Overview of the CMS Hospital Readmissions Reduction Program
In 2012, the federal government mandated the Centers for Medicare and Medicaid Services (CMS) to establish a value-based purchasing program focused on enhancing patient outcomes. This initiative, known as the Hospital Readmissions Reduction Program (HRRP), links hospital reimbursement rates to performance metrics aimed at decreasing preventable readmissions within 30 days post-discharge (Centers for Medicare & Medicaid Services [CMS], 2023). The primary objective of HRRP is to reduce unnecessary readmissions by encouraging hospitals to adopt evidence-based transitional care strategies that actively engage patients and caregivers during discharge planning.
CMS measures hospital performance across six clinical categories under HRRP: acute myocardial infarction, chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, coronary artery bypass graft surgery, and elective primary total hip and/or total knee arthroplasty (THA/TKA). Hospitals exceeding expected readmission benchmarks may face financial penalties of up to 3%. Although this penalty percentage may appear modest, it serves as a significant financial and reputational incentive for hospitals to investigate causes of readmissions and improve discharge processes.
Why is Transitional Care Planning Crucial in Reducing Readmissions?
Unplanned hospital readmissions often arise from complex, multifactorial issues, many of which relate to systemic gaps rather than disease inevitability. Key contributors include poor communication among healthcare providers, medication errors, insufficient follow-up care, and inadequate patient education. Feigenbaum et al. (2012) identified that lapses in transitional care planning, medication management, follow-up coordination, and multidisciplinary communication are major factors leading to 30-day readmissions. These insights emphasize that comprehensive and structured transitional care plans can markedly reduce preventable readmissions.
Elective primary total hip arthroplasty (THA) is specifically targeted by HRRP, requiring healthcare teams to implement standardized, evidence-based transitional care plans for all patients, regardless of discharge destination, whether home or skilled nursing facilities. Given the elective nature of THA, many post-discharge complications are foreseeable and thus can be mitigated through proactive and personalized care planning.
What are the Common Clinical Risks and Causes of Readmission after Total Hip Arthroplasty?
Patients undergoing total hip arthroplasty face several postoperative risks that may necessitate unplanned readmission. According to Kurtz et al. (2018), the most frequent complications include surgical site infections, atrial fibrillation, pulmonary embolism, septicemia, and pneumonia. These risks highlight the necessity for thorough patient education, vigilant monitoring, and timely follow-up care during the transition from hospital to home.
| Potential Complication | Risk Factors | Preventive Strategies |
|---|---|---|
| Surgical site infection | Obesity, diabetes, poor wound care | Adherence to antibiotics, wound hygiene education |
| Deep vein thrombosis / pulmonary embolism | Immobility, obesity | Anticoagulation therapy, early mobilization |
| Pneumonia | Reduced mobility, shallow breathing | Incentive spirometry, frequent ambulation |
| Joint dislocation or injury | Improper movement, unsafe home environment | Hip precautions, home safety modifications |
| Medication-related adverse events | Polypharmacy, drug allergies | Medication reconciliation, patient education |
Patient Case Scenario: Susan
Susan is a 68-year-old woman with advanced osteoarthritis scheduled for elective total hip arthroplasty. She presents with multiple comorbidities, including obesity (BMI 36.9 kg/m²) and depression. These health conditions not only necessitate surgical intervention but also elevate her risk for postoperative complications and potential hospital readmission.
What is the Role of the APRN in Preventing 30-Day Readmission?
The Advanced Registered Nurse Practitioner (APRN) plays a critical role in coordinating Susan’s discharge plan to reduce her risk of readmission. Infection prevention is a key focus. Susan must complete her prescribed course of oral antibiotics post-surgery. Due to her penicillin allergy, clindamycin is an alternative; however, because clindamycin carries a risk of Clostridioides difficile infection, the APRN must educate Susan to promptly identify symptoms such as persistent or bloody diarrhea.
Additionally, Susan should receive explicit instructions on maintaining surgical site cleanliness and reporting signs of infection immediately, including redness, warmth, swelling, pain, or drainage. Reinforcing the importance of contacting the orthopedic surgeon for postoperative concerns is essential to maintain continuity of care until formal discharge.
