Readmissions Reduction Pilot Program Overview 
HealthCareChaplaincyispartneringwithSt.Luke’s-RooseveltHospitalCenterand
NewYorkHospitalQueensinanefforttoreduceunnecessaryreadmissionsbythe
creationofapartnershipamongthehospital,thehospital’schaplaincyprogram,
andlocalhousesofworshiptoprovideinformationandsupporttopatientsupon
andimmediatelyfollowingdischarge.Thisprojectspecificallyonpatientssuffering
fromheartfailure,heartattacksandpneumonia,asstudieshaveshownthatthese
arethethreepopulationswiththehighestlikelihoodofreadmissiontohospitals
within30daysofdischarge(andthesearethethreegroupsthattheCentersfor
Medicaid/MedicareServicestracks).Thepilotprogramismodeledonthe
CongregationalHealthProgramlaunchedbyMemphisTennessee’sMethodist
Hospital,whichreducedreadmissionsby20%andsavedthehospital$2millionina
recenttwoyearperiod.

Studieshaveshownthatspiritualsupport-relatedservicescanhaveagreatpositive
impactonthereductionofreadmissionrates.Board-certifiedchaplainshave
traditionallybeenunderutilizedresourcesinreducingunnecessaryreadmissions.
Thisprojectbuildsonchaplains’expertiseinattentivelistening,thetrusttheyhave
withpatientsandfamilies,andtheirskillsincommunication.Thereductionof
unnecessaryreadmissionswillpositivelyaffecthospitalreimbursements,andalikely
sidebenefitisthatpatientexperience/satisfactionscoresmayincrease.HCC
researcherswillanalyzethechaplains’impactwithrespecttoreadmissionratesand
workwithahealtheconomicsteamtomeasurethesavingstothehospitalof
avoiding/reducingreadmissions.Thegoalistoreduce30-dayreadmissionratesfor
thetargetpatientpopulationby10%overthecourseofthepilot.

Readmissions Program Main Points:  LocalhousesofworshipwishingtoparticipatewillsignacovenantwithSt.
Luke’s-RooseveltHospitalCenter/NewYorkHospitalQueensandHealthCare
Chaplaincy  CongregationmembersofparticipatinghousesofworshipexperiencingAMI,HF,
orPN,whohaveprovidedconsent,willbeenrolledthroughtheEMRupontheir
admittancetothehospital  Aspatientsundergomedicaltreatmentinaninpatientsetting,chaplainsprovide
themspiritualcarethroughspiritualscreening,history-taking,andspiritual
assessments  Chaplainsserveasguidesforpatientsastheyworktheirwaythroughthe
dischargeprocess,utilizingHCC’sspiritualcareplanform,whichasksthe
patientsinsimpletermswhytheybelievetheywerehospitalizedandwhatsteps
mustbetakentocontinuerecovery  Chaplainswilldocumentanyotherconcernsandfearsthatpatientsmighthave
regardingdischargeandhelpthepatientidentifywhatresourceshe/shemightbe
abletocallupon,e.g.,communityclergy,friends,andfamily  Chaplainswilldophonefollow-upwithpatientsonceaweekforthreeweeksby
phonefollowingdischargetoidentifyconcernsthatmaynothavebeen
addressed.Issuesthatareidentifiedbythesechaplaincallswillberelayedtothe
appropriatememberofthemedicalcareteamorcongregationforfollowup The Affordable Care Act Readmissions Reduction Program 
TheAffordableCareAct(ACA)includesseveralMedicarereformsintendedto
advancethecarethatMedicarebeneficiariesreceive;inaddition,billionsof
dollarsinMedicaresavingswillbegenerated.AchiefACAinitiativeisthe
reductionofhospitalreadmissions.AsofOctober1st2012,theCenterfor
MedicareandMedicaidhasstartedtheHospitalReadmissionsReduction
Program,whichwillhelphospitalsmakesmoothtransitionsforpatients,and
rewardhospitalsthataresuccessfulinreducingavoidablereadmissions.1

ThebasisfortheReadmissionsReductionProgramstemsinpartfromahistory
ofU.S.healthcarewroughtwithmisalignedincentives.PriortotheACA,the
existingpaymentstructurerewardedprovidersforthequantityofservices
delivered,ratherthanthequalityoftheservices.Thiswasaprincipaldriverof
healthcarecosts.Thecombinationofperverseincentivesandfragmentedhealth
caredeliveryhavecontributedtotheU.S.havinghigherhealthcarespending
thananyotherdevelopedcountry,andalsoscoringamongthelowestonkey
healthindicators,suchasinfantmortality,obesity,andhealthsystem
performance.TheAffordableCareActseekstoalterthismodelandstrengthen
Medicare.

BeyondimprovingthequalityofcareforMedicarebeneficiarieswithchronic
conditions—whocompriseover80percentofallMedicareenrollees—theCMS
OfficeoftheActuary(OAct)projectsthattheReadmissionsReductionProgram,
whenfullyimplemented,willreduceMedicarecostsby$8.2billionfrom
implementationthrough2019.Specifically,paymentstohospitalswillbereduced
forunnecessary30-daypatientreadmissionsapplicabletothefollowing
1
"Readmissions Reduction Program." CMS.gov. Center for Medicare and Medicaid Services, 26 Apr. 2013.
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-ReductionProgram.html
conditions:Acutemyocardialinfarction(AMI),heartfailure(HF),andpneumonia
(PN).ReadmissionsarereportedonHospitalCompareat
www.hospitalcompare.gov,andtheuseoftransparencyhasproventohelpto
improvereportedmeasures.Thefinancialpenaltieshavepressuredhealthcare
professionalstopaymoreattentiontowhathappenstopatientsoncetheyleave
thehospital.Manyhospitalsarenowemployingvariousstrategiesinanattempt
tobetterfacilitatedischargedpatientrecoveries.2



2
"Affordable Care Act Update: Implementing Medicare Cost Savings." CMS.gov. Center for Medicare and
Medicaid Services. http://www.cms.gov/apps/docs/aca-update-implementing-medicare-costs-savings.pdf

Readmission Reduction Program: Pre-Implementation Phase Beforebeginningareadmissionsreductionprogram,healthcarechaplains
shoulddevelopaonepageconceptualoverview.Thefollowingstepsbeginthe
processtoestablishanimpactfulprogramatthehospital:
1. Gainhospitaladministratorapprovaltoestablishtheprogram.
2. Ifapproved,workwithhospital’sdevelopmentdepartmenttofundthe
pilotprogram.
3. Identifywhatotherreadmissionsprogramsareoccurringinthehospital.
4. Plotoutaninterventionplanandcatchmentarea.
5. Decideiftheprogramwillbearesearchinvestigationoraquality
improvementstudy.
6. Identifyneededdataforimplementation,aswellasdatasources.
7. Getbuy-infromhospitalleadershipinthekeyareas:socialwork,nursing,
andotherdepartmentstobeaffected.
8. Clearlycommunicatetheinterventiontoadministratorsofotherprograms,
andcollaboratewiththem.
9. Gainhospitalcommunityliaisonsupportforcommunityoutreach.
10. Identifylocalhousesofworshipwithincatchmentarea,andcreatean
assetmap.
11. Reachouttohousesofworship,andconductaninformationalbreakfast
launch.
Questions:
JessGeevarghese,Director,ClinicalServicesandAcademicAffairsSupport
Services,HealthCareChaplaincy;212-644-1111x122;
[email protected]