Transcript Ann Intern Med - Arkansas Hospital Association

Preventing Readmissions
and Discharges
Speaker
 Sue Dill Calloway RN, Esq. CPHRM
 AD, BA, BSN, MSN, JD
 President
 Patient Safety and Education
 5447 Fawnbrook Lane
 Dublin, Ohio 43017
 614 791-1468
 [email protected]
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Patient Protection and Affordable Care Act
 The Patient Protection and Affordable Care Act or
PPACA was signed into law on March 23, 2010
 The following week the Health Care and Education
Reconciliation Act of 2010 was signed which made
modifications to the PPACA law
 Constituted the largest change to healthcare system
since the creation of Medicare and Medicaid
 It has financial penalties for hospitals with excessive
readmissions
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Patient Protection and Affordable Care Act
 Section 1002, 10101, on health care quality
reporting requires the secretary of HHS, in consult
with health experts, to develop healthcare reporting
requirements
 Within two years or March 13, 2012
 Initiatives to prevent hospital readmission through a
comprehensive program for hospital discharge
planning
 Also post discharge reinforcement by an
appropriate healthcare professional
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Patient Protection and Affordable Care Act
 The new law establishes a VBP program, or valuebases purchasing, to pay hospitals for their actual
performance
 Will apply to all acute care PPS hospitals
 CAH and post acute facilities are excluded
 However, CMS will roll out to CAHs it Program for
Evaluating Payment Patterns Electronic Report (PEPPER)
 This provides hospital-specific data on Medicare
discharges identified as being at high risk for erroneous
payment, such as short stays, improper coding and
potentially avoidable readmissions (AHA News Jan 31,
2011, go to www.PEPPERresources.org)
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Patient Protection and Affordable Care Act
Measures selected for pay include those
used in the Medicare pay for reporting
program such as measures for heart attack,
heart failure, pneumonia, surgical care and
patient satisfaction (HCAHPS)
Program restricted from including
readmission measures
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Patient Protection and Affordable Care Act
 However, beginning in 2013, the HHS secretary
must establish a voluntary pilot program on
payment bundling (Sec, 3023, 10308)
 Purpose to improve coordination, quality and
efficiency of health care services
 For five years and can extend if does not reduce
quality but reduces cost
 Secretary required to identify a patient assessment
instrument to determine appropriate site for postacute care
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Patient Protection and Affordable Care Act
 Must develop episode-of-care and post-acute care
quality measures
 Hospitals are required to submit data on these quality
measures through an EHR which will be posted on
hospital compare
 Law specifies the following episode-of-care quality
measures
 Functional status improvement
 Rates of avoidable hospital readmissions
 Rates of discharge to the community
 Rates of admission to an emergency department after a
hospitalization
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Patient Protection and Affordable Care Act
 Law specifies the following episode-of-care quality
measures (continued)
 Incidence of healthcare-acquired infections (HealthcareAssociated Infections or HAI)
 Efficiency measures
 Measures of patient-centeredness of care
 Measures of patient perception of care and
 Other measures, including measures of patient outcomes,
as determined by the Secretary
 Will select condition with significant variation in
readmissions and post acute care spending
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Patient Protection and Affordable Care Act
 Beginning in FY 2012, the HHS Secretary will
develop a program for hospitals that have a high
rate of risk-adjusted readmissions (Section 399KK)
 The purpose is to help hospitals reduce the rate of
unnecessary readmissions within a specified time
period
 This is to be done through the use of PSOs
 A PSO is a patient safety organization
 To learn more about PSOs go to
http://www.pso.ahrq.gov/
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Hospital Readmissions Sec 3015
 Expected to save $7.1 billion over ten years
 Beginning in fiscal year 2013 hospitals with higher
than expected readmission rates will experience
decreased Medicare payments for all Medicare
discharges
 Remember that by March 23, 2012 the secretary must
make available a program to improve their readmission
rates through PSO
 CAH and post-acute care providers are exempt
 Performance data will be based on 30 day
readmission
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Hospital Readmissions Sec 3015
 Performance data will be based on 30 day
readmission rates for MI, HF, and pneumonia
 The base inpatient payment for hospitals with actual
readmission rates higher than their Medicarecalculated expected readmission rates will be
reduced by an adjustment factor that is the greater
of:
 A hospital-specific readmissions adjustment factor based
on the number of readmitted patients in excess of the
hospital's calculated expected readmission rate; or
 0.99 in FY 2013; 0.98 in FY 2014; and 0.97 in FY 2015
and beyond
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Hospital Readmissions Sec 3015
This means the largest potential reduction for
a hospital would be 1 percent in FY 2013
2 percent in FY 2014
 and 3 percent in FY 2015 and beyond
This reduction will apply to all Medicare
discharges. Hospitals with a small number of
applicable patient cases, as determined by
the Secretary, will be excluded from the
provision
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Hospital Readmissions Sec 3015
 In 2015, can expand list of conditions to include
COPD, severe cardiac and vascular surgical
procedures
 Can include other conditions or procedures that the
Secretary chooses
 Secretary is to seek endorsement from NQF for all
measures used to assess readmission performance
 Secretary can proceed without endorsement
 Secretary is directed to calculate and report all
payer readmission rates for conditions selected
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NQF
 NQF has published “Preferred Practices and
Performance Measures for Measuring and Reporting
Care Coordination”
 NQF notes care coordination is important to prevent
unnecessary returns to the ED and readmissions
 Especially important for patients with chronic
conditions such as diabetes and hypertension
 These standards provide structure, process and
outcome measures
 Goal to reduce 30 day readmission rates and
preventable ED visits by 50%
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NQF Care Coordination Preferred Practices
 Has domains on
 Home with five practices
 Proactive plan of care and follow-up with five practices
 Communication with four practices
 Information systems with three practices
 Transitions and handoffs with eight practices
 Plan of care and follow up
 P&P to create and update plan of care with every patient
 Follow up of all tests and treatments
 Include patient education, cardiac rehab for recent CV event
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NQF Care Coordination Preferred Practices
 Communication
 Plan of care made available to patient and home team
 Program to use a partner to support care when patient is
hospitalized
 Care coordination activities are assessed and
documented
 Transition or handoffs
 Transition program engages patients and families in self
management when discharged home
 Standardized communication template for transition of
care process including core data elements
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NQF Performance Measures
 Cardiac rehab patient referral from inpatient and
outpatient setting
 Biopsy follow up
 Reconciled medication list by discharge patients
 Melanoma continuity of care with recall system
 Transition record with specified elements received
by discharged patient
 Patient with trans ischemic event ED visit who had