How Should Medication Management and Anticoagulation Be Handled?
Medication reconciliation is vital to prevent adverse drug events and ensure continuity during care transitions. Susan should be discharged with a comprehensive medication list that includes drug names, dosages, administration schedules, and indications. This list must be shared with both Susan and her primary care provider.
To reduce the risk of thromboembolic events, Susan should adhere to a prophylactic regimen involving daily low-dose aspirin, injectable enoxaparin until completion, and regular ambulation. Pain management should employ a multimodal approach incorporating NSAIDs, opioids as needed, and scheduled acetaminophen to support mobility and minimize immobility-related complications.
What Nutritional and Weight Management Strategies Are Recommended?
Given Susan’s obesity, nutritional and weight management are crucial to her recovery and long-term joint health. Initially, she should consume a soft, bland diet that gradually advances based on tolerance. Emphasis should be placed on a balanced, protein-rich diet to promote wound healing and tissue repair. Once initial recovery is established, sustainable weight management plans guided by her primary care provider will be essential to reduce joint stress and prevent further musculoskeletal deterioration.
How Can Mobility, Physical Therapy, and Home Safety Be Optimized?
To protect the new joint and prevent injury, Susan must strictly adhere to hip precautions taught during inpatient physical therapy. Education should extend to her family, focusing on safe movements and home safety modifications aimed at reducing fall risk. Recommended safety measures include removing clutter, installing raised toilet seats, using shower chairs, and employing pillows or bed risers.
Durable medical equipment such as walkers and continuous passive motion (CPM) machines should be provided prior to discharge. Outpatient physical therapy appointments must be scheduled in advance, with transportation arranged to ensure attendance and compliance.
How Can Pulmonary Complications Be Prevented?
Pulmonary complications are another preventable cause of readmission after THA. Susan should be encouraged to use incentive spirometry, engage in deep breathing and coughing exercises, maintain adequate hydration, and ambulate frequently. These interventions help prevent atelectasis and pneumonia. Clear, easy-to-understand written instructions will reinforce adherence to these preventive measures.
How Does Multidisciplinary Discharge Planning and Social Support Affect Readmission Risk?
Before discharge, a multidisciplinary team—including physical therapy, occupational therapy, and social work—should evaluate Susan to ensure home safety and readiness. Social determinants such as access to transportation, medication availability, grocery shopping support, and family involvement must be addressed. Lack of sufficient logistical and social support significantly elevates the risk of readmission.
How Was the Care Plan Reviewed and Improved?
This transitional care plan was reviewed by MaryEllen Kopp, APRN, a postsurgical cardiac advanced practice provider. She emphasized the importance of multidisciplinary clearance prior to discharge, vigilant monitoring for Clostridioides difficile infection, and clear education regarding signs of wound infection. Her insights enhanced the clinical relevance and quality of the care plan and will inform future iterations of this academic work.
References
Centers for Medicare & Medicaid Services. (2023). Hospital readmissions reduction program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program
Feigenbaum, P., Neuwirth, E., Trowbridge, L., Teplitsky, S., Barnes, C., Fireman, E., Dorman, J., & Bellows, J. (2012). Factors contributing to all-cause 30-day readmissions: A structured case series across 18 hospitals. Medical Care, 50(7), 599–605. https://journals.lww.com/lwwmedicalcare/Abstract/2012/07000/Factors_Contributing_to_All_cause_30_day.7.aspx
Kurtz, S., Lau, E., Ong, K., Adler, E., Kolisek, F., & Manley, M. (2016). Which hospital and clinical factors drive 30- and 90-day readmission after total knee arthroplasty? The Journal of Arthroplasty, 31(10), 2099–2107. https://www.sciencedirect.com/science/article/pii/S0883540316300043
Phruetthiphat, O., Otero, J. E., Zampogna, B., Vasta, S., Gao, Y., & Callaghan, J. J. (2020). Predictors for readmission following primary total hip and total knee arthroplasty. Journal of Orthopaedic Surgery, 28(3). https://journals.sagepub.com/doi/10.1177/2309499020959160A