Potentially Preventable Readmissions: Overview of Definitions and Clinical Logic HSCRC April 6, 2010

1. Potentially Preventable Readmissions: Overview of Definitions and Clinical LogicHSCRCApril 6, 2010 Elizabeth McCullough, 3M Health Information Systems 6 April 2010

2. PPR Definition: A Potentially Preventable Readmission (PPR) is a readmission that is clinically-related to the initial hospital admission that may have resulted from a deficiency in the process of care and treatment or lack of post discharge follow-up rather than unrelated events that occur post discharge (broken leg due to trauma), or readmissions that were planned at the time of the discharge from the initial admission. Clinically-related: Clinically-related is defined as a requirement that the underlying reason for following a prior hospital readmission be plausibly related to the care rendered during or immediately following a prior hospital admission. PPR-Potentially Preventable Readmissions

3. Why PPRs What might cause a PPR to happen? A readmission is considered to be clinically related to a prior admission and potentially preventable if there was a reasonable expectation that it could have been prevented by one or more of the following: • The provision of quality care in the initial hospitalization • Adequate discharge planning • Adequate post-discharge follow up • Improved coordination between inpatient and outpatient Health Care Teams • **Identifying Potential Preventable Readmission Article, Health Care Financing Review Fall 2008

4. The Identification of Potentially Preventable Readmissions (PPRs) Three Phases Phase I: Identify Excluded Admissions and Non Events Phase II: Determine Preliminary Classification of Remaining Admissions Phase III: Identify PPRs and Determine Final Classification of Admissions

5. Phase I :Identify Excluded Admissions and Non-events

6. Exclusions from the readmission methodology • No possible clinical relation to the index admission (cholecsytectomy two weeks after total hip replacement); • Not clearly related to improvement opportunities in either hospital or outpatient care (e.g. readmissions for malignancy care or a motor vehicle accident) • If any of the following conditions apply to the initial admission, a subsequent readmission is globally excluded from consideration as a PPR • Admissions for which follow-up care is intrinsically extensive and complex • Major or metastatic malignancies treated medically • Multiple trauma, burns • Discharge status indicates limited hospital & provider control • Left against medical advice • Transferred to another acute care hospital • Neonates • Other exclusions • Specific eye procedures and infections • Cystic fibrosis with pulmonary diagnoses • Died – not included as candidate initial admissions (denominator) • PPR Definition Manual Appendix E for List of Globally Excluded APR DRGs • PPR Definition Manual Appendix G for List of Major and Metastatic Malignant Diagnoses

7. Non Event Admissions • Admissions for certain non-acute care services during the interval between a prior admission and subsequent admission do not affect the classification of the subsequent admission • List of Non Event APR DRGs • 860 Rehabilitiation, • 862 Other Aftercare & Convalescense, • 863 Neonatal Aftercare • List of Non Event Discharge Status Codes

8. Phase II: Determine Preliminary Classification of Remaining Admissions

9. Example Readmission

10. Examples of a Non EventsAdmissions that get “ignored”

11. Transfer Example Transfer To Another facility: Transferred from To Another facility:

12. Excluded and Only Admissions Example

13. Phase III: Identify PPRs and Determine Final Classification of Admissions

14. Clinically Related Medical Readmissions • Medical readmission for a continuation or recurrence of the reason for the initial admission, or for a closely related condition. • Medical readmission for an acute decompensation of a chronic problem that was not the principal reason for the initial admission, but may be related to care either during or after the initial admission. • Medical readmission for an acute medical condition or complication that may be related to or may have resulted from care during the initial admission or in the post-discharge period after the initial admission.

15. Clinically Related Surgical Readmissions • Readmission for a surgical procedure to address a continuation or a recurrence of the problem causing the initial admission. • Readmission for surgical procedure to address a complication that may be related to or may have resulted from care during the initial admission.

16. Methodology for Selecting Potentially Preventable Readmissions (PPRs)

17. PPR Matrix v27 • 98,596 cells in 314 Initial Admission (IA) APR DRG x 314 Readmission (RA) APR DRG Matrix • 22% clinically related IA by RA APR DRG combination • 37% globally excluded IA by RA APR DRG combination • 41% DRG specific clinical exclusion IA by RA APR DRG combination

19. Phase III- Identify PPRs and Determine Final Classification of Admission

20. Determine if a Readmission Chain is Terminated Reasons for terminating a readmission chain Admissions with a discharge status of “died” Still classified as PPR, but PPR terminates the readmission chain Excluded admissions Any subsequent admission may be classified as an initial admission and start a new chain Transfers to another acute care facility Considered a PPR Transfer readmission will terminate the readmission chain and no subsequent admission will be part of the readmission chain Phase III- Identify PPRs and Determine Final Classification of Admission

21. Re-classify Readmission when not Clinically Related to Initial Admission Phase III- Identify PPRs and Determine Final Classification of Admission

22. Re-classify Initial Admission when Readmission not Clinically Related Phase III- Identify PPRs and Determine Final Classification of Admission

23. Reasons for Readmission Florida, All Patients, 2004-2005

24. Top 15 Initial Admissions followed by one or more PPR - 2007 Top 15 represents 35% of all initial admissions followed by PPRs 24

25. Top 15 Reasons for PPRs - 2007 Top 15 PPRs represents 42% of charges on PPRs for a 30 day readmission time window 25

26. Top Five PPR Reasons for an Initial Admission of Heart Failure - 2007 26

27. Summary of PPRs • Determines if there is a probable clinical relationship between an initial hospitalization and a readmission • Identify admissions that are potentially preventable • Identify admissions that are “at risk” for being followed by a potentially preventable readmission • Identify chains of readmissions that are all related to the same prior admission • Determine numerator and denominator for computing readmission rates (dependent variable)