Multidisciplinary Transitional Care Program Policy Proposal for Heart Failure Readmission Reduction
Overview
This policy proposal addresses high heart failure readmission rates in an acute care organization by establishing a Multidisciplinary Transitional Care Program aligned with the CMS Hospital Readmissions Reduction Program requirements. The proposal implements evidence-based interventions including inpatient education, medication reconciliation, structured post-discharge follow-up, and social determinants of health screening to reduce preventable readmissions and associated financial penalties.
What this coursework covers
- Introduction and problem statement outlining HF readmission prevalence and HRRP penalties
- Need for policy and practice guidelines detailing organizational underperformance with ERR >1.0
- Environmental factors analysis addressing regulatory requirements and CMS priorities
Preview
Policy Proposal
Student Name
Capella University
NHS-FPX6004 - Healthcare Law and Policy
Dr. xxx
January 30, 2025
Policy Proposal
Heart failure (HF) is one of the most frequent causes of hospitalization of Medicare beneficiaries, and 30-day readmission leads to significant morbidity, mortality, and healthcare expenditure. The Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP) requires hospitals to face penalties when they have excess readmissions according to the excess readmission ratio (ERR) for conditions including HF. Hospitals whose ERR >1.0 on HF pay fines of up to 3% of base Medicare payments (Centers for Medicare & Medicaid Services, 2025). Despite national initiatives, there are numerous organizations that perform poorly, and HF 30-day readmission statistics tend to be higher than those in the country (usually 20-23, but peer-grouped since FY 2019 to play fair). This proposal addresses under-performance in a hypothetical acute care organization where HF ERR is already greater than 1.0 and causes punishment and overburdened resources.
The proposed policy will help establish a Multidisciplinary Transitional Care Program (MTCP) for HF patients that requires the use of evidence-based interventions during admission and 30 days after discharge. Among them are inpatient education with the use of the teach-back technique, pharmacist-led comprehensive medication reconciliation, scheduled post-discharge follow-up (7 days), which can be virtual or in-person, nurse-led phone follow-up at 72 hours and weekly, social determinants of health (SDOH) screening, and connection to community resources.