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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

March 2016

Reducing Preventable Readmissions in Medicare Advantage Population


As a participant in the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Project (QIP), Harvard Pilgrim operates transition of care support programs aimed at reducing preventable hospital readmissions.

According to the 2012 Annual Survey of Hospitals, nearly 20 percent of Medicare patients in the United States are readmitted to hospitals within 30 days of discharge. Harvard Pilgrim believes that a well-coordinated discharge plan and proper follow-up are essential to promoting patient health and reducing rates of readmission.

To expedite claims processing and initiate care management services to members following an inpatient stay, Harvard Pilgrim requires all acute care facilities to submit a daily list of discharged members, including commercial and Medicare Advantage members. We will accept the current format of your discharge census.

To submit discharge data electronically, email Discharges@HarvardPilgrim.org with a password-protected file using your NPI or existing password for the discharge file (please inform Harvard Pilgrim of the password used for the protected file). Alternatively, you may fax your discharge file to “Attn: Care Management Dept.” at 617-509-1159.

For details on the information required in daily discharge reports, refer to the "Acute Care Facility Discharge Notification Requirements" section of the “Access to Care” portion of our Medicare Advantage Provider Manual.

Transition support from nurse case managers

Within 48 hours of receiving notice of a hospital discharge, one of our nurse case managers will call the Medicare Advantage member to aid with the transition. During the call, the nurse case manager conducts a discharge assessment, which includes confirming whether the patient:

  • Has received discharge instructions from the hospital or facility
  • Understands the discharge instructions, including any required actions or special instructions
  • Will be comfortable at home and has adequate caregiver support
  • Understands how to appropriately use any prescribed medications and has an opportunity to discuss any potential barriers to taking prescribed medications as needed
  • Has notified his or her PCP of the illness prior to any emergency room visits
  • Has scheduled a post-discharge PCP visit (recommended within 7 days of discharge)
  • Needs assistance in scheduling ancillary services (for example, help with setting up home health visits or having DME supplies delivered)

Working together

Your support is crucial in helping to prevent avoidable readmissions. We appreciate your efforts to promptly inform us when members are discharged. Our case and disease management staff is available to you, whenever needed. If you believe a patient is at risk for a preventable readmission and may require further assistance, please call Harvard Pilgrim’s case management department at 866-750-2068.

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator