In 2008, PEPPER began monitoring all 30-day readmissions and in 2009, the 9th Scope of Work tasked QIOs to work to reduce hospital readmission rates. Fourteen pilot programs have been introduced so far.
This session will provide you insight into building and optimizing an admission review program that leverages Utilization Review expertise and Physician Advisement. It will examine how to create an admission review process that proactively addresses the appropriateness of readmissions. Attendees will gain an in-depth understanding of the importance of medical necessity review, hospital readmission requirements, and factors to be considered according to the QIO manual. Additionally, the Director of Care Coordination for Guthrie Health System will present data from an intervention workgroup that studies congestive heart failure and pneumonia readmissions.

This workshop will begin with a didactic overview and then transition into case studies and small group discussions facilitated by an executive from Executive Health Resources (EHR), the Director of Care Coordination for Guthrie Health System and physician advisors from EHR. This technique will reinforce learning and ensure ample opportunity for participants to ask questions specific to their facilities.

The needs assessment for this program came primarily from two sources - the American Hospital Association's (AHA) strategic objectives for 2009 and evaluation results from EHR Accelerated Compliance Training (ACT) Series audio conferences and other speaking engagements. AHA suggested education on the topic of Readmission based on conversations in Washington including managing financial implications of improved quality and patient safety. EHR executives presented a session on the Readmission topic at an EHR regional Customer Affinity Group meeting in June 2009 and received an exceptionally positive response; more education on the topic was desired and thus noted on the evaluations.

An outline for this presentation is below:
I. Overview of readmission issues in the current regulatory environment
a. CMS reports 18% of Medicare patients are readmitted within 30 days of discharge
b. CMS believes many of these are avoidable or unnecessary
II. Increased CMS monitoring
a. PEPPER
b. QIOs
III. Discussion of statutes, regulations and CMS guidance related to readmissions
a. Readmission same day as discharge
b. Readmission at greater than 1 day
IV. Common readmission problems discussion
V. Best practices and UR processes
VI. Case studies
VII. Q&A with presenters