2023 Reducing Hospital Readmissions Congress

7:15am – 8:00am
Conference Registration & Networking Breakfast 

8:00am – 8:15am
Chairperson’s Opening Remarks 

8:15am – 9:00am
Strategies for Reducing Hospital Readmissions
Reducing hospital readmissions is a major goal in healthcare. A readmission or rehospitalization occurs when a patient who has been discharged from the hospital is readmitted to the hospital within a certain timeframe—usually 30 days. Readmissions are costly to hospitals, patients and payers, and reduce patient care outcomes and satisfaction. Readmissions can be prevented with proper communication between healthcare providers and patients. This session will explore strategies hospitals can implement to reduce the risk of readmission after a patient is discharged.

Erik Arellano M.D.
Chief of Staff
Copper Queen Community Hospital

9:00am – 9:45am
Improving Discharge Procedures to Reduce Hospital Readmissions
Hospital discharge procedures can be confusing and anxiety inducing for patients and caregivers as they try to make sense of the often-complicated instructions for medication and follow-up care. There may be multiple providers contributing to the paperwork handed to patients, including clinical specialists, therapists and social workers, each focused on different posthospital goals. Unplanned readmissions of patients due to lapses in posthospital care account for an estimated $20 billion annually for Medicare patients alone. Hospitals are under increasing pressure to improve the situation because of a provision of the Affordable Care Act called the Hospital Readmissions Reduction Program, which penalizes hospitals financially if they have higher-than-expected 30-day readmission rates for certain conditions. Topics to be discussed will include:

- Interventions, such as medication counseling and disease education

- Community care transition programs

- Communication skills that integrate patients’ needs, perceptions, social considerations and health knowledge

- Working across clinical and social service disciplines to improve patient knowledge and treatment adherence

Sharlene Burgos BSN, RN
Assistant Nurse Manager for Project RED
VAAES Documentation Workforce Lead

9:45am – 10:15am
Networking & Refreshments Break

10:15am – 11:00am
Examining the Hospital Readmissions Reduction Program
CMS’s Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions. HRRP improves healthcare by linking payment to the quality of hospital care. CMS incentivizes hospitals to improve communication and care coordination efforts to better engage patients and caregivers on post-discharge planning. session will explore how HRRP improves quality of care and saves taxpayer dollars by incentivizing providers to reduce excess readmissions.

Emily Downing, MD
System Clinical Officer, Population Health, Home Care Services, Health Equity
Allina Health

11:00am – 11:45am
The Impact of Social Determinants of Health on Hospital Readmission Risk
The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals by withholding up to three percent of regular reimbursements if they have a higher-than-expected number of readmissions within 30 days of discharge for six specific conditions. Social determinants health—where people live, work, their mode of transportation—are critical data points that can be integrated into care management workflows to provide actionable data at the point of care and to enhance discharge planning. Taking that data in real-time to formulate a readmission risk score can help identify patients who may have SDOH barriers like transportation or housing instability risks. Care Management teams that have this information when a patient is admitted for care can appropriately plan and tailor their discharge plans to account for SDOH barriers before a patient leaves their facility. This session will explore how your health system can reduce hospital readmission risk using social determinants of health data and advanced analytics.

Samy Allam MD, MHA
Course Director | Clinical Informatics and Health Data Integrity
Arrowhead Regional Medical Center

11:45am – 12:30pm
Healthcare-Associated Infection and Hospital Readmission
Patients with healthcare-associated infections may be at increased risk of hospital readmission. These findings may be used to impact health outcomes after discharge from the hospital and to encourage better infection prevention efforts. Hospital readmissions are a current target of initiatives to reduce healthcare costs. This session will explore efforts to reduce healthcare-associated infections and its effect on reducing the incidence of hospital readmission and associated poor patient outcomes and increased healthcare costs.

Ron T. Martinson, MD, MSM-HCA, CPE, FAAFP
Community Medicine Officer
Knox Community Hospital

12:30pm – 1:30pm
Luncheon 

1:30pm – 2:15pm
How Health IT Solutions are Being Implemented to Optimize the Patient Experience and Improve Health Outcomes
Reducing hospital readmissions and decreasing the average length of stay (ALOS) is a common goal among clinicians and caregivers. Avoidable readmissions can be expensive and are often a sign of poor communication among care professionals. Discharging patients too early can be dangerous, and the resulting readmission can be physically and emotionally costly. Meanwhile, reducing ALOS in a safe and effective manner can lower the risk of hospital-acquired conditions while saving precious time and resources.

This session will explore how health IT solutions are being implemented to uniquely optimize the patient experience and improve overall health outcomes.

Brian Jack, MD
Professor of Family Medicine
Boston Medical Center

2:15pm – 3:15pm
Panel: Optimizing Transitions of Care to Reduce Hospital Readmissions
Transitions of care—when patients move from one healthcare facility to another or back home—that are poorly executed result in adverse effects for patients. Fortunately, programs can be implemented that enhance collaboration across care settings and improve outcomes including reducing hospital readmission rates. Traditional healthcare delivery models typically do not have mechanisms in place for coordinating care across settings, such as when a patient goes from the hospital to a skilled nursing facility or to home. Transitions can fail, leading to hospital readmission, because of ineffective patient and caregiver education, discharge summaries that are incomplete or not communicated to the patient and the next care setting, lack of follow-up with primary care providers, and poor patient social support. Hospitals are trying to improve transitions of care, with some showing reductions in hospital readmission rates and emergency department visits. These hospitals use multiple interventions simultaneously, including improved communication among health care providers, better patient and caregiver education, and coordination of social and health care services. This session will explore how these transitions of care strategies reduce hospital readmissions.

