CHAPTER

THE ROLE OF NUTRITION IN PREVENTING HOSPITAL READMISSIONS

20

Malnutrition is common among older adults across health care settings. Multiple factors contribute to mal- nutrition, including inadequate food intake, anorexia, and acute and chronic medical conditions. Malnutrition “results in negative clinical and economic outcomes, such as decreased strength, functionality and quality of life, increased morbidity and mortality, longer hospital stays, and increased risk for hospital readmissions. These outcomes have significant implications for the US health care system, including increasing the cost of care, which contrasts with the current health care law that is focused on cost containment and reducing hos- pital readmissions” (1). Fortunately, research has demonstrated that nutrition intervention can decrease patients’ risk for readmission and improve outcomes.

THE CURRENT HEALTH CARE LANDSCAPE AND FOCUS ON

HOSPITAL READMISSIONS Hospital readmissions are a growing problem for the US health care system, which drain resources and neg- atively impact the individual’s quality of life. Hospitals have become “revolving doors” for many people who are readmitted quickly after discharge, particularly older adults with certain chronic diseases or comorbid- ities. Almost one-fifth (19.6%) of Medicare beneficia- ries who had been discharged from a hospital were readmitted within 30 days (2). For older adults, three conditions account for almost 15% of hospitalizations: congestive heart failure (CHF), acute myocardial infarction (AMI), and pneumonia (PNA) (3). Among Medicare beneficiaries hospitalized for these condi- tions, 30 day readmission rates are 24.8%, 19.9%, and 18.3%, respectively, and the majority of readmissions

Preventing Rehospitalization

occurred within 15 days of the initial hospitalization (4).

Not only are readmissions common, but they are also costly to the health care system. Estimates show that readmissions cost approximately $26 billion annu- ally, including $17 billion for Medicare inpatient hos- pital costs, with up to 76% of these readmissions being deemed as potentially avoidable (2,5). These figures highlight significant gaps in the current health care delivery system during hospitalization and transition of care after hospital discharge and the need for compre- hensive solutions to improve care and reduce costs. The Patient Protection and Affordable Care Act (ACA) is making significant changes to US health care delivery and incorporates a “pay for performance” approach. The main goal of ACA is to decrease the number of uninsured Americans and reduce the overall costs of health care. A recent high-profile effort of ACA is reducing unnecessary hospital readmissions through the Hospital Readmission Reduction Program (HRRP). The HRRP provides incentives for the reduction of pre- ventable hospital readmissions while encouraging hos- pital care coordination (6). This program requires the Centers for Medicare & Medicaid (CMS) to reduce payments to hospitals and integrated delivery systems with higher-than-expected readmission rates. Effective October 1, 2012, CMS reduced payments to hospitals with excessive readmissions rates for the three key patient populations—CHF, AMI, and PNA. Through this program, CMS could withhold up to 1% of all inpatient Medicare payments starting in 2013, then up to 2% in 2014, and finally up to 3% in 2015. Additionally, starting October 1, 2014, CMS was able to begin withholding payments for excessive readmis- sions related to other diagnoses, including chronic obstructive pulmonary disease (COPD), elective total hip arthroplasty, and total knee arthroplasty. Figure 20.1 shows ACA key dates and events (see page 286 [7]).