Plan All-Cause Readmissions Tip Sheet
The number of members 18 years of age and older with acute inpatient and observation stays during the measurement year that was followed by an unplanned acute readmission for any diagnosis within 30 days.
Incentives will be paid on an annual basis, following the end of quarter 4. For additional information refer to the 2021 CBI Tech Specifications.
According to Journal of Family Practice, common contributing factors to readmissions are:
- Feeling unprepared for discharge
- Difficulty performing daily activities
- Difficulty accessing discharge medications
- Trouble adhering to discharge medications
- Lack of social support
- Member expired during the stay
- Female members with principal diagnosis of pregnancy, or perinatal hospitalization
- Planned admissions
- Potentially planned procedure without a principal acute diagnosis
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.
- What is my main problem?
- What do I need to do?
- Why is it important for me to do this?
Assign Clinic Staff To:
- Monitor the Provider Portal reports 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.
- 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.
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
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