Transcript Slide 1

Care Transitions: Best Practices in
Reducing Readmissions
Roland A. Grieb, MD, MHSA
Medical Director, Indiana Medicare Quality Improvement Organization
Nancy Meadows, RN, BS
Clinical Specialist, Care Transitions Initiative
May 5, 2011
1
Disclosures
The speakers for this CME activity have
no relevant financial relationships with
commercial interests to disclose.
2
Objectives
 Provide an overview of the Medicare Quality
Improvement Organization (QIO) work being done as
part of the Centers for Medicare & Medicaid Services
(CMS) Care Transitions Initiative
 Explain some of the commonly utilized evidence-based
care transition models and interventions
 Share key successes and challenges identified through
participation in the transitions sub-national theme
3
Problems Affecting Care Transitions
Patient
ER
Poor
Discharge
Coordination
ICU
OUTPATIENT:
• Home
• PCP
• Specialty
• Pharmacy
• Other Services
• Care Giver
Poor Discharge
Coordination
NO Medication
Reconciliation
NO Personal
Health Record
In-Patient
SNF
NO
Personal Health
Record
Patient
NO
Coordinated
Care Plan
Source: Case Management Society of America (CMSA)
HHA
Poor Care
Coordination
NO Medication
Reconciliation
NO Personal Health
Record
4
Background
 Re-hospitalizations are:
• Frequent
- Approximately 20% of Medicare beneficiaries
discharged from a hospital are readmitted
within 30 days
• Costly
- Account for $17B in annual Medicare spending
- Excludes costs associated with other payers
Source: Jencks et al. N Engl J Med 2009; 360: 1418-1428.
.
5
Background
• Potentially avoidable
- 75% identified as potentially preventable based on
3M report to the Medicare Payment Advisory
Committee (MedPAC 2007)
- 14-46% noted as potentially preventable in
retrospective clinical review
• Allow for actionable improvement
- Research and quality improvement initiatives have
shown >30% reduction of 30-day readmission rates
for various patient populations
6
Rates of Re-hospitalization within 30
Days after Hospital Discharge
Jencks S et al. N Engl J Med 2009;360:1418-1428
Source: Jencks et al. N Engl J Med 2009; 360: 1418-1428.
Why Do Hospitals Have Unwanted Readmissions?
Poor Provider-Patient interface
Medication management, no effective patient
engagement strategies, unreliable follow-up
Unreliable system support
Lack of standard and known processes
Unreliable information transfer
Unsupported patient activation during
transfers
Lack of community
infrastructure for achieving
common goals
Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock,
MD, MSPH, and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:
http://www.cfmc.org/caretransitions/learning_sessions.htm
What’s the Hold Up?
If re-hospitalizations are prevalent, costly,
potentially avoidable, and actionable—
what’s the hold up?
 Providers: Lack of financial incentives and/or
decentives
 State: Lack of population-based data, fragmented
payer systems
 Community: Difficult to engage organizations
across the continuum (silos), lack of Information
Technology (IT) acceptance, connectivity and
infrastructures, lack of reimbursement
9
Health Care Reform: Promote Better
Care After Hospital Discharge
 By linking payments between hospitals and
other care facilities, reform is intended to
accomplish the following
• Promote coordinated care after discharge from
the hospital
• Encourage investments in hospital discharge
planning and transitional care to ensure that
avoidable readmissions are prevented
What’s in Reform for My Community? www.whitehouse.gov
10
Structure of Health Care Incentives
• Expansion of pay-for-performance (P4P) to
value-based purchasing (VBP)
• Bundled payment pilots
• Potential avoidable admissions, readmissions,
and sites of care
• Fixed hospital payments
• Increasing focus on “cost and comparative
effectiveness”
11
Evolution of Health Service Delivery
 Shift of accountability and financial risk
(clinically and economically) across the
continuum of care
• Shift to episodes of care
• Shift to outcomes of care
12
A Major Focal Point of Interest
 National Quality Forum (NQF) included improved
care transitions as 2009 and 2010 priority goals
 The Joint Commission has included and is expanding
as part of National Patient Safety Goals (NPSGs)
 New CMS quality reporting of 30-day readmission
rates (AMI, HF, and Pneumonia)
 Addresses many of the hospital- and health careacquired conditions for which CMS is now and
proposing to withhold payment
 Focus of numerous pilots, projects, and
demonstrations
 August 2008, CMS focus for QIOs in 9th Scope
of Work (SOW)
13
The Indiana Opportunity: Care Transitions 2008-2011
15
Key Elements to Improvement
1. Examine current state of readmissions
and discharge processes
2. Assess and prioritize improvement
opportunities
3. Develop an action plan of strategies to
implement
4. Monitor and evaluate progress
17
Key Elements to Improvement
 Identify the opportunity!
