This is not about your chronic "offenders" from the street who use the ED like a revolving door. That is another issue to address but CMS readmission penalties that went into effect yesterday are rather clear.
Hospitals have been monitoring AMI, CHF and PNA patients for a few years to collect data for CMS and to see where they also stand for the treatment and their readmission rates. During this time most hospitals have improved overall and have been aware of the penalties which are now being made official. This has been no surprise.
For the hospital who prepared for this, it seems to be business as usual. Those which are not strong in Social Work and Case Management areas due to cut backs may feel it more than others. The patients most at risk for readmission are those who used the ER physicians as their primary care. A few hospitals are finally investing in putting more Nurse Practitioners into home health. This makes much more sense than a Paramedic since they are also concerned about skin integrity, nuitrition and can order and do some of the necessary tests in the home whereas a Paramedic cannot. Keeping the care as direct as possible is the best way to prevent readmissions for the 3 things which also includes whatever is associated with them such as skin break down and other infections.
Essentially, what it means is these patients were admitted for an AMI, CHF or PNA. They supposedly had their problem addressed, treated and put on a long term maintenance program. Social Services or Case Management is involved as necessary, communication to a primary physician has been made, instructions given for discharge medications and activity and the necessary appointments have been made.
Essentially CMS has been in conflict with the hospitals by putting limitations on care per disease which started releasing patients from the hospital too soon.
Medicare pays hospitals based on diagnosis related groups, or DRGs, that allow a single payment for services related to a specific diagnosis and not the actual level of services required for a particular patient. This DRG based payment system is an incentive for hospitals to deliver necessary care at or below the DRG rate. In 2007, the Medicare program did transition to the use of Medical Severity DRGs to better reflect the acute health care needs of Medicare beneficiaries. While this change enhanced reimbursement rates, the incentive to treat patients at or below the MS-DRG rate remains as no reimbursement is provided for the cost of care delivered beyond the DRG rate, outside of an outlier payment. If a hospital discharges a patient before it is medically appropriate to do so, the patient is more likely to return to the hospital for additional care that in some circumstances may be more costly due to exacerbation of the underlying condition(s).
Since 2008, CMS has already penalized hospitals for these if they occured while in the hospital.
foreign object retained after surgery
air embolism
blood incompatibility
stage III and IV pressure ulcers
falls and trauma
fractures
dislocations
intracranial injuries
crushing injuries
burns
catheter-associated urinary tract infection (UTI)
vascular catheter-associated infection
surgical site infection/mediastinitis after coronary artery bypass graft surgery.
Some of these are also in place in the LTC facilities which EMS fails to understand and complains about. They fail to understand about UTI and the need for foley catheter changes. In most facilities, the foley is changed every 30 days. Only a few patients require a trip to the ED for a special situation where the patient has had problems before. IFT trucks only see a very small number of these even though some make it sound like 1 or 2 patients each month out of the thousand in LTC is a big deal.
Some in EMS have gotten bent out of shape because the hospital pulls their IVs in the ED. The hospitals that have done this probably did their QA monitor in that area and found a higher than acceptable infection rate. It is easier for a hospital to change even with a 1000 employees working with IVs than it is to get EMS to change a few Paramedics and their infection policies.
So until EMS understands more about disease processes and just the things they are doing and how they affect the patient, it may still be a hindrance rather than a help in the health care system.
Hospitals have been monitoring AMI, CHF and PNA patients for a few years to collect data for CMS and to see where they also stand for the treatment and their readmission rates. During this time most hospitals have improved overall and have been aware of the penalties which are now being made official. This has been no surprise.
For the hospital who prepared for this, it seems to be business as usual. Those which are not strong in Social Work and Case Management areas due to cut backs may feel it more than others. The patients most at risk for readmission are those who used the ER physicians as their primary care. A few hospitals are finally investing in putting more Nurse Practitioners into home health. This makes much more sense than a Paramedic since they are also concerned about skin integrity, nuitrition and can order and do some of the necessary tests in the home whereas a Paramedic cannot. Keeping the care as direct as possible is the best way to prevent readmissions for the 3 things which also includes whatever is associated with them such as skin break down and other infections.
Essentially, what it means is these patients were admitted for an AMI, CHF or PNA. They supposedly had their problem addressed, treated and put on a long term maintenance program. Social Services or Case Management is involved as necessary, communication to a primary physician has been made, instructions given for discharge medications and activity and the necessary appointments have been made.
Essentially CMS has been in conflict with the hospitals by putting limitations on care per disease which started releasing patients from the hospital too soon.
Medicare pays hospitals based on diagnosis related groups, or DRGs, that allow a single payment for services related to a specific diagnosis and not the actual level of services required for a particular patient. This DRG based payment system is an incentive for hospitals to deliver necessary care at or below the DRG rate. In 2007, the Medicare program did transition to the use of Medical Severity DRGs to better reflect the acute health care needs of Medicare beneficiaries. While this change enhanced reimbursement rates, the incentive to treat patients at or below the MS-DRG rate remains as no reimbursement is provided for the cost of care delivered beyond the DRG rate, outside of an outlier payment. If a hospital discharges a patient before it is medically appropriate to do so, the patient is more likely to return to the hospital for additional care that in some circumstances may be more costly due to exacerbation of the underlying condition(s).
Since 2008, CMS has already penalized hospitals for these if they occured while in the hospital.
foreign object retained after surgery
air embolism
blood incompatibility
stage III and IV pressure ulcers
falls and trauma
fractures
dislocations
intracranial injuries
crushing injuries
burns
catheter-associated urinary tract infection (UTI)
vascular catheter-associated infection
surgical site infection/mediastinitis after coronary artery bypass graft surgery.
Some of these are also in place in the LTC facilities which EMS fails to understand and complains about. They fail to understand about UTI and the need for foley catheter changes. In most facilities, the foley is changed every 30 days. Only a few patients require a trip to the ED for a special situation where the patient has had problems before. IFT trucks only see a very small number of these even though some make it sound like 1 or 2 patients each month out of the thousand in LTC is a big deal.
Some in EMS have gotten bent out of shape because the hospital pulls their IVs in the ED. The hospitals that have done this probably did their QA monitor in that area and found a higher than acceptable infection rate. It is easier for a hospital to change even with a 1000 employees working with IVs than it is to get EMS to change a few Paramedics and their infection policies.
So until EMS understands more about disease processes and just the things they are doing and how they affect the patient, it may still be a hindrance rather than a help in the health care system.
