Enter Title

FACTS

100

 Definition

_{Readmission is an admission to a hospital within 30 days of a discharge from the same or another hospital}

200

HRRP

• _{Medicare value-based purchasing program} 

• _{Improves communication and care coordination} 

• _{Engage patients / caregivers in discharge plans}

300

CMS HRRP conditions/procedures

• _{Acute myocardial infarction (AMI)}
• _{Chronic obstructive pulmonary disease (COPD)}
• _{Heart failure (HF)}
• _Pneumonia.
• _{Coronary artery bypass graft (CABG) surgery.}

400

CSH focused HRRP diagnosis

• _Sepsis

• _{Heart failure}

• _COPD 

• _Pneumonia

500

Finanical Toll

3% payment rembursement reduction penalty for each readmission

REASONS

100

Patient-Related readmision factors 

• _{Socioeconomic Status (SDOH)}

• _Age

• _{Comorbidities} 

• _{Functional Status}

• _{Medication Adherence}

• _{Health Literacy}

• _{Mental Health}

• _{Social Support}

200

Healthcare-Related factors

• _{Quality of Care}

• _{Hospital Length of Stay}

• _{Access to Post-Discharge Care}

• _{Communication Gaps}

• _{Discharge Planning}

• _{Transition of Care}

300

Disease-Specific readmission factors

• _{High risk DRGs}

• _{Severity of Illness}

• _{Specific Disease Complications}

400

5 SDOH Domians

• _{Food insecurity}

• _{Interpersonal safety}

• _{Housing insecurity}

• _{Transportation insecurity} 

• _Utilities

500

Common Causes for Readmission

• _{Poor Family Support}

• _{Lack of understanding about medications}

• _{Failure to understand discharge plan}

• _{Inadequate transition plan} 

• _{No follow up appointments post DC} 

• _{No transportation to appointments}

PREVENTION

100

Medication Strategy 

• _{Medication reconciliation} 

• _{Medications education}

• _{Pharmacy to educate on medications} 

• _{Provide referrals to patients for access to medications}

200

High risk for readmission Readmission

• _{Clinical Risk assessment tools}  

• _{Clinical Judgement} 

• _{Data Analysis}

300

MDR Responsbilities 

• _{Ensure MDRs are completed}

• _{Develop conversations around high-risk patients} 

• _{Educate healthcare team members}

400

Communication

• _Teachback 

• _{WarmHand off to Post Acute Providers}

500

 Community Collaboration

• _{Collaborate with preferred network PAC providers}

• _{Identify community resources}