Assessment, review, and redesign of
provider-specific policies and processes that
include (at a minimum) the following areas
• Patient and caregiver education and
communications
• Medication reconciliation and safety
• Symptom management
• Discharge treatment plan and follow-up care
• Sharing and transfer of vital patient information
18
Examine Current Rate of Readmissions




Readmission rates by diagnoses
Readmission rate by practitioners
Readmission rates by readmission source
Readmission rates at different time
frames
19
Assess and Prioritize
Focus on:
 Specific patient populations
 Stages of the care delivery process
 Hospital organizational strengths and
available resources
 Hospital priority areas and current and
upcoming quality improvement
initiatives
20
Hospital Readmission Rates
All Discharges
Overall
Hospital
Service
Area (HSA)
All AMI, CHF, & PNE
Number of
Discharges
% of
Readmitted
Cases
Number of
Discharges
% of
Readmitted
Cases
40,356
17.32%
3,717
20.20%
Patients discharged 1/1/2007—12/31/2007 within the HSA
21
HSA Admission Sources:
Discharges and Re-hospitalizations
Point of Origin Source
All Discharges
Re-hospitalization
Physician referral
40.48%
34.78%
Clinic referral
0.01%
1.26%
Medicare Advantage referral
0.00%
0.01%
2.73%
4.17%
Transfer from SNF
Transfer from another facility
0.97%
1.57%
0.26%
0.75%
Emergency room
55.40%
57.33%
Court and/or law enforcement
0.15%
0.01%
Not available; Other
0.01%
0.12%
Transfer from another acute care facility
22
HSA Re-hospitalizations: Top 10 MS-DRGs
641
293
291
292
682
392
189
194
871
683
NUTRITIONAL & MISC METABOLIC DISORDERS
W/O MCC
HEART FAILURE & SHOCK W/O CC/MCC
HEART FAILURE & SHOCK W MCC
HEART FAILURE & SHOCK W CC
RENAL FAILURE W MCC
ESOPHAGITIS, GASTROENT, & MISC DIGEST DISORDERS
W/O MCC
PULMONARY EDEMA & RESPIRATORY FAILURE
SIMPLE PNEUMONIA & PLEURISY W CC
SEPTICEMIA W/O MV 96+ HOURS W MCC
RENAL FAILURE W CC
23
Patient’s Perspective of Care Survey
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
How often did staff explain about medicines before
giving them to patients?
Average for All reporting hospitals in the USA
Average for ALL reporting hospitals in Indiana
Range for hospitals within the Hospital
Service Area (HSA)
Hospital Compare September 2008
59%
58%
56%-67%
24
Patient’s Perspective of Care Survey
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Were patients given information about what to do
during their recovery at home?
Average for All reporting hospitals in the USA
Average for ALL reporting hospitals in Indiana
Range for hospitals within the HSA
80%
81%
78%-82%
Hospital Compare September 2008
25
Source: Improving Care Transitions. Jane Dorman. Care Management Institute,
Kaiser Permanente. January 13, 2010.
