Readmission Costs Are Real and Case Managers Are on the Hot Seat

Carelike Team | Care Coordination, | September 28, 2017

For those of us working in the U.S. healthcare system, the term “readmission” is heard on a daily basis, and it’s a term we don’t take lightly. For Case Managers and Discharge Planners, the term invokes a feeling of stress as we are responsible for making sure our patients are discharged with an airtight plan that will prevent a return to the hospital. The pressure is real. The ramifications directly impact our jobs not to the mention the hospital’s bottom line and, most importantly, our patients’ quality of life.

The Affordable Care Act's Hospital Readmission and Reduction Program (HRRP) applies financial penalties for readmissions of Medicare patients that are higher than expected according to algorithms derived by the Centers for Medicare and Medicaid Services’ (CMS). The penalties are imposed against a hospital’s total book of Medicare business and constitute significant reimbursement reductions for hundreds of hospitals across the country. According to the Kaiser Family Foundation, total Medicare readmissions penalties will increase to $528 million in 2017, which is an increase of $108 million over 2016[1].

To reduce readmissions, we need to understand some basic facts. First, a readmission occurs when a patient is admitted to a hospital within a pre-determined time period (Medicare defines this time period as 30 days) after being discharged from a prior hospitalization and includes readmissions to any hospital, not just the one where the patient was originally hospitalized. Furthermore, Medicare doesn’t take into consideration cases where a patient is readmitted for a diagnosis completely unrelated to the original hospitalization. For example, if my mom’s discharge diagnosis was Congestive Heart Failure and she returns to the hospital due to a hip fracture, the hospital still gets dinged for a readmission.

Currently, the HRRP focuses on six conditions: heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), elective hip or knee replacement, and coronary artery bypass graft (CABG). CMS will likely continue to add conditions to this list to maximize savings and improve quality over time.

So, what does this mean for the Case Manager? If you consider the six conditions eligible for penalties, you can see that these are high acuity diagnoses in need of complicated discharge services. These patients often require one or more interventions including:

  • Transfer to a skilled nursing facility for more intense post-acute rehabilitation
  • Follow-up by a Registered Nurse for medication management, especially those with polypharmacy and/or high-risk medications, vital sign assessment, wound care, etc.
  • Physical Therapy/Occupational Therapy to regain strength after a hospital stay
  • Durable Medical Equipment (DME) such as oxygen, walker, wound care supplies, etc.
  • Home care to assist with Activities of Daily Living, transportation, shopping, etc.

CMS not only imposes stiff penalties for readmissions, but it has also established requirements regarding which facilities patients can be sent to, which home care agencies can follow patients and which DME companies can provide supplies. In addition, there is an important element to consider around the regulations of patient choice in making decisions for the post-acute care they require. Patients need access to information to make the most informed choices.

These criteria pose challenges for the Case Manager as she tries to coordinate services and comply with regulations while at the same time, remaining cognizant of the need to discharge the patients in a timely manner. What we lack, quite frankly, are the tools necessary to facilitate this process. We need a resource database that not only provides lists, qualifications and special offerings of post-acute care providers but offers quality scores to help assure the Case Manager is creating the best discharge scenario for the patient. Furthermore, it’s essential to understand the need for a database that captures both medical and non-medical providers. The non-medical resource team is just as vital as the medical team in restoring the patient to his or her level of independence prior to the admission. Armed with this type of information, Case Managers and Discharge Planners can tackle our readmission challenge and provide the highest quality care to our valued patients.


About Carelike


Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 


Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination.