Plan All-Cause Readmissions Tip Sheet

Incentives will be paid on an annual basis, following the end of Quarter 4. For additional information refer to the 2021 and 2022 CBI Technical Specifications.

• Members enrolled in hospice.
• Deceased members in the measurement year.
• Member died during the stay.
• Female members with principal diagnosis of pregnancy or perinatal condition on the discharge claim.
• Planned admissions associated with:
  • A principal diagnosis of maintenance chemotherapy.
  • A principal diagnosis of rehabilitation.
  • Organ transplants (kidney, bone marrow, organ, and introduction to autologous pancreatic cells).
• Potentially planned procedures without a principal acute diagnosis (Example: Coronary Artery Bypass, drainage of upper extremity, and fusion of lumbosacral joint).

According to Journal of Family Practice, common contributing factors to readmissions are:

1. Feeling unprepared for discharge.
2. Difficulty performing daily activities.
3. Difficulty accessing discharge medications.
4. Trouble adhering to discharge medications.
5. Lack of social support.¹

1 Institute for Healthcare Improvement. (n.d.). Ask Me 3: Good Questions for Your Good Health. Retrieved from http://www.ihi.org/resources/Pages/Tools/Ask-Me-3-Good-Questions-for-Your-Good-Health.aspx

Educate All Members To:

• Call their PCP office for a follow-up appointment after their hospital discharge.
• Use the Alliance’s Nurse Advice Line: 1 (844) 971-8907 – available to all Alliance members 24 hours a day, 7 days a week, 365 days a year
• Utilize Ask Me 3® during visits to encourage members to ask three specific questions of their providers to better understand their health conditions, and what they need to do to stay healthy.

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?²

Assign Clinic Staff To:

• Monitor the Provider Portal Linked Members Inpatient Admissions report as a tool for tracking linked members who were recently admitted in the hospital.
• Contact members who have been recently discharged from inpatient care to bring them in for a follow-up visit. This can also be accomplished through a telehealth visit.
• Use the follow-up visit to educate the patient about his or her diagnosis and medicines and assess the degree of the patient’s understanding of discharge plan and medications.
• Track and trend clinic’s most vulnerable patients. Attempt multiple outreach efforts to those who are most fragile before they are readmitted.
• Contact the patient a few days after post discharge visit to reiterate the care plan and check-in with the member. Post discharge telephone follow-up has been shown to reduce hospital readmissions and is the most effective closer to the date of discharge.
• Refer Alliance Members to Care Management Services, including Complex Case Management and Care Coordination, by calling Case Management at (800) 700-3874 ext. 5512.
• Refer patients that have transportation challenges to the Alliance’s Transportation Coordinator at 1-800-700-3874 ext. 5577; this service is not covered for non-medical locations or appointments that are not medically necessary.
• Utilize the “5 whys” to gain insight from the member to understand the factors that brought them to the hospital. For example, an interview might reveal that a member did not take her medication, which then contributed to her rehospitalization.
  • Why did she not take her medication? She did not take it because she did not have it.
  • Why? She did not go to pick it up from the pharmacy.
  • Why? She did not have transportation to the pharmacy. Continue to ask until you have identified opportunities that your team can address³.

2 White, MD, B., Carney, PhD, P., Flynn, MD, J., Fields, MD, MHA, S., & Department of Family Medicine. (2014, February). Reducing hospital readmissions through primary care practice transformation. Retrieved from https://www.mdedge.com/jfponline/article/80074/practice-management/reducing-hospital-readmissions-through-primary-care

3 Designing and Delivering Whole-Person Transitional Care. Content last reviewed June 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/patient-safety/settings/hospital/resource/guide/index.html