a follow up in the office
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Source AHS Legislative Advisory
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www.aha.org/aha/issues/HealthReform/reform-movingforward.html?group=hospital
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Bundled Payments Based on Episodes of Care
 Bundled Payments
 Would eliminate a single payment based on an
index hospitalization
 Instead it would provide reimbursement based on
the episode of care
 The episode of care may include post-acute care
and would therefore provide inpatient providers
incentive to complete effective care coordination
and other identified best practices upon discharge
from the inpatient setting
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Cedar-Sinai Medical Center & 5 Hospitals
 October 15, 2010 article
 6 hospitals in California get a $9.9 million grant to
study how wireless technology and telephone care
management can reduce the number of hospital
readmissions
 Looking at prevent readmissions of patient with
heart failure
 Funding is critical as we reinvent healthcare
 Project compares two approaches for patients to
make a smooth transition from hospital to home
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Cedar-Sinai Medical Center & 5 Hospitals
 It is three-year grant called Variations in Care:
Comparing Heart Failure Care Transition
Intervention Effects
 It is funded under the AHRQ's Clinical and Health
Outcomes Initiative in Comparative Effectiveness
(CHOICE) program
 Did study 6 months ago that found out that heart
failure readmissions were less at hospitals with
more healthcare resources (Cardiovascular Quality
and Outcomes in Circulation Magazine)

Read more: UCLA-led consortium gets $9.9M to reduce hospital readmission of heart failure patients
FierceHealthcarehttp://www.fiercehealthcare.com/press-releases/ucla-led-consortium-gets-9-9m-reduce-hospitalreadmission-heart-failure-patients#ixzz11W9ZjymV
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Readmission Rates Vary
 Readmission rates vary widely in the US
 Too often quality of care during transition from hospital to
home is not good
 Data shows readmission rate for MI and CHF vary
 Found only modest association between performance on
discharge measures and patient readmission rates
 Public reporting unlikely to yield large reductions in
unnecessary readmissions
 We need to improve in the ambulatory section
 See A. K. Jha, E. J. Orav, and A. M. Epstein, Preventing
Readmissions with Improved Hospital Discharge Planning,
NEJM Dec 31, 2009 361 (27):2637-2645
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Geographic Variation in Hospital Readmissions
2007 Medicare SAF data
http://www.commonwealthfund.org/Content/Publications/LiteratureAbstracts/2010/Jan/Preventing-Readmissions-with-Improved-Hospital-DischargePlanning.aspx
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http://www.nejm.org/doi/full/10.1056/NEJMsa0803563?si
teid=nejm&keytype=ref&ijkey=3CQjS3yxXjOtY
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AHRQ Patient Safety Primer
AHRQ has a patient safety primer that is
designed to help users to understand key
concepts in patient safety
 It has a section on handoffs and sign-out’s,
healthcare associated infections, and adverse
event after discharge
 The adverse events after discharge is data about
unnecessary readmissions
 It includes adverse events after discharge
 http://psnet.ahrq.gov/primerHome.aspx
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Readmissions and Discharges
 One in 5 hospital discharges (20%) is complicated
by adverse event within 30 days
 20% were readmitted within 30 days with 1/3 leading to
disability
 Often leads to visits to the ED and rehospitalization
 6% of these patients had preventable adverse
events
 66% were adverse drug events
 The incidence and severity of adverse events affecting patients
after discharge from the hospital. Forster AJ, Murff HJ,
Peterson JF, Gandhi TK, Bates DW. Ann Intern Med.
2003;138:161-167
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Preventing Readmissions
 76% of readmissions are thought to be preventable
 It is the preventable ones that hospitals need to
work on
 Medicare data shows that over half of patients
readmitted received no follow up care
 Recent studies show interventions targeted at postacute care transition can reduce readmissions by
one third (Coleman and Naylor)
 Technologies for Improving Post-acute Care Transitions,
Center for technology and Aging, Sept 2010
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Preventing Readmissions
 HHS study finds a high rate of Medicare patient
deaths due to adverse events (AE)
 15,000 Medicare patients experience an AE during
healthcare delivery that lead to their death every
month
 Nov 16, 2010 OIG study
 Found 1 in every 7 discharges (13.5%) experience
an AE and the cost to CMS is $324 million
 44% of all AE were preventable and 51% were not
 November 2010, OEI-06-09-00090
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Preventing Readmissions
 Care Transitions Intervention and Transitional care
Model are two common interventions that focus on
the post-acute care transitions
 Guided care and Geriatric Resources for
Assessment and Care of Elderly are promising care
coordination intervention models
 Technologies to improve medication adherence,
medication reconciliation, patient monitoring,
communication between clinicians, risk assessment
are important aspects of care transitions
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Readmissions and Discharges
 40% of patients who were discharged had test results
pending
 Many discharged patients had pending workups with
interventions to be followed up by outpatient physicians
 More than 1/3 of the recommended follow ups were not
followed
 Frequently because the discharge summary did not contain
the details of the necessary work up
 But availability of discharge summary increased likelihood
of work ups being done
 Tying up loose ends: discharging patients with unresolved medical issues.
Moore C, McGinn T, Halm E. Arch Intern Med. 2007;167:1305-1311
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Readmissions and Discharges
 Another study finds that 41% of inpatients were
discharged with a study pending
 It was also discovered that 2/3 of the physicians were
not aware of the results
 37% of the tests required some action on behalf of the
physician
 Inpatient physicians were dissatisfied with system for
following up test results returning after discharge
 Roy, Christopher etc. Patient Safety Concerns Arising
from Test Results that Return after Hospital Discharge,
Ann Intern Med 2005; 143(2):121-8
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Readmissions and Discharges
 Many were not done because the discharge
summary was not available at the time of the first
clinic or office visit
 Later study found that 78% of patients who went for
the first post hospital visit the primary care physician
did not have a discharge summary for the patient
 Note NQF 34 Safe Practices to dictate the discharge
summary when patient discharged and ensure it gets
to the PCP timely and document this communication
 Incomplete handoffs lead to unnecessary readmission
 Care transition important for high risk and the elderly
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Readmissions and Discharges
 37.2% of patients did not know the purpose of their
medication
 Only 14% knew the side effects of the medications
they were taking
 Only 41.9% of patients were unable to state their
diagnosis
 Hospitals may want to focus on ensuring adequate
medication information, discharge diagnosis and
plan of care information to the patient
 Patient Understanding of their Treatment Plans and Discharge Diagnosis at
Discharge, Mayo Clinic Proceedings, Aug 2005;80(8):991-994
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Readmissions and Discharges
 This lead to the development of a formal discharge
checklist to ensure communication at discharge
 Transition of care for hospitalized elderly patients—
development of a discharge checklist for hospitalists.
