Late to the Game

While we were attention to other things, the rules of the hospitalization game changed just slightly. Although penalizing hospitals for readmissions in not new, hospitals are finally paying attention when hit with their third year of fines and the potential for even greater fines in 2015.

Currently, the penalties are for Congestive Heart Failure and pneumonia. More measures have been added and the total penalty for re-hospitalizations next year will max out at 3 percent. That may not sound like a lot but consider that the median operating margin for hospitals with 200 beds was -7% and the average is increased by a few hospitals making an obscene profit. The ‘operating margin’ is the profit when only the payment and services are calculated. Other sources of income such as gifts, grants and investments are excluded. If a hospital that was average was to be hit with even a 0.5% penalty, it could be deadly. Furthermore, less than 1000 of the almost 5000 hospitals were not fined for 2013. If you are curious about the hospitals in your town, click here and look for the scrolling table in the middle of the page.

I know that numbers are boring. I appreciate that you suffered through this much of tonight’s post and hopefully you now have an idea of how your hospitalization rate has become less important than numbers you do not have. So, before you plan to attack the diagnoses that are troublesome to your referral sources, you should do just a little more math and find out your hospitalization rate for the following diagnoses.

  • Congestive Heart Failure
  • Pneumonia
  • COPD
  • MI
  • Elective Hip and Knee replacements (are they ever emergent?)

This should be easy but every coder sees the problem. Home Health agencies do not admit patients for pneumonia, MI or hip and knee replacements. There is no report that can be easily run. And yet these numbers are critical to your ability to demonstrate value to your best referral sources.

There are any number of ways this can be done. My preference is an old fashioned Excel spreadsheet. Another option would be for coders to add a suffix to Medical record numbers for each of the diagnosis categories to make it easy to run reports. Some computer systems have attributes that can be added. If your system allows it, you can query all OASIS data for the diagnoses the patient had treated in the hospital. Any or all of these options should be considered and at least one should be implemented.

After you have decided how to identify patients within the criteria, the next step is to regularly calculate the 30 day hospitalization rate for each subset of patients. Home Health hospitalization rates are calculated at 60 day intervals and the hospitals are interested in 30 days. Sadly, it is not enough to merely divide the 60 day number by two. I tried it. It does not work.  Patients go back to the hospital within 21 days for the most part.

Those of us who are mathematically challenged rely on simple rules. Count all the patients in a category and then count all of the ones who went to the hospital within 30 days (look for an OASIS transfer assessment). Then divide the big number into the little number. Example: 15 patients were admitted with Congestive Heart Failure. Two patients went to the hospital within thirty days of admission or Resumption. Divide the big number (15) into the small number (2). 2/15 = 13 percent.

For those of you who are not mathematically challenged, please rest assured that nobody is trying to insult you. This really is a big deal for some of us. If you are very gifted with calculating percentages, drop by the QA department and offer your services. Expect them all to say they know it already because many of us are embarrassed to admit we were daydreaming during 6th grade math. Still make a pretty graph or something for them. They will secretly love you.

After you establish the baseline, your agency can get an idea of how you are performing and what needs to happen to make your agency appealing to the referral sources. The answers are going to be different throughout communities and agencies but over the next few months, there will certainly be discussions on how to address each diagnosis code. In all instances, it will require constant monitoring. That much I promise.

Hopefully, once you get those numbers, you can next start planning to reduce them. We will be here doing as much as we can to help you. If you have any insight, please share it with us so we can enlighten the world.

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