26
Typical Failure Modes in the
Transition Process
•
•
•
•
•
•
Medication errors and/or adverse events
Poor, incomplete, or missing discharge instructions
Lack of follow-up appointment
Follow-up scheduled too long after hospitalization
Inadequate or lack of outpatient management
Ineffective provider-to -provider communications
(skills and tools)
• Confusion over self-care instructions
• Lack of adherence to medications, therapies, and diet
• Lack of social support
27
Develop an Action Plan
 Learn from where failures lie
 Develop community connections to
eliminate barriers to successful care
transitions
 Develop strategies and interventions
to engage patients, families, and
caregivers in addressing the issue
28
Targeted Areas for Improvement





Communication
Medication reconciliation
Patient empowerment and
self-management skills
Physician follow-up
Plan of care
29
Major Strategies to Reduce
Avoidable Readmissions
 During Hospitalization
• Use a multi-interdisciplinary care team
approach
• Risk screen patients
• Risk assessment of patients for “end-of-life”
discussions
• Establish effective communication
• Use of “teach-back” and coaching skills to
educate patients and caregivers
30
Major Strategies to Reduce
Avoidable Readmissions
 At Discharge
• Implement comprehensive and patient-tailored care
plans
• Use “teach back” and coaching skills to educate patients
and caregivers
• Schedule and prepare patients and caregivers for “early”
follow-up appointments
• Medication reconciliation and patient medication selfmanagement techniques
• Facilitate discharge communications with post-acute care
providers
31
Major Strategies to Reduce
Avoidable Readmissions
 Post Discharge
•
•
•
•
Promote patient and caregiver self-management
Coaching home visits and/or telephonic follow-up
Telehealth for at-risk patients
Personal Health Records for information
management
• Emergency Care Plans and Zone Tools for
symptom management
32
Major Strategies to Reduce
Avoidable Readmissions
 Post Discharge
• Verification that follow-up appointments are
scheduled
• Timely transmission of discharge summaries
to primary care physicians
• Early physician follow-up
- low risk 0-14 days
- high risk 0-7days
• Establish community networks
33
Major Interventions
Intervention
Key Elements
Key Players
Location
Boston Medical
Center
Re-Engineered
Discharge/RED
Patient education;
comprehensive discharge
planning; After Hospital Care
Plan (AHCP); post-discharge
phone call for medication
reconciliation
Nurse
discharge
advocate,
clinical
pharmacist
Hospital and
home (phone
only)
http://www.bu.edu/fam
med/projectred/
Care Transitions
Program
http://www.caretransitio
ns.org/
Care Transitions Intervention
Transitions
(CTI); medication selfcoach
management; patient-centered
record (PHR); follow-up with
physician; and risk appraisal
and response
Home
34
Major Interventions
Intervention
Key Elements
Transitional Care
Model (TCM)
Care coordination; risk
Transitional care Hospital and
assessment; development
nurse (TCN)
home
of evidence-based plan of
care; home visits and phone
support; patient and family
education
http://www.transitionalc
are.info/
Home Health Care
Telemedicine
http://www.innovativecar
emodels.com/care_model
s/18/key_elements
Telehealth care;
Telemonitoring; front-load
and in-home visits
Key Players
Location
Telemedicine
Home care
nurse and
traditional home
health nurse
35
Major Interventions
Intervention
Key Elements
Key Players
Location
Home Health Quality
Initiative (HHQI) 2010
National cross setting
initiative; strategies and
best practice tools that
will reduce potentially
