Chartbook on Care Coordination

• Centers for Medicare & Medicaid Services (CMS) defines a transition of care as:
  • The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.
  • These transitions place patients at heightened risk of adverse events. Important information can be lost or miscommunicated as responsibility is given to new parties.
  • Unsafe transitions of care from the hospital to the community are common and frequently associated with postdischarge adverse events (Forster, et al., 2003).

Measures of Transitions of Care

Measures reported in this section include:

• Hospitalized adult patients with heart failure who were given complete written discharge instructions.
• Median hospital 30-day risk standardized readmission rate or certain conditions.
• Median hospital 30-day risk standardized readmission rate.

Management: Complete Written Discharge Instructions

• Effective care coordination begins with ensuring that accurate clinical information is available to support medical decisions by patients and providers.
• A common transition of care is discharge from the hospital.
• A successful transition depends on whether hospitals have adequately educated patients about key elements of care such as diagnosis and followup plans (Horwitz, et al., 2013).

Complete Written Discharge Instructions

Hospitalized adults with heart failure who were given complete written discharge instructions, by sex and ethnicity, 2005-2012

Left Chart:

2012 Achievable Benchmark: 96.2%.

Right Chart:

2012 Achievable Benchmark: 96.2%.

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2012.

• From 2005 to 2012, the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved from 57.4% to 93.5%.
• Improvements were observed among both sexes and all racial and ethnic groups.
• There were no statistically significant differences by sex.
• In all years from 2005 to 2012, the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions was lower for American Indians and Alaska Natives (AI/ANs) than for Whites.
• The 2012 top 5 State achievable benchmark was 96%. At the current rates of increase, this benchmark could be attained overall and by both sexes in less than a year. All ethnic groups could attain the benchmark in less than a year except AI/ANs, who could achieve the benchmark in about 2 years.
• The top 5 States that contributed to the achievable benchmark are Illinois, Maine, Ohio, New Hampshire, and New Jersey.

Readmissions:

• Hospital readmission shortly after discharge is a marker of inpatient quality of care and a significant contributor to rising health care costs (Hasan, 2010).
• In 2013, approximately two-thirds of U.S. hospitals will be charged financial penalties from CMS because of excessively high 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia (Rau, 2013).

Risk-Standardized Readmission Rate

Median hospital 30-day risk-standardized readmission rate for certain conditions, 2006-2011

Key: AMI = acute myocardial infarction.
Source: Hospital Compare Chartbook, 2013.
Denominator: Expected number of readmissions for each disease type given the hospital's case mix.
Note: For this measure, lower rates are better.

• Importance: Although not all hospital readmissions are preventable, readmission rates may show whether a hospital is doing its best to deliver quality care, prevent complications, teach patients at discharge, and ensure that patients make a smooth transition to their home or another setting, such as a nursing home.
• Overall Rate: The median 30-day risk-standardized readmission rate in 2011 was 19.7% among patients with acute myocardial infarction (AMI), 24.7% among patients with heart failure, and 18.5% among patients with pneumonia.
• Change Over Time: The median 30-day risk-standardized readmission rates for AMI, heart failure, and pneumonia have remained stable from 2006 to 2011.

Median hospital 30-day risk-standardized readmission rate, by the percentage of patients who are African American and the percentage of patients who have Medicaid, 2009-2011

Left Chart:

Right Chart:

Key: AMI = acute myocardial infarction.
Source: Hospital Compare Chartbook, 2013.
Denominator: Expected number of readmissions for each disease type given the hospital's case mix.
Note: For this measure, lower rates are better. For a hospital's percentage of patients who are African American, low is defined as 0% for all three measures. High is defined as ≥22% for AMI, ≥23% for heart failure, and ≥22% for pneumonia. For the percentage of the hospital's patients who are insured by Medicaid, low is defined ≤8% for AMI, ≤7% for heart failure, and ≤6% for pneumonia. High is defined as ≥30% for AMI, ≥29% for heart failure, and ≥29% for pneumonia.

• Importance: Although not all hospital readmissions are preventable, readmission rates may show whether a hospital is doing its best to deliver quality care, prevent complications, teach patients at discharge, and ensure that patients make a smooth transition to their home or another setting, such as a nursing home.
• Groups With Disparities: The median 30-day risk-standardized readmission rates in 2009-2011 for acute myocardial infarction (AMI), heart failure, and pneumonia were similar between hospitals whose patients include a high percentage of African Americans and hospitals whose patients include a low percentage of African Americans. Hospitals whose patients include a high percentage of Medicaid recipients had similar median 30-day risk-standardized readmission rates for each of the three conditions compared with hospitals whose patients include a low percentage of Medicaid recipients.

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