Background: Although readmission rates have decreased since the implementation of higher-than-expected 30-day readmission penalties by the Centers for Medicare & Medicaid Services (CMS), rates remain above optimal. Hospital readmissions reflect two processes: discharge planning and access to care after discharge. To increase access to care, the US Congress passed the Patient Protection and Affordable Care […]

Background: Post hospital discharge review during the transition from hospital to skilled nursing facility (SNF) is critical to avoid medication errors, improve patient outcomes and reduce hospital readmissions (1-3). Despite increased integration of electronic health records (EHR) across health entities, communication gaps and discharge-related medication errors still persist (2,4). These challenges can be more predominant […]

Background: Although readmission rates have decreased since the implementation of higher-than-expected 30-day readmission penalties by the Centers for Medicare & Medicaid Services (CMS), rates remain above optimal. Hospital readmissions reflect two processes: discharge planning and access to care after discharge. To increase access to care, the US Congress passed the Patient Protection and Affordable Care […]

Background: Post hospital discharge review during the transition from hospital to skilled nursing facility (SNF) is critical to avoid medication errors, improve patient outcomes and reduce hospital readmissions (1-3). Despite increased integration of electronic health records (EHR) across health entities, communication gaps and discharge-related medication errors still persist (2,4). These challenges can be more predominant […]

Background: Many patients continue their post-acute care in settings such as skilled nursing facilities (SNFs). One in four hospitalized Medicare patients are discharged to SNFs. These patients are generally the elderly or require more care than patients discharged home, placing them at greater risk of clinical decline and rehospitalization. Moreover, 25% of patients discharged to […]

Background: Hospital readmission reduction has gained greater awareness since the passage of the Affordable Care Act and within it the Hospital Readmission Reduction Program (HRRP). Policy makers sought to improve quality of care by increasing reporting transparency and imposing financial penalties on facilities for excessive readmission rates. Baylor Scott & White Health (BSWH) remains committed to reducing hospital readmissions and in doing […]

Background: Equity is an essential domain of healthcare quality [1] but is rarely addressed within quality measurement programs. Quality initiatives, without explicit equity focus, may exacerbate underlying disparities.[2]To address this historic lack of focus on equity, the Centers for Medicare & Medicaid (CMS) now provides confidential reports to hospitals on two disparity metrics for Medicare […]

Background: At our Level 1 trauma center, geriatric trauma (GT) patients are primarily managed by hospitalists with surgical consultation. This care model offloads the trauma surgical services, improving time to surgery and hospital throughput. As the number of injured GT patients rose, so did the need to address a higher complication risk, longer hospital stays, […]

Background: Identifying patients who may benefit from a Serious Illness Conversation (SIC) in the hospital is an important step in increasing SIC timeliness. Epic’s Readmission Risk Score (RRS) is an electronic health record integrated composite score (0-100%) that includes diagnostic, laboratory, medication, order, and utilization variables to predict unplanned, 30-day readmission and was found by […]

Background: Adequate documentation of patient diagnoses is essential for hospitals to capture the extent of services provided, to submit bills, and ultimately receive payment. These diagnoses are used to calculate hospital performance as part of the Hospital Readmission Reduction Program. Diagnoses taken from medical record documentation are also used to place patients in diagnosis-related groups […]