The Centers for Medicare and Medicaid Services (CMS) publishes rates of readmission for seven (7) categories of Medicare patients. These rates of unplanned readmission focus on patients who were discharged from a hospital and hospitalized again within 30 days. Patients may have been readmitted back to the same hospital or to a different hospital. They may have been readmitted for a condition that is related to their recent hospitalization, or for an entirely different reason. Planned readmissions are not included.

Measurement and public reporting on Hospital Compare of the CMS 30-day readmission measures fulfills federal mandates.  Hospital Compare states that measuring readmission rates  is important because unplanned readmissions may indicate whether a hospital is doing its best to prevent complications, provide clear discharge instructions to patients and help patients make a smooth transition from the hospital to home or another post hospital setting.

CMS uses three years of data for these readmission measures: Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD), Acute Myocardial Infarction (AMI) or Heart Attack, Pneumonia (PN), Stroke (STK), Elective Primary Total Hip and Arthroplasty (THA) or replacing the hip joint and Total Knee Arthroplasty (TKA) or replacing the knee joint. The Hospital Wide All Cause Unplanned Readmission (HWR) measure is the only measure that uses one year of data.

What are we measuring?

Although it is not possible to duplicate the CMS data exactly, we measure readmissions internally.  There are differences between our internal data and CMS’ data. We do not know when our patients are readmitted to another hospital.  Patients discharged from JFK and readmitted to another hospital within 30 days are not included in our internal data. Second, our data is more current than the CMS data.

The following graph shows our internal data.


What is our performance telling us?

In the most recent 3 year period of time measured by CMS (Q 3 2012 - Q 2 2015), readmissions for AMI, COPD, pneumonia and hospital wide (Q 3 2014 – Q 2 2015), are in the “worse than National rate” category.  More recent internal JFK data (Quarter 1 2015 compared to Q 1 2016)   indicates that readmission rates for AMI, Heart Failure, and hospital wide categories have decreased. 

CMS acknowledges that all unplanned readmissions may not be preventable.  JFK has a several programs to help avoid preventable readmissions.  In 2013 JFK established an Accountable Care Organization (ACO).  ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to provide coordinated high quality care to their Medicare patients. At the time of this publication there were over 200  physicians and 40,000 beneficiaries enrolled in the ACO.  The goal of this coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time.  The ACO also works to provide care in the best setting for the patient after discharge from the hospital.   Post hospital care may be provided in the home, in a sub acute facility, in a rehabilitation facility, or long term care.    In order to help patients understand their care and receive the needed post hospital care, patient are followed by a care manager.  Care managers may call patients when they return home to discuss medications, physician appointments, equipment, and other related topics. 

Another way JFK helps prevent patients from unnecessary readmissions is by preparing patients for hospital discharge using best practices.  JFK began using a best practice model for patients with Heart Failure called Project RED (Re-Engineered Discharge) in 2012.  Subsequently, there was a decrease in Heart Failure readmissions. Project RED includes arranging post hospital physician and lab appointments, education about Heart Failure, a written discharge plan, discussing medicines and a plan to obtain and take them, and a follow up phone call.   We are now expanding this model to many more patients including those with COPD and pneumonia as well as other patients hospital wide.

In addition, we are currently preparing for Joint Commission certification in COPD and Heart Failure. The certification process includes an on-site review and validation of the care provided to these patients.  Obtaining these certifications demonstrates our ongoing commitment to quality and consistent use of best clinical practices to deliver care.

It is our goal to help our patients avoid preventable readmissions. 

What can you do to prevent an unnecessary readmission?

Before you leave the hospital make sure you understand all your medication and discharge instructions and ask any questions you may have.  It is important to follow up with your physician as written in your discharge instructions. 

Most patients return home.  Some patients need continued care in other facilities.  Talk with your physician, nurse, case manager or social worker about where you will go when you leave the hospital.  It may be helpful to include a family member as you plan your hospital discharge. 

In addition, there are many resources available online to help you understand your role as you transition from the hospital. Below are links to two excellent resources that will help you manage your health needs as you transition from the hospital.

As a patient or family member you and your family are an essential part of the health care team. You can help during care transitions by understanding your needs, following up on appointments, understating and taking your medications, and knowing when to call your healthcare provider. Patients who are actively involved in their health and health care achieve better health outcomes and have lower health costs, than those who are not actively involved (Hibbard & Greene, 2013; Hibbard, Greene, & Overton, 2013; Stewart, 1995). By building the knowledge and skills to manage your health, navigate the health care system and make informed health care decisions, you can be an effective team member (IOM, 2011).