Halasyamani L, Kripalani S, Coleman E, et al. J Hosp
Med. 2006;1:354-360
 The Pa Patient Safety Authority has excellent
resources including suggested elements for a
discharge checklist
 See Care at discharge—a critical juncture for
transition to posthospital care. Pa Pat Saf Advis 2008
Jun;5(2):39-43
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PaPSA Checklist
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http://patientsafetyauthority.org/Educational
Tools/PatientSafetyTools/tk_discharge/Pag
es/home.aspx
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PaPSA on Preventing Readmission
 Had more than 800 reports in 3 ½ year period of
harm from patients from incomplete discharge
 30% of patients did not receive verbal or written
discharge instructions before they left the facility
 Lack of medication reconciliation was evident
 Essential parts of the discharge process include
 Educating the patient and or family including what to do if a problem
occurs
 Assessing the patients understanding of the plan
 Scheduling follow up appointments
 Confirming the medication plan
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PaPSA on Preventing Readmissions
 Some patients received another patients instructions
 Many patients did not have their IV access device
removed prior to discharge
 Many patients returned with an IV site infection and or
phlebitis
 Discharge of patients before test results were made
available to the attending who would have postponed
discharge based on the final results
 Many medication related issues such as lack of
instructions
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CMS Checklist
 CMS, in the QIO 9th scope of work, has 14
states in the care transition project,
 Each of the 14 states will summarize their
results and these calls are free to listen to
 Sign up for upcoming sessions at
http://www.cfmc.org/caretransitions/learning_ses
sions.htm
 CMS has published a checklist which is
available at www.medicare.gov
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http://www.cfmc.org/caretransitions/pati
ent_resources.htm
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http://www.cfmc.org/caretransitions/
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CMS Table of Interventions
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http://www.cfmc.org/caretransitions/files/Care_Transition_Article_
Remington_Report_Jan_2010.pdf
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11 Essential Steps of RED Process
 Greenwald etc. identified 11 essential steps to the
reengineered discharge process at Boston Medical
Center
 Educating patients and families about their diagnosis
throughout the hospital stay
 Assessing the patients’ understanding of the plan by
asking them to explain the plan in their own words
 Advising the patient and family of any tests completed
in the hospital with results pending at time of
discharge and identifying the clinician responsible for
the results
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11 Essential Steps of RED Process
Scheduling follow-up appointments and tests
to be done following discharge
Organizing services to be initiated following
discharge
Confirming the medication plan
Reconciling the discharge plan with national
guidelines and critical pathways when
relevant
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11 Essential Steps of RED Process
 Reviewing with the patient what to do if a problem
occurs
 Expediting the transmission of the discharge
summary to the healthcare providers who are
accepting responsibility for the patient’s care
 Giving the patient written discharge instructions
 Greenwald JL, Denham CR, Jack BW. The hospital
discharge: a review of high risk care transition with
highlights of a reengineered discharge process. J
Patient Saf 2007 Jun;3(2):97-106.
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3 Factors Leading to Errors at Discharge
 Greenwald etc identified factors that lead to error at
discharge to three types
1. Hospital care system characteristics
 Many hospitals don’t get discharge summaries to PCP
timely
 Many errors around lack of medication reconciliation at
discharge
2. Patient characteristics

Factors in literature at risk for hospitalization include lack of
social, financial, and familial support and low health literacy,
lack of follow up and adherence to treatment
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3 Factors Leading to Errors at Discharge
 3. Clinician characteristics
 These focus on quality and effectiveness of
communication and
 Timeliness and completeness of discharge
summaries provided to subsequent caregivers
 Clinicians with limited time or lack of effort put into
educating patients at discharge lead to lack of
patient understanding
 This is why studies that used transition coaches to
assist and encourage the patient to participate in their
care were successful at unnecessary readmissions
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Transitions Research
 Research on preventing unnecessary readmissions
looks at the studies on improving transitions
 Transitions is the process designed to ensure
coordination and continuity of healthcare as patients
transfer between different locations or different
levels of care
 We want to improve the transition to home, long
term care, home health, assisted living or other post
discharge places
 How do we do this right so the patient does not
have a unnecessary readmission
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AHA Reducing Avoidable Hospital Readmissions
 One study found that the cost to Medicare for
unplanned readmissions in 2004 to be 17.4 billion
in 2004
 Jencks, Stephen F., Williams, Mark V., and Coleman, Eric A. 2009.
Rehospitalizations among Patients in the Medicare Fee-for-Service Program.
N Engl J Med 360 (14):1418-1428
 Considered to be a quality of care issue by payers
 MedPac in 2005 found that hospital readmissions
cost Medicare about $15 billion dollars
 Congressional Budget Office (CBO) suggested Medicare
program could save money if payments to hospitals with
high readmissions were reduced
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AHA Guide to Reduce Readmissions
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AHA Reducing Avoidable Hospital Readmissions
 MedPac (Medicare Payment Advisory Council) in
2009 concluded that large proportion of rehospitalizations was preventable
 Improvements needed include better communication and
more coordinated care before and after discharge
 Medicare Payment Advisory Commission. Report to Congress:
Improving Incentives in the Medicare Program 2009
 Not all readmissions are preventable
 Predictors of readmission include certain clinical
conditions such as CV conditions, stroke, and depression
 Certain patient demographics such as elderly, dually
eligible Medicare enrollees,
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AHA Guide to Reduce Avoidable Readmissions
 AHA had committees look at the issue of how to
reduce unnecessary hospital readmissions
 AHA published several memos and a 2010 Health
Care Leader Guide to Reduce Avoidable
Readmissions
 Issues memo on Sept 2009 on Reducing
Avoidable Hospital Readmissions
 Includes evaluation of post acute transition
process which is the process of moving from the
hospital to home or other settings
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AHA Reducing Avoidable Hospital Readmissions
 Some readmissions can be avoided by evidenced
based practice but the means for achieving this still
remains controversial
 Preventing readmissions is a complex, system-wide
problem that involves hospitals, physicians, other
providers, patients and their families
 AHA created a framework
 AHA included a list of strategies that hospitals might
find helpful in both documents
 AHA worked with 3 states and got payer data on
readmissions
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AHA Classifications of Readmissions
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AHA Reducing Avoidable Hospital Readmissions
Recommended that public policy seeking to
reduce readmission should focus on the
category of unplanned and related
readmissions
 Example patient has surgery and on way home
injured in an auto accident which would be
unrelated
 Patient is noncompliant with dietary
recommendations or medications prescribed
AHA continues to monitor this issue carefully
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AHA 4 Steps
First, examine your hospital’s current rate of
readmissions
Second, assess and prioritize you
improvement opportunities
Third, develop an action plan of strategies to
implement
Fourth, monitor you hospital’s progress
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Step 1 Current Rate of Admissions
 Compile data on your readmission rate
 Hospital compare has 30 day admission rates on
CHF, MI, and pneumonia
 listed at www.hospitalcompare.hhs.gov
 Will also need to know for pci
 Knowing data will help hospital target strategies for
reducing readmissions
 First, look at rates for different conditions so
examine by diagnosis and significant co-morbidities
and correlate with patient’s severity
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Step 1 Examine Current Rate of Readmissions
 For example, MI, CHF, pneumonia, patients with diabetes,
obesity, or COPD
 Second, look at readmission rate by
practitioner to look for patterns or if any type of
practitioner is associated with unexpected
readmissions
 Third, look at readmission rates by
readmission source such as nursing homes,
home health etc. to determine the places
where most often patients are being
readmitted
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Step 1 Examine Current Rate of Readmissions
 Lastly, look at readmission rates at different time
frames such as 7, 30, 60, and 90 days which can
bring into flaws in transitioning patients to the
ambulatory setting
 Hospitals should also pull the charts of a few
patients who were readmitted from various setting
 Purpose is to understand why patient was
readmitted and what could have been done to
prevent the readmission
 Look at financial impact on the hospital that reduced
payments would have
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2. Prioritize Improvement Opportunities
 AHA recommends to assess and prioritize your
improvement opportunities
 There are one of more approaches that can be
followed
 Focus on specific patient populations such as older
adults with co-morbidity since need a more rigorous
assessment process to determine discharge needs
 COPH, diabetes, renal failure, liver failure etc.
