30-day readmissions rate: What’s behind the number?

Both the acute care and post-acute care (PAC) industries have their full attention focused on the much discussed and hyper-analyzed 30-day readmission metric. On the acute care side, this number determines whether a reimbursement penalty will be applied—affecting revenue streams. On the PAC side, the number increasingly will be used to judge the quality of PAC partners and ultimately communicate that information to discharging patients. High stakes stuff for sure. Unfortunately the fixation on this magical metric might be obscuring various subtle and more nuanced aspects of this readmission puzzle.

As I have considered this metric and its implications both as a PAC administrator and in my current job on the acute care side of the of the healthcare world, I have stumbled on three not-so-obvious angles that PAC providers need to be aware of and, if at issue, develop a means to address.

1. FAILED DISCHARGE VS. AVOIDABLE READMISSION

As a lifelong PAC administrator, I am well acquainted with the notion that if something goes wrong in our industry, it is pretty much preordained to be our fault. With respect to the 30-day readmission challenge, the general assumption is that if the readmission was avoidable, the fault must lay with the PAC provider in some way, shape or form.

Fortunately for beleaguered PAC providers, this assumption is not always the case. This is especially true with readmissions that occur within a short period of time after the discharge from acute care. The debate about what constitutes a short time period could go on forever. For my purposes, any readmission that occurs within seven days of discharge from acute care has the potential to be related in part, or in the whole, to a problematic discharge from acute care. Obviously the closer to the acute care discharge that a readmission occurs, the greater the likelihood that the acute care discharge may have been a major contributing factor. 

The analysis of readmissions is in its infancy. Until such time that this analysis evolves into a more systematic and encompassing review, PAC providers would be well served to nominally track and trend the numbers associated with re-admissions that occur within seven days of discharge from acute care. If, in fact, they are experiencing an inordinate number of readmissions in this one to seven day category, engaging with acute care partners for a more in-depth analysis might well make sense.

2. PAC DISCHARGE FOLLOW-UP CALL

Medicare managed care plans are exerting ever-increasing downward pressure on PAC lengths of stay. This pressure has resulted in stays of 10 to 20 days becoming the norm and no longer the exception. Among many things, this phenomenon of shorter stays fuels the “turnstile effect,” with admissions and discharges churning turnover of patients. This activity forces PAC providers to focus on the person who will fill an empty bed (those that help meet next week’s payroll) and not so much on the patient who is going home (those not in a position to help to cover payroll).

This ever-shorter length of stay magnifies the importance of sound PAC discharge planning for several reasons, including the greater number of days remaining in the 30-day readmission window. In the old days, when lengths of stay routinely exceeded 30 days, the patient was inside of the PAC provider’s four walls with a far greater ability to control outcomes and avoid rehospitalizations. This is no longer the case, as patients routinely spend 20 or more days of their post-hospital stay in their own homes.

On the PAC side, PAC facilities might have a sense that once the patient has been discharged from a facility to the community, the facility no longer has an impact on the PAC’s 30-day readmission rate.  This thinking might be driven by the perception that when such patients return to the hospital, their discharge location will show as the community—not the discharging PAC facility.

Although this largely may be true now, acute care providers eventually will acquire the ability to track patients for the whole of their post-acute journey. They will come to understand that connecting the dots on readmissions from the community will include identifying the PAC provider involved in providing immediate care and the number of days between the discharge from the PAC facility and readmission to acute care. 

Similar to the failed discharge from acute care discussed previously, PAC providers will have responsibility for sound discharge planning and, at some level, will share responsibility for the impact that these readmissions have on a hospital’s 30-day readmission rate.

The bottom line is that PAC providers must make it an organizational imperative to connect with all discharged patients. Ideally this contact should occur within 24 hours and absolutely no later than 48 hours after discharge. In spite of gold standard discharge plans, discharges to an unstructured community setting are ripe for system and people failures. A simple phone call to check on how the discharged patient is doing and to identify any gaps in the discharge plan, followed by assistance with addressing such issues, can potentially salvage a discharge plan that is heading south.

3. IDENTIFYING A LATENT READMISSION PROBLEM

PAC professionals by necessity live by the credo that there is no need to actively dig for problems because, more often than not, they will find you. Unfortunately as it relates to the 30- day readmission conundrum, what you don’t know may hurt you.  Plainly stated, the simplistic 30-day readmission rate may not tell the whole story.

As a PAC administrator, I worked in a market with a health system that pioneered the tracking and reporting of 30-day readmission rates (Summa Health System). Upon learning that my facility’s 30-day readmission rate was below the magical standard of the time, I would turn my attention to the literally hundreds of other issues confronting me. Although this may have seemed like a sound approach back then, in today’s environment PAC administrators need to be pointedly aware of near-miss readmissions. Near-miss readmissions are ones that occurred outside of the magical 30-day window and that if the winds of fate had blown in a different direction may have resulted in readmissions inside of that window.

Again, the comparative metrics for such near-miss readmissions do not currently exist. As with potentially failed acute care discharges discussed previously, PAC administrators should, at a minimum, seek to determine the gross number of readmissions in the 31- to 37-day range, for example. If this number is high, then PAC administrators need to further analyze the effect that a percentage of these readmitting sooner would have on the facility’s overall 30-day readmission rate. If this impact is significant, then steps should be taken similar to what would be done for an out-of-standard 30-day readmission rate.

Finally, it must be said that nothing is magical about the “30 days” in this whole readmission conundrum. At some point the 30-day readmission rate no longer will present a challenge to the PAC industry. At that point I can well imagine we will be discussing the 37-day readmission rate. For this future reason as well as the current imperative of identifying a latent readmission problem, tracking and trending readmissions above 30 days makes a good deal of sense.

SUMMARY

The 30-day readmission conundrum is by no means a simple, easy-to-solve puzzle. No single solution exists and, likewise, an infinite number of potential causes exist in the intertwined worlds of acute and post-acute care. PAC administrators who make themselves aware and responsive to the nuances of the readmission phenomenon will be steps ahead as they seek to identify paths to managing this increasingly important issue.

Kevin R. McMahon, MPA, LNHA, is Seniors Program Coordinator, Summa Institute for Senior Health at Summa Health System in Akron, Ohio. He can be reached at mcmahonk@summahealth.org.

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