Hospital Readmission Without Septicemia

Palmetto GBA just this week posted on its website an article titled Hospital Readmission Without Septicema discussing the CMS Hospital Readmission Reduction Program. pointing out the cost of unplanned readmissions is $15 to $20 billion annually. Interesting enough the following statements in the article run contrary to findings of a study published in January’s Health Affairs that called into question the realization of readmission reductions achieved through the HRRP since its inception. “The value-based reimbursement program contributed to significantly less hospital readmissions between 2010 and 2015, according to CMS data from September 2016. General readmission rates fell by 8 percent nationally during the time period, resulting in Medicare beneficiaries avoiding nearly 100,000 unnecessary readmissions in 2015 compared to 2010.”

From a documentation standpoint CDI can do best in insuring clear and accurate communication of patient care of key factors that impact likely readmission probability including an encompassing discharge summary that provides a brief summary of the investigation, treatment and outcomes for all active clinical conditions managed during the stay. Additionally, the CDI should insure an accurate and complete clinical picture told in the H & P including the following that impact readmissions:

• Progression in the natural history of the patient’s underlying disease

• Separate problem that is unrelated to the initial admission

• Consequence of patient inability to follow through with a portion of a discharge plan (e.g., the patient is unable to fill prescriptions)

A few other key points highlighted in the Palmetto GBA article on readmissions are worthy of notation. I have always maintained that complete and accurate communication of patient care must be the vision and purpose of CDI with an unwavering commitment to achieving communication of patient care the adequately and effectively describes, shows, tells, depicts and reflects and paints a true clinical picture of the patient story where the patient can be easily found in the story. Consider the following factors that can potentially contribute to a patent hospital readmission or serve as risk factors for readmission:

• Premature discharge
• Inadequate post-discharge support
• Insufficient follow-up
• Therapeutic errors
• Adverse drug events and other medication related issues
• Use of high-risk medication (antibiotics, glucocorticoids, anticoagulants, narcotics, antiepileptic medications, antipsychotics, antidepressants and hypoglycemic agents)
• Polypharmacy
• More than six chronic conditions
• Specific clinical conditions (e.g., advanced chronic obstructive pulmonary disease, diabetes, heart failure, stroke, cancer, weight loss, depression, sepsis)
• Prior hospitalization, typically including unplanned hospitalizations within the last six to 12 months
• Reduced social network indicators (e.g., being alone most of the day with limited or no family or friend contact by phone or in person)
• Discharge against medical advice

Premature Discharge

Premature discharge is always a real contention when an unplanned readmission occurs. There exists no universal definition of a premature discharge, looking at premature discharge from another angle, the medical necessity for continued hospitalization is primarily determined by the presence of an acute health condition of sufficient severity that ongoing diagnostic or therapeutic intervention, or careful monitoring is required. (UpToDate.com) One particular area CDI can strengthen as part of the regular daily chart review is to enhance the focus upon the progress note beyond diagnosis capture. The purpose of progress notes is to provide a daily account of the physician’s patients and their illnesses, and of developments in their diagnosis and treatment, for all of those who share in their care. Copy and paste is prevalent creating a hodgepodge of information that may or may not be accurate and certainly contributes to excessive note bloat creating a situation where it is challenging to find the patient in the note. Progress notes tend to recapitulate the patient’s care from the previous day at best or even worse the recapitulation of the entire stay with population in the record of all lab values and radiological findings from day one of admission. This is where CDI can play an active role in advocating for, promoting and achieving communication of solid progress notes that reflect and report clear concise consistent and contextually correct information about the patient, updating the patient’s progress from the previous day. At a minimum CDI should as a matter of principle partner with case management and utilization review to ensure that the last few progress notes clearly highlight the patient’s clinical condition with stability of the patient in comparison to the patient’s clinical instability at time of decision to hospitalize the patient. The profession must alter the current practice of reviewing a record at time of admission, identify any opportunities for additional diagnosis reporting based upon clinical indicators or need for additional clinical specificity in diagnosis reporting, generate a query and then follow-up to determine if the query was responded to by the physician. This represents little more than setting a bait trap for an animal and waiting to see what transpires after the trap is placed. I liken this analogy to drop, grab abd run, drop a query and seen what transpires, grab the query when and if answered and run to the software system used to record a win if achieved. CDI in short must develop a holistic approach to chart review recognizing and capitalizing upon the opportunity to affect real improvement in the communication of patient care.

Closing Thoughts

I submit to all CDI professionals when reviewing daily work flow processes to consider whether we are performing with the right purpose, mission and vision. At the end of the day are we achieving any real improvement in the quality and completeness of the record? Are we facilitating positive improvement in communication of patient care throughout the hospital stay to the extent we are assisting case management and utilization review fulfill their obligations to the patient and physician in insuring the most clinically appropriate level of care status, need for continued stay and sound post-acute discharge plan of care with proper fiscal fiduciary responsibility to the patient? Proper reimbursement for the facility will ensue with achievement of sound documentation and communication of patient care. Time to take a pause from traditional practices of CDI, evaluate where we are as a profession both individually and collectively and revamp our programs. Doing the same thing repeatedly and expecting achieved results of improved documentation is not reality with current CDI processes. We can and should do better.

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