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2. Prioritize Improvement Opportunities
 Focus on stages of the delivery process so if you
identify patients being admitted for the same reason
look at the resources available
 Such as CHF patient , MI, asthma, diabetes, renal failure and
pneumonia
 Patient and family education can help patients take care of their
care
 Focus on the hospital’s priority areas and current PI
initiatives
 Look at current PI program and can redesign fundamental care
processes
 See AHA list of past and current PI programs
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3. Develop Action Plan of Strategies
 Develop an action plan of strategies to implement
 This is why doing a literature search and have
librarian obtain articles from evidence based
research
 Need many in the community to work together to
prevent unnecessary readmissions to the hospital
 See list of major strategies to reduce avoidable
readmissions
 Need to use technology such as remote monitoring,
electronic medical records and telehealth
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Strategies During Hospitals
 Risk screen patients and tailor care
 Tailor patient care needs based on evidenced
based guidelines, clinical practice guidelines, care
path
– Develop pathways that include discharge steps
consistent with these evidenced based guidelines
– CHF CPG, CABG, Pneumonia pathways, Total hip and
total knee pathways
– Pathways are not cook book medicine but assist in
ensuring evidenced based practice is followed
– Include actions to take if variances occur with CPG
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Strategies During Hospitals
– Get with the guidelines!!!
– www.ahrq.gov and www.guidelines.gov
 Have healthcare worker responsible for discharge
planning and define scope of their responsibility
 Have a social worker or nurse case manager to provide
discharge planning services
 Some have discharge advocate
 Remember to include education to patients and families
about their disease
 Provide patient with disease specific, low literacy and
language and age appropriate educational material
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Strategies During Hospitals
 Be aware of research that shows patients at
increased risk of readmission such as patients with
low health literacy
 20% of population reads at the 5th grade level
 ½ of adults have trouble understanding simple health
information (consent, prescriptions, oral instructions)
– Can not tell health literacy by looking so observe closely in elderly,
unemployed, did not finish high school, born in US but English a
second language, noncompliant, immigrant, can’t name
medications, forgot glasses and will read later, etc.
 High risk patients also include history of readmission,
failed teach back, longer stay than expected, high risk
conditions, poor, disabled or on dialysis
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Strategies During Hospitals
 Respond to patient needs for early ambulation,
early nutritional interventions, PT, social work etc
– Nursing assessment and identified criteria to see dietician
timely
– Quality and patient safety initiatives to improve surgical
outcomes such as prevention of PE and DVT
 Develop a multidisciplinary team to evaluate and
implement discharge needs
– Consider a checklist of things to consider in the discharge process
– See Society of Hospital Medicine at
http://www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_I
mprovement_Tools&Template=/CM/ContentDisplay.cfm&ContentID=
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8363
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Strategies During Hospitals
 Consider putting together a hospital team to
evaluate the literature and reengineer the discharge
process in your hospital
– Research shows increased number of readmissions due to phlebitis
so consider annual orientation and credentialing of nurses to start IV
– Strict adherence to the IV standards such as the IV Nurses Infusion
Society Standards of Practice
– Consider infusion nurses
– Restarting IVs started by squad under less than ideal circumstances
– Strict adherence to how long IVs can stay in
– Have a process to ensure all IVs and IV access devices are removed
prior to discharge
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Strategies During Hospitals
 Evaluate all patients on admission and throughout
hospitalization for discharge planning
 Physical therapist can assess ability to do ADL and
environmental barriers in postdischarge care area and
what services will be needed after discharge
 Discuss end of life care wishes
 Some hospitals require code status of all patients upon
admission
 Studies found that often RRT or code called and then after
wards patient was made a DNR
 Pneumonia readmissions may reflect need for end of life
care
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Strategies During Hospitals
 Develop community connections to eliminate
barriers to successful transition
 Need to build relationships with other healthcare
providers, and public and private groups
 Parish nurse programs, meals on wheels, etc.
 Community partners that can help with nonmedical such
as behavioral, health literacy, and cultural issues
 Engage families, patients and caregivers
 Get their active participation, teach back,
 Get their feedback in addressing healthcare delivery
issues such as understanding discharge instructions
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Strategies at Discharge
 Implement comprehensive discharge planning
 Should be written out so the patient can understand
 Should be comprehensive to include medication use, activity
level, symptoms that patient should call the physician or
return
 TJC has a discharge tracer
 Provide discharge plan to patient
 Make sure PCP gets discharge summary
 Reconcile discharge plan with national guidelines/CPGs
 Standardized checklist of transitional services
 Give patient care record including pending tests
89
Strategies at Discharge
 Use teach back method to educate the patient and
their care giver
 Have the patient repeat back the instructions in their own
words to make sure they understand the discharge
instructions
 Focus handoff information on patient and family
 Make sure patient repeats back what to do if a problem
arises
 Make sure patient has it in writing the signs and
symptoms to watch for
90
Strategies at Discharge
 Schedule the patient’s follow up appointment
 Make the appointment for all follow up
appointments before the patient is discharged
 Provide times and information and directions to
the patient in writing
 The nurse case manager or discharge planner
can also schedule any further diagnostic tests
that were ordered
 Also want to confirm services to be received
before the patient leaves the hospital
91
Strategies at Discharge
 Develop standardized checklist to assess that all
discharge components are completed
 Finalize the plan with the patient and make sure
patient verbalizes understanding
 Perform a final physical assessment with attention
to the removal of all IV lines or other access ports
 Want to get a timely transfer of the discharge
summary to the primary care physician and
 Follow up by telephone 2 to 3 days after discharge
to assess optimal care and recovery
92
Strategies at Discharge
 Standardize the discharge instruction document and
include:
 primary and secondary diagnosis, patient
education, services to be provided
 dietary and other lifestyle modifications,
medications, follow-up appointments
 pending tests
 adverse events or complications to watch for, and
provider contact information for any problems that
occur
93
Strategies at Discharge
 Assist the patient in managing their medications
 Give patient complete list of medications at
discharge
 Include times to take and reason
 Pharmacist role in assisting with understanding
new medications or high risk medications
 Some use MAR to have patient document when
meds given
 Use transitional coach to help
94
Strategies at Discharge
 When patient are discharged to LTC make sure
transfer summary has detailed instructions
 Make sure a complete list of medications to be
taken are provided
 Include comprehensive information on hospital
care and what needs to be done for continuity of
care
 Partner with nursing home practitioners
 Consider call back to see if any questions
 Use NP in LTC facility
95
Strategies Post Discharge
 Promote patient self management
 Patients with HTN monitor BP at home
 Diabetics and patients on Coumadin use home monitoring
devices
 Follow up with patients via telephone
 Some hospitals have the nurse call the patient to reinforce
discharge instructions usually in 2-3 days
 Many of the transition programs involve calls or visits to
the patient in the home
 Offer telephone support for period post discharge
96
Strategies Post Discharge
 One author noted that hospitals, physicians, HHAs,
nursing homes and pharmacist can prevent more
readmissions by working together that hospitals can
by improving the discharge process alone
 Slide presentation on Reducing Avoidable Readmissions by
Steve Hines PhD, June 4, 2010
 Quality of LTC and HHA can drive readmission rates
 Establish community networks
 Parish nurse programs, meals on wheels
 Establish private/public partnerships to meet patient needs
 Homeless shelters with medical care and dental care
97
Strategies Post Acute Care Technologies
 Medication adherence
 Devices that remind patients to take the right medication
at the right time
 Hospitals should take a serious look at this issue
 Medication non-adherence contributes to 33%-69% of
medication related hospital admissions
 The New England Healthcare Institute estimates that $290
billion of health care expenditures could be avoided each
year if medication adherence were improved
 Delate T, Chester EA, Stubbings TW, Barnes CA. Clinical outcomes of a
home-based medication reconciliation program after discharge from a skilled
nursing facility. Pharmacotherapy. Apr 2008;28(4):444-452.
