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Preventable Readmissions Initiative

Identifying the Causes of Readmissions

The NYSPFP approach to identifying and understanding the possible underlying factors of preventable readmissions includes an in-depth look at hospital-specific preventable readmissions data; an organizational assessment of current practices; and a hospital-specific analysis to identify the significant causes of readmissions among certain patient cohorts, and opportunities for improvement. Altogether this focused study approach is based on five quantitative and qualitative tools that are drawn from national best practices and methodologies and will assist hospitals to confirm and target opportunities specific to the need of their patients and organization. Summary information gathered from these reviews will facilitate development of a targeted work plan for reducing preventable readmissions.

A hospital-specific analysis could include the following:
  1. Readmissions Reports
  2. Hospital Assessment of Current Practices
  3. Patient and Family Caregiver Interviews
  4. Medical Chart Abstraction
  5. Primary Care Provider and Other Community Based Provider Feedback
To view the NYSPFP approach to conducting a hospital-specific analysis of preventable readmissions, click here.

Readmissions Reports

Hospital-Specific Readmission Diagnostic reports will be regularly updated and available for download through myNYSPFP on the NYSPFP Web site. Log in to the NYSPFP Web site and navigate to the “Data” tab to find the most recent update to the quarterly Hospital-Specific Readmissions Diagnostic Report. These reports are an interactive, Excel® based tool, utilizing the 3M Potentially Preventable Readmission (PPR) Software and calendar year 2011 Statewide Planning and Research Cooperative System (SPARCS) data. The reports identify readmissions attributable to each hospital, whether they occurred in that hospital or another. The report identifies readmissions attributable to each hospital, whether those readmissions occurred in that hospital or another, and drills down into the readmissions by product line, diagnostic-related group, admission source, discharge status, payer, and the case level.

NYSPFP will use aggregate data from the Readmissions Diagnostic Report to develop targeted educational programming for the Preventable Readmissions Initiative. Hospitals are encouraged to use these data to conduct their readmissions assessments and develop their work plans. The report can be particularly valuable for identifying target populations on which to focus in-depth assessment of the causes and potential avoidance of readmissions. Work with your NYSPFP project managers to interpret your readmissions reports and develop a strategic approach to your preventable readmissions reduction activities.

Hospital Assessment of Current Practices

NYSPFP administered an assessment of current hospital practices to better understand hospital readmission reduction efforts, and to identify opportunities for improvement. The results of these assessments will be posted to the myNYSPFP section of the NYSPFP Web site.

Patient and Family Caregiver Interviews

NYSPFP encourages hospitals to conduct interviews with a sample of at least five patients who have been readmitted to the hospital within 30 days to provide insight into patients’ perceptions of why the readmission occurred. Hospitals may wish to expand the survey to include additional readmitted patients if no pattern is discernible from the initial sample set of five patients.

To access the NYSPFP template Patient Caregiver Interview Tool, please click here.
Medical Chart Abstraction

To derive information about specific causes or trends in readmissions, NYSPFP recommends that hospitals conduct retrospective chart reviews on a sample of at least 10 patients who experienced unplanned readmissions within 30 days. This review can provide important information regarding the risk factors for readmissions.

To access the NYSPFP template Medical Chart Abstraction Tool, please click here.
Primary Care Provider and Other Community Based Provider Feedback

Hospitals are recommended to communicate with at least three outpatient and other post-hospital care providers in order to ascertain their perspectives on the causes of preventable readmissions. These discussions can be informal and can offer instructive feedback. Hospital staff may find it most convenient to identify one patient who has been readmitted to the hospital within 30 days and use that case to guide a broader discussion with the provider. A similar approach may also be beneficial for reaching out to high volume skilled nursing facilities and home care agencies.

To access the NYSPFP template High Volume Primary Care or other Community-based Providers Interview Tool, please click here.
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Persons with disabilities having problems accessing any NYSPFP materials or resources for this initiative may call 518-431-7685 or email Nancy Landor.
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