving communication and coordination between the teams and study sites and patient education on management of CHF (Hernandez et al., 2010). On the Same day access clinic study, Duke Researchers conducted a research study on registry data and found out that the risk of readmission was reduced by seeing a doctor within 7 days of hospitalization. This study was the basis for the launch of Same Day Access (SDA) that allowed CHF patients to see a specialist immediately without appointment (Duke Translational Medicine Institute, 2013). In these three studies the Duke Team showed that improved healthcare delivery can significantly reduce readmissions and reduce unnecessary reimbursements.

In another study, like Duke University, Colorado also re-designed its CHF care with specific focus on use of technological innovation to reduce the length of inpatient hospitalizations and reduce costly readmissions. Colorado adopted the thirty-day model 4 bundle. In this model, Colorado received a large sum from Medicare and then distributed it to healthcare providers and if their cost exceeded the set budget, Colorado absorbed the extra costs. This made Colorado accountable for post-acute care services and hospital readmissions and significantly reduced the latter (Herman, 2011). This proved that the 30-day readmission is an effective and ideal metric for assessing quality and patient safety.

Patients Reimbursement within Thirty Day Readmission Conclusion

The healthcare system in the USA is in the onset of seismic shifts. The continuing pressure from different stakeholders to increase healthcare access, increase coverage improve quality and minimize financial costs will eventually result in a more efficient healthcare system. CHF is a chronic disease that accounts for a substantial portion of treatment costs of cardiovascular defects in the USA. As such delivery of CHF patient care is set to evolve due to these seismic forces. Payers have increasingly shifted to value based reimbursements and this further affects an already struggling healthcare system. The facilities survival now lies on how well they will manipulate these financial and logististical forces to their own advantage. One of those ways will be to put measures in place so as to avoid unnecessary readmissions of CHF and other related conditions.

Patients Reimbursement within Thirty Day Readmission References

Bradley, E., Curry, L., Horwitz, L., Sipsma, H., Wang, Y., and  Walsh, M. . (2013). Hospital Strategies Associated With 30-Day Readmission Rates for Patients With Heart Failure. . Circulation: cardiovascular Quality and Outcomes, 6(4), 444-450.

Centers for Medicare and Medicaid. (2014). Readmissions Reduction Program (HRRP).

Dearholt, S. L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and

Guidelines (2nd edition). Indianapolis, IN: Sigma Theta Tau International Lawton, G.

(2010).Tele-health delivers many benefits, but concerns linger. PT in motion  journal.

Herman, B. (2011). The advantages and disadvantages of CMS bundle payment initiative: 8

responses. Beckers Hospital Review.

Hernandez, A. F., Greiner, M. A., Fonarow, G. C., Hammil, B. G., Yancy, C. W., Peterson, E. D., & Curtis, L. H. (2010). Relationship Between Early Physician Follow up and 30-day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure. JAMA, 303(17), 1716-1722.

Janice M. Vinson, M. W. R., Jane C. Sperry, Atul S. Shah, and Timothy McNamara. (1990). Early Readmission of Elderly Patients With Congestive Heart Failure. Journal of American Geriatirics Society, 38(12), 1290-1295. doi: 10.1111/j.1532-5415.1990.tb03450.x

Jessup, M. (2014). The Heart Failure Paradox: An Epidemic of Scientific Success: Presidential Address at the American Heart Association 2013 Scientific Sessions. Circulation, 129(25), 2717-2722.

Joynt, K. E., & Jha, A. (2013). A Path Forward on Medicare Readmission. J.Med, 368, 1175-1177.

McIlvennan, C., Eapen, Z., & Allen, L. (2015). Hospital Readmissions Reduction Program. Circulation, 131(20), 1796-1803. Circulation, 131(20), 1796-1803.

Medicine, D. T. I. (2013). Same day access heart failure clinic provides inter-disciplinary research oportunities.

Smith, C., Piamjariyakul, U., Wick, J., Spertus, J., Russell, C., & Dalton, K. (2014). Multidisciplinary Group Clinic Appointments: The Self-Management and Care of Heart Failure (SMAC-HF) Trial. Circulation: Heart failure, 7(6), 888-894.

Yancy  C. W. (2013). ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary. Journal of American College of Cardiology, 62(16), 1495-1539.


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