98
Strategies Post Acute Care Technologies
 Strategies to increase medication adherence
include;
 Simplifying the patient’s medication regimen
 Identifying if the medication has untoward effects
 Improving patient self-efficacy and activation
 Providing cues or reminders to take medications as
prescribed
 New England Healthcare Institute. Thinking Outside the Pillbox: A
System-wide Approach to Improving Patient Medication Adherence
for Chronic Disease. A NEHI Research Brief July 2009.
99
Strategies Post Acute Care Technologies
 Philips Medication Dispensing System
 Dispenses 10-30 days worth of medications
 Reminds patients to take it
 Can alert physician and 3 others if pills not
removed from dispenser
 Provides alert and dispensing information
 Has been shown to reduce hospitalizations
 Especially good for those with cognitive problem
on Coumadin
100
Strategies Post Acute Care Technologies
 Mini-mental state exam (MMSE) correlates with
medication adherence
 Medication reconciliation
 Software that stores medication information and detects
certain problems such as duplicate prescriptions
 Remote patient monitoring
 Technology to help detect early deterioration of a patient’s
medical condition
 Patient or care giver access to medical records
101
Strategies Post Discharge
 Use personal health records to manage patient
information
 Also helpful to have patient maintain important
medical record information including reason for
admissions, dates, and complete medication
information
 Conduct patient home visits
 Home health nursing program after discharge and
regularly after that when needed
 Some have nurse practitioner make home visits
102
Strategies Post Discharge
 Use telehealth in patient care
 Technology can be used to help prevent readmissions
 See Technologies for Improving Post-Acute Care
Transitions, September 2010
 Use of EHR to support care coordination
 Monitor patient progress such as electronic cardiac
monitoring and remote patient telemonitoring
 Medication reminders and dispensers
 In home diagnostic devices
 Videoconferencing
103
Tech4Impact Diffusion Grant Program
 June 2010, the Center for Technology and Aging
(CTA) announced the release of their Tech4Impact
Diffusion Grants Program
 The goal is to help selected states expand the use
of technologies for improving post-acute care
transitions (PACT) and reduce avoidable
rehospitalizations
 Has a 45 page book to explain some of the
technology to reduce unnecessary readmissions
104
PACT Technology
 Medication adherence (e.g., devices that remind patients to
take the right medication at the right time and alert
caregivers when a medication has not been taken)
 Medication reconciliation (e.g., software that stores
medication information and detects potential problems, such
as duplicate prescriptions)
 Remote patient monitoring, including technologies that help
detect early deterioration of a patient’s health condition
 Patient or caregiver access to health records and other
important health information
 Social support and communications between and among
patients and caregivers
105
106
4. Monitor the Hospital’s Progress
 The last key to reduce readmissions is for hospital
leadership to monitor the progress
 Look at readmission rates by
 Different conditions such as MI, CHF, COPD, Pneumonia,
TKA, THA, asthma, diabetes, cellulitis, etc
 By practitioner to look for patterns
 Over different time frames (7, 30, 60, and 90 days)
 By readmission source (home, LTC, etc.)
 Data should be included in key indicators tracked
107
Diagnostic Specific Reasons for Readmissions
 There are reported diagnostic specific reasons for
avoidable readmissions
 Many COPD and pneumonia patients need home health
care but do not receive it
 Cardiologist may rely on primary care physician and not
arrange follow up care for HF patients
 Readmission rate appears higher for HF patients with
behavioral diagnosis
 Dialysis patients are very vulnerable to changes in
medications during hospitalization
– ESRD have higher than average readmission rates (MedPAC)
– Medicare Payment Advisory Commission. 2007. Report to the Congress: Promoting Greater Efficiency in
Medicare. Washington, DC: Medicare Payment Advisory Commission, p. 107
108
Diagnostic Specific Reasons for Readmissions
 Surgeons do not arrange for post surgery primary
care
 Studies show there is inadequate teaching of
surgical patients in caring for themselves after
surgery
 Incision care
 Post CABG patients expecting to be pain free and
seek readmission for angina
 Hospitals should know this information
109
NQF 34 SAFE PRACTICES
 Released in 2003, updated 2006, 2009
and April 2010
 34 Safe Practices for Better Healthcare
 These should followed in all healthcare
facilities
 All clinical care settings to reduce risk of
harm to patients
 A roadmap to preventing harm
 States 10 years after IOM report, To Err Is
Human, uniformly reliably safety in
healthcare has not been achieved
110
NQF Safe Practices 15 Discharge System
 A "Discharge Plan" must be prepared for each
patient at the time of hospital discharge, and a
concise discharge summary must be prepared for
and relayed to caregivers accepting responsibility
for postdischarge care in a timely manner
 Hospital must ensure that there is confirmation of
receipt of the discharge information by the LIP who
will assume the responsibility for care after
discharge
 TJC and CMS also require discharge summary
 TJC tracer on discharge process
111
15. Patient Discharges
 Often because of errors from fragmentation of care
at discharge
 High rates of low health literacy, and lack of
coordination for post care lead to adverse events
 Need to do medication reconciliation (TJC
requirement)
 Need structured discharge communication
 AHRQ has Project Red to improve patient
discharges (Re-Engineered Hospital Discharges)
 http://www.ahrq.gov/news/kt/red/
112
Safe Practice 15 Discharge System
 Need discharge P&P to include
 Roles in the discharge process
 Preparing for the discharge with documentation
throughout hospitalizations
 Complete discharge summary before discharge
 Reliable information flow from PCP to referring
caregiver and back
 Benchmarking, measurement, and continuous
quality improvement of discharge process
113
SP15 NQF Discharge System
 Written discharge plan must be given to each patient
at the time of discharge
 That is understandable by the patient (remember
issue of low health literacy)
 Discharge plan needs to include reason for
hospitalization
 Medications to be taken post discharge
 What to do if condition changes
 Coordination and planning for follow up appointments
and follow up tests and for studies if results not
available at time of discharge
114
15 Discharge System
 Discharge summary needs to be provided to LIP
who is caring for the patient after discharge
 Current problem where 78% of LIP who see patient for
first visit do not have discharge summary
 Include reason for hospitalization and significant findings,
procedures done, medication list, list of tests and studies
of results and ones not back
 Copies of lab, x-ray reports, and tests results in hands of
person doing discharge summary
 Need receipt confirmation by physician caring for patient
after discharge of discharge summary by fax, phone,
email etc
115
Discharge instructions
 Include activity level, medications and education on
medications, potential drug food interactions and follow up
information
 TJC RC.02.04.01 requires documentation of the patient’s
discharge information
 Document if you give patient specific patient education
sheets like fracture care sheet-should have copy on chart
 Ask Me 3 is three most important questions that can help
during discharge instructions
 What is the main problem?, what does the patient need to
do? And why it is important for them to do this?