avoidable acute care
hospitalization (ACH)
from Home Health
Home health
stakeholders
and multiple
health care
providers
Home care
Strategies and tools that
will reduce potentially
avoidable acute care
transfers (ACT) from
nursing homes
Nurse,
Certified Nursing
Assistants
(CNA), discharge
advocate
Nursing Home
(NH) and
Skilled Nursing
Facility (SNF)
http://www.homehealthqual
ity.org/hh/default.aspx
Nursing Home
Interventions to
Reduce Acute Care
Hospitalizations
(INTERACT)http://www.qualitynet.org/d
cs/ContentServer?cid=12115
54364427&pagename=Med
qic%2FMQTools%2FToolTem
plate&c=MQTools
36
Major Interventions
Intervention
Key Elements
Key Players
Location
Better Outcomes for
Older Adults Through
Safe Transitions
(BOOST)
Clinical interventions,
practical step-wise
project management
tools, and resources to
train multidisciplinary
teams about quality
improvement and best
practices in discharge
planning and effective
communication strategies
Nurses, social
workers, case
managers,
residents,
hospitalists
Hospital and
home
http://www.hospitalmedicin
e.org/ResourceRoomRedesig
n/RR_CareTransitions/CT_Ho
me.cfm
37
CMS’s Table of Interventions
http://www.cfmc.org/caretransitions/files/Care_Transition_Article_Remington_
Report_Jan_2010.pdf
38
Monitor and Evaluate Progress
 Critical element often not thought out
• Informs hospital leaders of the efficacy of
strategies
• Helps guide implementation of additional
strategies
 Readmission data can be tracked and reported
as quality indicator to the following
• Hospital boards
• Quality committees
• Front-line and clinical staff
39
Intervention Pilots in Our Community
Intervention
Redesign of case management
processes
Number of
Organizations
Implementing
Type of Stakeholder
5
Hospital,
Inpatient Rehabilitation
8
Hospital, Home Health,
Community
Pharmacist involvement
4
Hospital
Telephonic follow-up
4
Hospital
Telehealth
6
Home Health
Early warning and reporting
4
Nursing Home
Redesign of educational
materials and processes
6
Hospital, Inpatient
Rehabilitation, Home Health
40
Coaching
30 days to the same or another short-term acute care PPS hospital
Source: Short Term Program for Evaluating Payment Patterns Electronic Reporting (PEPPER) Version Quarter 3 (Q3) Fiscal
Year (FY), release date of February 5, 2010
Q3 FY 08
Q3 FY 09
(April, May, June)
(April, May, June)
Point
Change Q3
FY 08 to Q3
FY 09
Point
Change
from State
Mean
Point
Change
from
Jurisdiction
Mean
Point
Change
from
National
Mean
Hospital A
16.6 %
15.8%
-0.8%
-0.1
-0.6
-0.2
Hospital B
15.8%
12.0%
-3.8
-3.9
-4.4
-4.0
Hospital C
17.4%
14.6%
-2.8
-1.3
-1.8
-1.4
State
Mean
Jurisdiction
Mean
National
Mean
NA
15.9%
NA
NA
-0.5
-0.1
NA
16.4%
NA
+0.5
NA
+0.4
NA
16.0%
NA
+0.1
-0.4
NA
41
Summary of Preliminary
National Results
42
Total Participating Providers Among
14 Communities




70 Hospitals
277 Skilled Nursing Facilities
316 Home Health Agencies
89 Other types of providers (Dialysis,
Hospice, etc.)
 1,125,649 Medicare Beneficiaries
43
Preliminary Results*: CY 2007 compared to CY 2009
14 Care Transitions Communities in contrast to
56 Comparison Communities
Measure
CT Theme (Comparison)
CT Theme (Comparison)
Absolute Change
Relative Change
% readmitted
-0.08%
(+0.30%)
-0.39%
(+1.91%)
Readmissions/1000
-2.96/1000
(-0.36/1000) -4.75%
(+0.15%)
Admissions/1000
-15.23/1000 (-7.62/1000) -4.59%
(-2.11%)
Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia
Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:
http://www.cfmc.org/caretransitions/learning_sessions.htm
*Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the
QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.
