Getting it “right”: Risk-adjusted rates for potentially preventable readmissions

Nov. 2, 2015 / By Cheryl Manchenton, RN

Ever wonder how states (or CMS) set thresholds for readmission rates? Much has been said about and written on the subject, but there a few things I think are highly overlooked.

1. Organizations actually set readmission rates themselves

Now before you fire off an email to me, let me clarify. Documentation (or lack thereof) on a patient’s health status is gathered by government agencies via claims data and analyzed.   In determining readmission rates, what else is at their disposal on a detailed claim besides diagnoses and health status? As a whole, lack of complete documentation for many years gave data to CMS and state agencies that may not have told the whole story on the health of a populations. And remember, CMS and states are typically utilizing a three-year rolling period of data. So not only did our documentation probably not accurately reflect the health of our populations three or even five years ago, we probably aren’t doing it correctly now either.

Yes, I agree that government agencies should take into account the disproportionate share of underserved populations with insufficient health resources to care for themselves or of critically ill patients, and much has been written and stated about this across the industry. But is that in our control? Point is, let’s work on something that is actually within our control: documentation. And of course I am not discounting the need for improved measures to prevent readmissions, but that is something beyond my expertise.

2. Ignoring documentation improvement efforts around readmissions may be costly

I frequently hear organizations state that readmission improvement efforts that focus on documentation improvement are a low priority for their organization right now. But the effort needed is not that immense and the rewards (or penalties) are large. Complete documentation of patient health states and comorbid conditions is truly not that difficult of a concept and, honestly, providers should know the complete and current health state of their patients during the stay. In this way, they can monitor and maintain those patients with chronic conditions and watch for flares or new conditions resulting from these chronic health conditions. Holistic medicine!

3. Prove that your patients are sicker

Another lesser-known fact is that the expected rates of readmission are also set by the severity of illness and risk of mortality stratification of the population. In other words, the expected readmission rate for a COPD patient with a severity of illness subclass of 1 is much lower than that of a COPD patient with a severity of illness subclass of 3. So it is not just about capturing the list of comorbid conditions noted by CMS to be part of the risk-adjustment. It is fully capturing the severity of illness and risk of mortality of a population, and not just those that expire. Every patient coming in the door needs complete documentation that is reflective of their health state and risk of mortality.

Let us not bury our heads in the sand waiting for government agencies to “get it right” or waste time bemoaning the methodology. Start today on improving your documentation to justify your institution’s readmission rates and reflect the care you deliver!

Cheryl Manchenton is a Senior Inpatient Consultant and Project Manager for 3M Health Information Systems.

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