(www.npsf.org/askme3)
116
Part 2
117
AHRQ 10 Patient Safety Tips for Hospitals
 AHRQ published above
 Number 2 is re-engineer hospital discharges
 Reduce by assigning a staff member to work closely
with patients and staff to reconcile medications
 Schedule necessary follow up appointments
 Create a simple and easy to understand discharge plan
 Include a medication schedule and record of all
upcoming appointments
 Who to call if problem arises
118
119
Joint Commission Standard for Hospitals
 PC.01.02.01 and RC.2.01.01 EP2 Medical record
must contain information on plan of care and
revisions to the plan of care and discharge
diagnosis
 TJC has PC.01.03.01 which provided information
on planning the patient’s care
 PC.02.02.13 has end of life standards
 This is provided for reference
 Discharge planners and social workers should be
familiar with these standards in addition to the floor
nurse caring for the patient
120
Planning the Patient’s Care PC.01.03.01
 The hospital plans the patient’s care
 Need to individualize the patient’s treatment based on
their unique needs
 Treatment must be appropriate to the results of the
assessment performed
 May need to modify the plan of care based on the
assessments done
 Could result in transfer to another facility or discharge
 EP1 Patient’s care is based on what is identified by
the assessments and reassessments and the
results of the diagnostic tests
121
Planning the Patient’s Care PC.01.03.01
 EP5 The written plan of care is based on the
patient’s goals and the time frames, settings, and
services required to meet those goals
 EP22 Staff need to evaluate the patient’s progress
in light of the goals and the patient’s plan of care
 EP23 Hospital revises the plan of care and goals
based on the patient’s need
 Failure to do a plan of care soon after the patient is
admitted and maintained it in the medical record
after the patient is discharged is a top problematic
standard with CMS
122
Patient Education PC.02.03.01
 The hospital provides patient education and training
based on each patient’s needs and abilities
 Patients are often discharged home earlier than in the
past
 Patients may have to do more self care such as changing
bandages, drains to home infusion therapy
 This makes patient education even more important
 Also important to prevent unnecessary readmission
especially related to medication use
 Patient learning needs must be assessed
 Patient education is important issue to TJC
123
Patient Education PC.02.03.01
 EP10 Education and training to patient will include
the following based on the patient’s condition and
assessed needs
 Explanation of the plan for care
 Basic health practices and safety
 Safe medication use
 Nutritional interventions, diets, supplements
 Pain issues such as pain management and methods
 Information on oral health (much information later on this
including oral bacterium (periodontal disease) as cause of
cardiovascular disease, MI, VAP, stroke, CAD)
124
Patient Education PC.02.03.01
 EP10 Education and training to the patient
(continued)
 Safe use of medical equipment
 Safe use of supplies
 Rehab to help the patient reach maximum independence
 EP25 Must evaluate the understanding of the
education and training provided
 Teach back is one method to verify understanding
 Ask me three program by the National Patient Safety
Foundation
125
http://www.npsf.org
/askme3/
126
Use a Patient Education Form
127
Use a Patient Education Form
128
http://www.docstoc.com/docs/downloaddoc.aspx/?d
oc_id=35987557&pt=16&ft=11
129
Patient Education Checklist
130
Patient Education PC.02.03.01
 EP27 The hospital provides the patient education
on how to communicate concerns about patient
safety issues that occur before, during, and after
care is received
 Instructions might be to contact their physician after
discharge
 May be if certain condition reoccurs to call 911 or
go to the closest emergency department
 Patients when discharge should be informed of
signs and symptoms of when to return (TJC
discharge tracer)
131
Care After Discharge or Transfer
 PC.04.01.01 states that the hospital has a process
that addresses the patient’s need for continuing care
after discharge or transfer
 EP1 Hospital describes the reason for and conditions
under which the patient is discharged or transferred
 For example care may no longer be medically necessary
 Patient may need services that are not provided by your
hospital such as open heart surgery
 EP2 Need to describe the process for shifting
responsibility to a new clinician or hospital or service
132
Care After Discharge or Transfer
 EP3 Hospital describes mechanism for external
transfer of patient
 Example would be to contact receiving hospital and get
acceptance, fill out transfer form, send medical records,
send in ambulance when appropriate etc.
 Remember the federal EMTALA law for patients who in
the ED and are unstable
 EP4 The hospital agrees with the receiving
organization about each of their roles to keep the
patient safe during transfer
 May need transported by helicopter or ACLS or BLS unit
133
Care After Discharge or Transfer
 EP22 Patients are informed of their rights to choose
among participating Medicare providers and the
hospital does not limit those qualified providers (DS)
 EP23 and 24 During discharge planning if
determine patient needs home health or LTC then
give them a list of the ones available and document
you gave the list (DS)
 This is a CMS requirement
 The hospital can not just automatically send the patient to
their home health agency
 It is truly the patient’s freedom of choice
134
Care After Discharge or Transfer
 EP26 The hospital has written discharge planning
P&P applicable to all patients (DS)
 Must also disclose any financial interest such as the
hospital owns the nursing home or the home health
agency
 Remember to take care to prevent any unnecessary
readmissions to the hospital
 Dictate the discharge summary immediately and
document that you got it into the hands of the PCP
who is going to see the patient post discharge
135
Assessment & Discharge PC.04.01.03
 The hospital discharges or transfers the patients
based their assessed needs and the hospital’s
ability to meet those needs
 EP1 Need to begin the discharge process early in
the patient’s admission
 EP2 Identify any need for psychosocial or physical
care after discharge
 EP3 Patient, family, staff, physician, LIPs etc all
participate in the planning the patient’s discharge or
transfer
136
Assessment & Discharge PC.04.01.03
 EP4 Arrange the services the patient will need after
discharge before they leave
 EP10 The hospital conducts reassessments of its
discharge planning process within its established
time frames for reassessment (DS)
 EP11 The reassessment of the discharge planning
process includes a review of discharge plans to
determine if the discharge plans meet the needs of
patients (DS)
137
Education Before Discharge PC.04.01.05
 Before the hospital discharges or transfers a patient
is informed and educated the patient follow-up care
 EP1 When the patient needs to be discharged or
transferred this information is shared with the
patient along with the patient’s needs
 EP2 Hospital informs the patient the kinds of care
that will be needed after discharge
 Some patients will need to be in a LTC or might need
home health services or assisted living
138
Education Before Discharge PC.04.01.05
 EP3 Hospital needs to give the patient information
about why they are being discharged or transferred
 EP5 Patient must also be provided about any
alternatives to the transfer
 EP7 The hospital needs to educate the patient
about continuing care the patient will need and how
to obtain this care
 EP8 Patient must be given understandable
discharge instructions
 Remember issue of low health literacy and studies show
patients may not understand discharge instructions
139
Communication Discharge to Service Providers
 PC.04.02.01 state that when a patient is discharged
or transferred
 The hospital gives information about the care
provided to the patient
 And to other service providers who will provide the
patient with care
 Continuity of care is important so that the next treating
practitioner has the information need to take care of the
patient
 Communication is important for patient safety reasons and
to prevent readmissions
140
Communicate Information to Next Provider
