The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Month: April 2016 (page 1 of 2)

Covenant Health: How we used MVC to drive improvement

Karen Bush

Author: Karen S. Bush, MSN, FNP, BC, NCRP is a Transition Coach for Covenant Health Care and President of SelfCare Solutions

We know that the clinical status of a heart failure patient is negatively impacted by non-adherence to the self-care demands of this disease. Engaging heart failure patients with proper tools to manage their disease and understand changes in body weight and symptoms, allows these items to be addressed at home, therefore avoiding clinical deterioration and potential hospitalization.  At Covenant HealthCare we created a heart failure toolkit called Balancing Your Daily Fluid© and studied the effectiveness of the kit in improving heart failure maintenance, management and confidence on patients hospitalized with a heart failure diagnosis.   This toolkit with the education and follow up by the transition coaches has offered patients the opportunity to engage in their care and manage their disease, which has resulted in  significantly lower readmission rates and improved maintenance, management and confidence with patients’ heart failure.

What Covenant did

As a result of the above activities, we began looking for other opportunities for utilization of this model.  After looking at the Key Insights page on the Michigan Value Collaborative website we could see that patients with an index admission for acute myocardial infarction (AMI) demonstrated opportunities not only for readmission, but also for cost reduction.  Additionally, in our work with heart failure patients, we noted that often the index heart failure diagnosis followed an admission for AMI. To further investigate this theory and to better understand how to approach the readmission issue, we downloaded our site specific data for these 2 diseases separately and noted the following.  Under the diagnosis of AMI we had 1,451 data points with a higher unadjusted mean cost per episode compared to MVC all.  When we filtered for patients who had co-morbid condition of CHF there were 26 patients with a mean unadjusted cost per episode that was almost $10,000.00 higher than our non-comorbid CHF group.   This is a significant cost increase on patients who are admitted with AMI, who also have CHF. 

In looking at the readmissions on our key insights page we noted that our readmission rate for AMI at this time was at 17% which was higher that the MCV all which is 15.6%.  In looking at the drill down for the readmitted population, we were able to review 31 charts.  We applied a filter for patients who had co-morbid condition of CHF which gave us a list of 5 patients.  The mean cost per episode and readmission costs were significantly higher on these 5 patients. This did not however, indicate if our problem with readmissions was related to the heart failure or another issue.  To investigate this further we entered the individual patient’s billing record to identify the first diagnosis listed on the readmission record following the index admission.  We also looked to see if heart failure was listed as any diagnosis on the readmission.  In 13% of the cases heart failure was listed as the first diagnosis and in 36% of the cases it was listed as one of the diagnosis on readmission. 

In conclusion

In light of the current data we have expanded our use of the heart failure toolkit to patients admitted with diagnosis of CHF and AMI who have EF of less than 50%.  We will also be looking to expand this to our CABG patients as well to assist those patient’s in proactively managing their heart failure as there is similar evidence to support this expansion.  Additionally, we are assigning a transition coach to all high risk patients who fall under the diagnosis of CHF, AMI or CABG.


Questions or comments?  We’d love to hear from you.  You can comment on this article, or use the form at the bottom of this page. 

If you’d like to learn more about what Covenant Health did, please contact Karen Bush here.

10 facts about Medicare’s Hospital Readmissions Reduction Program (HRRP) that may surprise you

Michelle Hou

Michelle Hou is a statistician working with MVC.

Chad Ellimoottil

Dr. Chad Ellimoottil is a research fellow working with MVC.

Many hospital administrators and clinicians are under increasing pressure to reduce readmissions. At least part of this pressure comes from Medicare’s Hospital Readmissions Reduction Program (HRRP). This program imposes a penalty on hospitals that have an excess number of readmissions. All hospital readmissions as well as readmissions for specific conditions (e.g., congestive heart failure, heart attack, pneumonia, chronic obstructive pulmonary disease, or joint replacement) are measured by Medicare. We scoured the literature and performed our own analysis of Michigan Medicare data to bring you 10 surprising facts about the HRRP program.

  1. In 2015, almost 80% of hospitals received a penalty under HRRP. While the average hospital penalty was less than a percent of total income, Medicare collected more than $400 million in penalties.
  2. In 2015, ten percent of hospitals accounted for nearly 50 percent of the penalties. Because socioeconomic factors play such a big role in readmissions, it is understandable that the impact of the penalties are concentrated.
  3. A readmission from three years ago may impact your hospital’s score today. Because the program incorporates three years of data in its calculation of condition-specific readmission rates, some patients may impact readmission performance for years to come.
  4. While readmission measures may be “condition-specific”, readmissions from “all-causes” count against your hospital. For example, if the patient is admitted for joint replacement, and then is readmitted for stomach pain, the readmission counts against the hospital.
  5. Small hospitals may not be unfairly penalized for a few extra readmissions. There are sophisticated statistical adjustments made to account for hospitals that may have a small number of yearly admissions.
  6. Readmissions caused by patients who leave “against medical advice” do not count against the hospital. Because providers were not given the full opportunity to provide care and discharge planning for these patients, they are excluded from the readmission measure.
  7. Over 50 different comorbidities are considered to make sure hospitals are compared on an equal playing field. In other words, Medicare’s readmission measures are “risk-adjusted”.
  8. About 21% readmissions in the state of Michigan occur at hospitals other than one where the patient was initially hospitalized. These findings were based on an internal MVC analysis of readmissions and speak to the importance of using claims-based data to track readmissions.
  9. Approximately 85% of patients who are readmitted within 30-days come in through the emergency room.
  10.  About 8% of readmissions are considered “planned”. Planned readmissions are not counted against the hospital. They can occur for planned procedures or diagnoses that are not associated with an acute condition.

Questions or comments?  We’d love to hear from you.  You can comment on this article, or use the form at the bottom of this page.

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