Preliminary Results*: CY 2007 compared to CY 2009
14 Care Transitions Communities in contrast to the Nation
Measure
CT Theme (National)
CT Theme (National)
Absolute Change
Relative Change
% readmitted
-0.08%
(+0.05%)
-0.39%
(+0.24%)
Readmissions/1000
-2.96/1000
(-1.93/1000) -4.75%
(-3.34%)
Admissions/1000
-15.23/1000 (-11.8/1000)
-4.59%
(-3.77%)
Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia
Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:
http://www.cfmc.org/caretransitions/learning_sessions.htm
*Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the
QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.
Preliminary Results*: CY 2007 compared to CY 2009
Transitions: Hospital—Skilled Nursing Facility (SNF)—Hospital
Drivers: Lack of Standard and Known Process, Information Transfer
Measure
CT Theme (Comparison)
CT Theme (Comparison)
Absolute Change
Relative Change
% discharged to SNF
+0.56%
(+0.81%)
+3.79%
(+6.57%)
SNF readmission rate
-0.41%
(+0.75)
-1.09%
(+4.64%)
Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia
Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:
http://www.cfmc.org/caretransitions/learning_sessions.htm
*Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the
QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.
Preliminary Results*: CY 2007 compared to CY 2009
Transitions: Hospital—Home Health—Hospital
Drivers: Lack of Standard and Known Process, Information Transfer,
Patient Activation
Measure
% discharged to HH
CT Theme (Comparison)
CT Theme (Comparison)
Absolute Change
Relative Change
+0.4%
(+1.13%)
+1.67%
(+8.49%)
HH readmission rate -0.47%
(0.00%)
-1.87%
(+0.30%)
Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia
Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:
http://www.cfmc.org/caretransitions/learning_sessions.htm
*Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the
QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.
Preliminary Results*: CY 2007 compared to CY 2009
14 Care Transitions Communities in contrast to
56 Comparison Communities
Measure
CT Theme
Comparison
Average Cost Savings/Beneficiary†
$15.23
$6.91
Average Cost Savings/Community†
$835,441
$132,482
$11,696,180
$7,419,003
Total Cost Savings†
† This measure represents cost savings associated with readmissions only.
Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia
Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:
http://www.cfmc.org/caretransitions/learning_sessions.htm
*Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the
QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.
National Results
 Hospital readmissions work reduces hospital ‘admissions’
 Population-based measures of readmission going down
 Population-based measures of admission also going
down
 Nursing Home and Home Health utilization has increased
slightly while 30-day readmission rates for Nursing Home
and Home Health have decreased
 Preliminary cost-savings are very promising
Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented
by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado.
Accessed at: http://www.cfmc.org/caretransitions/learning_sessions.htm
49
Challenges to Care Coordination
 Workforce and provider shortages (e.g., supply of
physicians or places to go for medical care)
 Limited access to specialty care
 Limited financial capacity
 Under-resourced infrastructures
 Populations with multiple chronic conditions
 Isolation and sometimes large areas due to
geographic and travel distances
50
Challenges to Care Coordination
 Lack of coordination and communication
across information systems and between
providers
 Health care professionals are not
necessarily trained in care coordination
 Broadband availability
51
Strengths Needed in Health Care Systems
 Becoming innovative to meet new changes
and challenges
 Improving communications across large,
complex and /or multiple delivery systems
 Establishing strong primary care physician
infrastructure
 Building and encouraging effective multiple
disciplinary teams and networks to ensure
access and improve quality of care
52
Strengths Needed in Health Care Systems
 Learning to become less competitive
and more cooperative…
leading to…
 Establishment of culture norms that
contribute to a level of community
engagement and collaboration
(“shared interest in accomplishment”)
53
We Don’t Need Any “New” Interventions
 We need implementation experience
 We need cooperative, cross-setting,
community-wide, population-focused
implementation experience
54
Questions?
Roland A. Grieb, MD, MHSA
(812) 234-1499 Extension 221
[email protected]
This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents
presented do not necessarily reflect CMS policy. 9SOW-IN-TRAN-11-002 02/17/2011
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