 PC.04.02.01 states that the hospital must inform
other service providers who will provide care to the
patient
 When they are discharged or transferred about the
following (EP1);
 Reason for discharge or transfer
 Patient’s physical and psychosocial status
 A summary of care provided
 Patient’s progress toward goals
 List of community resources given to the patient
141
Utilization Review Plans
 2 new EPs effective January 1, 2011
 LD.04.01.01 EP 17 and 18 (deemed status)
 LD.04.01.01 EP 17: The hospital (and CAH distinct
units) has a utilization review plan that provides for
review of services furnished by the hospital and the
medical staff to patients entitled to benefits under
the Medicare and Medicaid programs. LD.04.01.01
EP 18: Utilization review activities are implemented
by the hospital/critical access hospital in
accordance with the plan
CMS Hospital Conditions of Participation
 CMS has a hospital CoP manual which any hospital
that received Medicare or Medicaid must follow for
all patients in their facility
 It includes the federal register provisions and CMS
adds interpretive guidelines and some have survey
procedures
 370 pages long and tag number 0001 to 1163
 Has a section on discharge planning starts at tag
800
 Manual is located at
www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
143
144
145
Discharge Planning A-800
 Must have a discharge planning process that
applies to all patients (inpatients and outpatients)
 P&P must be in writing
 Written discharge planning process must reveal a
clear process to be followed
 Necessary to prevent readmission
 Surveyor will review patient care plans for discharge
planning interventions
146
Identification of Patients 806
 Must identify at early stage of hospitalization, all
patients who are likely to suffer adverse
consequences if no discharge planning
 No national tool to do this
 May include factors as functional status,
cognitive ability and family support
 Patients at high risk should be identified from
screening process
147
Discharge Planning Evaluation
 Hospital must provide a discharge planning evaluation to
patients or upon the request of the physician
 Needs assessment can be formal or informal
 Assess factors on what the patient will need when
discharged; bio-psychosocial needs and patient and
caregiver’s understanding of discharge needs
 Can be a tool or protocol
 Surveyor will ask how patients are made aware of their right
to request a discharge plan
 Are they given the pamphlet “important message from
Medicare”
148
Discharge Planning Responsibility
 RN, SW, or qualified person must develop and
supervise the development of the evaluation (807)
 Person who does discharge planning evaluation
needs to have experience and knowledge of social
and physical factors that affect functional status to
meet patient needs (emphysema -coordinate
respiratory therapy, nursing care, financials for
home health)
 Ideally, discharge planning is interdisciplinary
process
149
Evaluation 809
 Discharge planning evaluation must include
likelihood of needing post-hospital services
and availability of services
 Keep complete file on community based
services such as LTC, sub acute care, and
home care
 Is physical, speech, OT or RT needed
 Use QAPI program to determine if discharge
planning process is effective
150
Self Care Evaluation
 Discharge planning evaluation must include if
patient can do self care and return to pre-hospital
environment
 Willingness of patient and family to do
 Inform patient of freedom to choose providers or
post hospital care (823)
 Give list of Medicare certified HHA that serve your area
(SSA 1861) including ownership information
 Must assess if need hospice and give list of Medicare
certified hospices and LTC (809)
 Counsel patient and family for post hospital care (822)
151
Discharge Plan
 If in MCO hospital must indicated which ones have
contract with home health or LTC (825)
 Hospital must now document in the medical record
that the list of home health or LTC facilities was
presented to the patient (827)
 Rewrite your P&P to include this
 Hospital must inform patient of freedom to choose
post hospital provider (828) and respect their
wishes (829)
 HHA must request to be on the list
152
Timely Discharge Evaluation
 Hospital must complete the evaluation timely
 So appropriate arrangements can be made
 Assessment should start soon after admission
 Surveyor will review several patient discharge
plans for appropriate coordination of health and
social resources
 Also need to reassess discharge planning process
on an ongoing basis (843)
153
Transfer or Referral 837
 Must transfer or refer patients to appropriate
facilities, agencies, or outpatient services for follow
up care
 Must send along necessary medical records
 Make sure patients get appropriate post hospital care
 Must document if patient refuses discharge
planning services
 Written authorization before release of information
154
Real World Success Stories
Improved transitions out of the hospital
 Project RED, CMS Discharge List
 BOOST, INTERACT II, InterAct
 IHI’s Transforming Care at the Bedside(TCAB),
Best Practices Intervention Package (BPIP, home
health)
 STARR initiative,
 Hospital to Home “H2H” (ACC/IHI)
 See list at AHA Preventing Readmissions
155
Real World Success Stories
Supplemental transitional care between
hospital and other settings
 Care Transitions Intervention (Coleman)
 Transitional Care Intervention (Naylor)
 Guided Care,
 GRACE model (Geriatric Resources for
Assessment and Care of Elders) neutral
 Evercare Care Model
– See comprehensive list of intervention in the AHA Preventing
Readmissions
156
157
158
159
http://www.bu.edu/fammed/projectred/
160
161
Initiatives
 IHI (Institute for Healthcare Improvement) has
excellent resources, seminars, and project to
prevent unnecessary readmissions
 Has initiative with the American College of
Cardiology to reduce unnecessary readmissions
with heart failure, MI patients, and cardiovascular
patients
 Called H2H or hospital to home, reducing
readmissions and improving transitions
 STARR is state act on avoidable rehospitalization
initiatives
162
Series on Preventing HF Readmissions
163
http://www.h2hquality.org/
164
165
STAAR
 State Action on Avoidable Rehospitalizations
developed a new worksheet to help hospitals
perform a review of five rehospitalizations
 To determine what could have been done to
prevent any readmissions
 Working across organizational boundaries and
engaging payers, patients, families, and care givers
in Michigan, Ohio, Massachusetts, Washington, and
Massachusetts
 IHI initiative at
http://www.ihi.org/IHI/Programs/StrategicInitiatives/STateActiononAvoidableRehospitalizatio
nsSTAAR.htm
166
167
168
169
http://www.commonwealthfund.org/Content/Blog/2010/Sep/A-Callfor-Standardized-Rehospitalization-Measures.aspx
170
http://www.commonwealthfund.org/Content/Innovations/Case-Studies/2008/Mar/CaseStudy--Reducing-Hospital-Readmissions-Among-Heart-Failure-Patients-at-CatholicHealthcare-Partn.aspx
171
Reducing Readmissions Among HF Patients
 HF advocates were hired to educate patients about
their disease, coordinate their care and follow up
with them after discharge
 There are more than 5 million Americans with HF
 HF can be managed with appropriate medications
and lifestyle changes
 HF is most common reason why patients are
readmitted to the hospital
 Between 29 to 47% of HF patients are readmitted
within 3-6 months after initial hospitalization
172
Reducing Readmissions Among HF Patients
 Catholic Health Partners, based out of Cincinnati
Ohio, created a program called HF Guidelines Applied
in Practice (HF GAP)
 Created a heart failure training program
 Creators of National HF Training Program at OSU
offered advice on the design of the program
 Looked at readmission rates, % of patients given ACE
inhibitor or ARB (angiotension receptor blocker) for
left ventricular systolic dysfunction (LVSF), % of
patient given evaluation for this, discharge
instructions and smoking cessation advice
173
Reducing Readmissions Among HF Patients
 HF readmission rate was 22% and set goal of 15%
 Reduced mortality 40% and readmission rate to 5.5%
 Hired RN to be heart failure advocate
 Program to reduce the gap between guidelines and
actual practice (ACC, AHA (American Heart
Association), and Heart Failure Society of America
 Training focused on causes of HR, evidenced based
