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 Tactical Operations

Providing the right care to the right patient at the right time

Strategies for limiting readmissions while complying with the two-midnight rule

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   By Wayne Sensor, CEO of Ensocare and Kyle Salem, Ph.D., Managing Director, CQuence Health Group, August 2014

Wayne Sensor

Wayne Sensor,
CEO of Ensocare

Kyle Salem

Kyle Salem,
Ph.D., Managing Director, CQuence Health Group

In recent months, the Centers for Medicare and Medicaid Services (CMS) has started revisiting its two-midnight rule, reviewing whether it is the most effective way to structure Medicare payments for patients who require less than a two-day hospital visit. In fact, CMS is considering eliminating the rule following wide criticism from influential hospital and physician groups, in addition to recent legislation further delaying its implementation.

Regardless of if or when the two-midnight rule or similar payment regulations are enforced, hospitals should focus on doing the right thing for patients by getting them to the right level of care as efficiently as possible and mitigating readmission risks head on rather than establishing practices just to meet regulation.

A brief background on the two-midnight rule
A chief impetus for the two-midnight rule was the way organizations were approaching observation status. Observation status has been used in hospitals for decades, when they required time to assess patients’ needs and identify the right care path for their conditions. Sometimes patients are placed in observation status when entering the hospital through the emergency department (ED) and may be held in observation for further evaluation or for non-clinical reasons, such as the hospital not having enough inpatient beds available or because the patient lacks support at home.

 According to a recent MedPac report to Congress, the number of hospital visits categorized under “observation” jumped nearly 65 percent between 2006 and 2011. Some believe this is due to hospitals overusing the observation status as a means for reducing readmission rates – as patients that are kept in observation status are never technically admitted, and hospitals cannot be penalized for readmission if the patient returns.

In response to this growing cost issue, Medicare introduced the two-midnight rule, which specifies that patients who are anticipated to require care spanning fewer than two midnightsare treated and billed as outpatient services. And those with needs requiring more than two midnights are treated and billed as inpatients. By limiting the amount of time patients can be treated as outpatients, Medicare is also limiting how long patients can be held in observation as it falls under outpatient services.

Although compliance with the two-midnight rule was originally expected in October 2013, new legislation has further delayed its enforcement until March 31, 2015. As mentioned before, CMS is considering eliminating the rule altogether in place of an alternative payment methodology, according to a recent statement, for which they are seeking stakeholder feedback.

Addressing readmissions head on
Complying with any healthcare regulation like the two-midnight rule should not be about ticking boxes on a checklist or meeting requirements strictly out of technicality. It should be about improving patient safety and keeping the patient’s needs and interests at the center of care. To effectively reduce readmissions, for example, hospitals need to look beyond the semantics of the impending legislation and employ more patient-focused methods.

Rather than using workarounds or quick fixes to limit readmissions, hospitals should employ strategies and solutions that ensure patients receive the right care in the right setting at the right time from the get-go. Doing so will help hospitals reduce readmissions and promote patient safety and better outcomes while also being cognizant of Medicare payment structures.

The following strategies can help hospitals directly address the root causes of readmissions, ultimately decreasing readmission rates:

Stratifying the patient’s risk for readmission. At the point of discharge (and even as early as admission), providers should have a good understanding of a patient’s risk for readmission based on the diagnosis or condition, availability and level of family support and other factors. Using a risk stratification methodology provided by some technology-based solutions, hospitals can easily identify a patient’s likelihood for readmission and apply additional interventions to reduce the chance of the patient revisiting the hospital.

Applying interventions to address specific risk factors. Along with risk stratification, hospitals should establish an arsenal of predetermined interventions that go above and beyond standard discharge protocols to reduce specific risk factors. Once a patient has been identified at an elevated risk for readmission, appropriate interventions should be leveraged upon discharge. These interventions might include follow-up calls to the patient, additional services or arranging transportation for the patient. Some technology-based solutions even continue risk stratification following the patient’s discharge and will adjust the level of risk based on the patient meeting (or not meeting) post-acute milestones.

Coordinating post-acute care. When patients are discharged, oftentimes they still require care services from medical and nonmedical providers. For instance, patients may need to go to a rehabilitation facility or perhaps a long-term care organization. Similarly, they may require outpatient physical therapy or dietary counseling, or they may need assistance from nonmedical providers, including transportation, food delivery, cleaning or laundry services. When hospitals coordinate patient care following discharge, they ease the transition process and further promote the patient’s continuity of care.

Leveraging technology to streamline post-acute care. Coordinating post-acute care for patients is important, but it can be daunting if it must be done manually. One method for coordinating care and streamlining transitions is to use technology. More specifically, hospitals can leverage discharge and care coordination technology to connect patients with possible post-acute providers while the patient is still in the hospital. Automated solutions can streamline the process by conveniently delivering information about post-acute providers to patients and their families, enabling them to make informed decisions quickly and easily. While manually arranging post-acute care can take days, care coordination and discharge technology helps hospitals obtain responses from area providers in as little as 30 minutes, allowing patients and family members to efficiently review their options, identify preferred providers and make choices without having to add unnecessary days to a patient’s stay – which in some cases may push the stay from outpatient to inpatient if it crosses the two-midnight mark.  

Providing post-discharge follow up. Once patients are “out of sight,” it is difficult to monitor their compliance with medications and care plans, which is key to achieving healthier outcomes and mitigating readmission risk. By scheduling post-discharge follow-up care visits or other services, such as calling or emailing, providers can continue monitoring patients outside the hospital walls and empower them to remain engaged in their care.

By pursuing targeted strategies for reducing readmissions and then leveraging technology-based solutions and tools to streamline patient movement to the next level of care, hospitals can more accurately realize appropriate care paths for patients. This ensures patients receive the right care in the right setting at the right time – which will not only help achieve improved patient outcomes and satisfaction but also decrease the likelihood of readmission.


Tags:  Tactical Operations