Tressy Gleason
Manager, Navigation and Post ED Programs
Care Coordination Center
Ochsner Health Network

3:15pm – 3:45pm
Networking & Refreshments Break 

3:45pm – 4:30pm
Reducing Medicaid Readmissions
Reducing readmissions is a national priority for payers, providers and policymakers seeking to improve healthcare and lower costs. Readmissions are a significant issue among patients with Medicaid. This session will explore strategies to reduce readmissions that can be adapted or expanded to better address the transitional care needs of the adult Medicaid population. 

4:30pm – 5:15pm
Patient Engagement Strategies That Prevent Hospital Readmission
Hospital readmission is a key metric in the value-based care landscape, with many programs looking for organizations to lower their readmission rates in an effort to cut healthcare costs. Using strong patient engagement strategies, organizations can move the needle on hospital readmission rates. Reducing hospital readmissions can be difficult because it depends on numerous variables. In addition to delivering high-quality care, providers must motivate patients to engage in post-discharge care management and ensure the patient condition does not unpredictably worsen. This session will explore how healthcare professionals can work to reduce hospital readmissions using key patient engagement strategies, including identifying their high-risk patients, engaging them during the care planning process, and addressing the social determinants of health.

Carla Beckerle
Vice President of Clincial Programs
Esse Health

5:15pm
End of Day One 

7:15am – 8:00am
Networking Breakfast 

8:00am – 8:15am
Chairperson’s Remarks 

8:15am – 9:00am
Providing Palliative Care Across the Continuum to Reduce Readmissions from Community Settings
Patients at the end of life often experience unwanted transitions of care. This session will explore improving transitions of care and reducing hospital readmissions for patients receiving palliative care, as well as how collaboration between inpatient palliative care teams and community partners can improve care transitions and reduce hospital readmissions for this subset of patients.

Emily Downing, MD
System Clinical Officer, Population Health
Home Care Services, Health Equity
Allina Health

9:00am – 9:45am
Reducing Hospital Readmissions: Lessons from a Top Performing Hospital
Significant variability in 30-day readmission rates across U.S. hospitals suggests that some are more successful than others at providing safe, high-quality inpatient care and promoting smooth transitions to follow-up care. Hospitals’ environments contribute to their capacity to reduce readmissions. Hospitals are influenced by the policy environment, their local healthcare markets, their membership in integrated systems that offer a continuum of care, and the priorities set by their leaders. A top performing hospital will explore successful strategies in reducing hospital readmissions, including:

- Seeking to achieve clinical excellence and invest in quality improvement strategies

- Incorporating evidence-based practices into daily protocols

- Standardizing procedures

- Using electronic information systems as tools to gather information, provide feedback and support clinical decisions

- Ensuring smooth care transitions as patients are discharged

- Identifying and targeting patients at the highest risk for readmissions

Tressy Gleason
Manager, Navigation and Post ED Programs
Care Coordination Center
Ochsner Health Network

9:45am – 10:15am
Networking & Refreshments Break

10:15am – 11:00am
Leveraging the ED Observation Unit to Reduce Hospital Readmissions and Improve Patient 

Patrice Callagy
Director, Emergency Medicine
Stanford Hospital and Clinics

Shashank Ravi
ED Quality Director
Stanford Hospital and Clinics

11:00am – 11:45am
Applying a Readmission Predictive Model to High-Risk Patients
Most of readmission prediction models are implemented at the time of patient discharge. However, interventions which include an early in-hospital component are critical in reducing readmissions and improving patient outcomes. Thus, at-discharge high-risk identification may be too late for effective intervention. Nonetheless, there is a tradeoff between early versus at-discharge prediction and the optimal timing of the risk prediction model application. This session will explore a high-risk patient selection process with readmission prediction models using data available at two time points: at admission and at the time of hospital discharge

Jerry Barnes
Vice President, Value Based Care Operations
Satellite Healthcare

11:45am – 12:30pm
Health Equity and Hospital Readmissions
Medicare’s Hospital Readmissions Reduction Program (HRRP) was intended to encourage hospitals to improve care for older adults. However, the program has raised health equity concerns because its risk-adjustment model does not account for patient social complexity; the concern is that HRRP may aggravate healthcare disparities by penalizing financially challenged hospitals and reducing their resources to improve care. While the HRRP assesses hospitals for penalties based upon readmission performance that is adjusted for patient age, gender, and clinical severity of illness, it does not account for functional and social patient factors. Because of this, it may assume similar readmission risk for hospitals that treat more or fewer functionally and socially complex patients, even if risks appreciably differ for these patients. As a result, the program may generate unwarranted penalties and financial pressure for resource-scarce hospitals that serve socially complex patients. This session will explore how the inclusion of patient functional and social factors can reduce hospital readmissions.

Michelle Nelson
Director Ambulatory & Supportive Care Services
United Regional

12:30pm
Conference Concludes

12:45pm – 2:45pm

Workshop: Reducing Medicaid Readmissions

Reducing readmissions is a national priority for payers, providers and policymakers seeking to improve healthcare and lower costs. Readmissions are a significant issue among patients with Medicaid. This session will explore strategies to reduce readmissions that can be adapted or expanded to better address the transitional care needs of the adult Medicaid population.

Jacqueline Vece-Boyer
Case Management Consultant