approach to medication adherence, patient centered
care coordination, and effecting change
 Importance of low salt diet, monitoring weight,
medication reconciliation and S/S of decompensation
174
http://www.nheft.org/
175
IHI Transforming Care at the Bedside
 IHI also has a how to guide to create an ideal
transition home for patients with heart failure
 Builds on relevant research and published literature
 Step by step sequence of activities to assisted staff
in adopting changes
 Highlights 4 key components of program
 enhanced assessment, teaching, communication, and post acute
follow up
 Has tools, resources, tips and examples
 available at
http://www.ihi.org/IHI/Topics/MedicalSurgicalCare/MedicalSurgicalCareGeneral/Tools/TCABHowTo
GuideTransitionHomeforHF.htm
176
177
178
Initiatives
 Dr. Brian Jacks Project RED (Re-engineered
Discharges) at Boston Medical Center ensures that
patients see a PCP shortly after they leave the
hospital
 Dr. Eric Coleman at the University of Colorado
developed the Care Transition Project and coaches
teach patient self management skills and help them
their first month out of the hospital
 Mary D. Naylor, at the University of Pa School of
Nursing organized a program to get nurses to work
with chronically ill patients to coordinate care and
develop plan for care after they go home
179
Care Transition
 Strong evidence for several types of intervention for
lower re-hospitalization rates
 Care Transition Intervention (Coleman Model)
 Transitional Care Model (Naylor Model)
 Geriatric Resources for Assessment and Care of
Elders(GRACE) Model, a physician based care
management program in which preventive services
increased and hospital admissions decreased
 Guided Care, nurse-physician care management program
showed fewer hospital days
180
http://www.caretransitions.org/
181
Care Transition Intervention CTI Coleman
 Program for patients 65 or older
 Had one of 11 diagnosis
 Four week hospital to home transition model
 Transitions coach to make sure needs are met
 One hospital visit, one home visit, and three week
follow up calls by the transitions coach
 Coach had to have training course
 Coach does not have to be healthcare practitioner
 Focus on medication management
182
Care Transition Intervention CTI Coleman
 Focus on awareness of symptoms or warning signs
that trigger the need for care
 Assisted in setting up follow up appointments
 Helped the patient develop a personal health record
 Study showed program cost for 379 patients was
$196 each
 Another study estimated a cost savings above the
cost of intervention at $844 per patient
183
Free full article at
http://archinte.amaassn.org/cgi/content/full/166/17/1822
184
Transitional Care Model TCM Naylor
 Older adults at high risk for poor outcomes
 Used nurse practitioner
 Focus on comprehensive discharge planning
 Comprehensive assessment done in the hospital in
collaboration with team members
 Developed evidenced based plan of care
 Did home visits
 Telephone support available 7 days a week for 2
months after discharge
185
www.transitionalcare.info/
186
Transitional Care Model TCM Naylor
 Active engage both patient and family
 Uses physician-nurse collaboration
 Tested and refined for more than 20 years by
researchers at the University of Pennsylvania
 Used for chronically ill, high risk older adults
 Emphasizes coordination, continuity of care,
prevention and avoidance of complications
 Patient gets individualized care guided by
evidenced based protocols
187
Hospital to Home or H2H
 Reducing Readmissions and Improving transitions
program and is a national QI initiative
 To assist to reduce the 30 day readmission rate for
heart failure and acute myocardial infarction (MI or
heart attack)
 Led by the American College of Cardiology (ACC)
and Institute for Healthcare Improvement (IHI)
 Use a three question framework, tools and strategies,
satisfaction surveys, and other resources
 Has webinars and suggested literature on preventing
unnecessary readmissions
188
Hospital to Home H2H
Http://h2hquality.org
189
Boost Recommendations
 University of Michigan is involved in a project called
BOOST (Better Outcomes for Older adults through
Safe Transitions)
 Reduced readmission 11-13% with goal to reduce by
20% by December 2012
 A collaboration project to improve the discharge
process and to prevent unnecessary readmissions
 Communication is important and transition requires
input from all disciplines including hospitalist, floor
nurses, discharge planners, social workers, PCP
etc
190
Boost Recommendations
 Suggest to use a risk assessment tool to identify
patients at risk (has 2 page checklist)
 To improve the flow of information from hospital to
outpatient physicians
 To help improve patient and family preparation fro
discharge
 Reduce 30 day readmission rates for general medicine
patients
 To improve patient experience or patient satisfaction
scores
 H-CAHPS scores related to discharge
191
Society of Hospital Medicine
192
193
Four Key Elements of Project Boost
194
BOOSTing Care Transitions
 Has BOOST toolkit with project management tools
and resources
 One year mentoring program
 Currently 47 mentor sites in 24 states and 1 in
Canada
 Teach back training, video and curriculum
 Data collection and analysis tools and can share
results with others
 http://www.hospitalmedicine.org/
195
BOOST Checklist Covers 7 Main Areas (7P)
 The two-page checklist covers these seven main
risk assessment areas:
 problem medications;
 punk (depression)
 principal diagnosis
 polypharmacy
 poor health literacy
 patient support
 prior hospitalization
196
BOOST Problem Medication Section
 Medication-specific education using teach-back
provided to patient and caregiver
 Monitoring plan developed and communicated to
patient and aftercare providers where relevant (e.g.
Warfarin, digoxin, and insulin)
 Specific strategies for managing adverse drug events
reviewed with patient/caregiver
 Follow-up phone call at 72 hours to assess adherence
and complications
 Remember 2/3 of readmission surround medication
related issues
197
Guided Care
 Nurse/physician coordination model
 Conducted for a long time
 Guided Care Nurse conducts a comprehensive
home assessment
 Creates a evidence based care guide for the patient
 Creates patient friendly action plan for the patient
 Smooth transition in and out of other institutions
 Coordinates care
 Provides family and caregiver education
198
http://www.guidedcare.org/
199
Guided Care
Facilitates access to community based
services
Program for patient 65 or older who are likely
to need many health services in the next year
Annual intervention cost is $1743 per patient
and the cost of this intervention was $1,364
Had better patient and physician satisfaction
Johns Hopkins University Model
200
Guided Care
 Boyd CM, Reider L, Frey K, et al. The effects of
guided care on the perceived quality of health care
for multi-morbid older persons: 18-month outcomes
from a cluster and randomized controlled trial. J
Gen Intern Med. Mar;25(3):235-242
 Wolff JL, Giovannetti ER, Boyd CM, et al. Effects of
Guided Care on Family Caregivers. Gerontologist.
Aug 26 2009
 Marsteller J. Guided Care: Better Care for Older
People with Chronic Conditions. 2010.
http://www.guidedcare.org/pdf/Guided%20Care%20summar
y%20and%20results.pdf.
201
GRACE
 Geriatric Resources for Assessment and Care of
Elders
 Long term amount of time
 Requires NP and social worker
 Test for low income patient 65 or older in primary care
 Included a group at high risk for hospitalization
 Total intervention cost for high risk patients is $1,432
per patient and intervention cost neutral
 Counsell SR, Callahan CM, Clark DO, et al. Geriatric care management for low-income
seniors: a randomized controlled trial. JAMA. Dec 12, 2007;298(22):2623-2633
202
http://clinicaltrials.gov/show/NCT00182962
203
http://medicine.iupui.edu/IUCAR/research/grace.asp
204
Project RED
 Project RED is probably one of the best known
projects to re-engineer the hospital discharge
process
 A nurse discharge advocate followed 11 steps to
improve the discharge process and prevent
unnecessary readmissions
 Developed for AHRQ by Boston University
researcher Dr Brian Jack
 AHRQ has a free toolkit which includes after
hospital care plan forms, training manual and other
resources
205
Project RED
 Has been shown to reduce unnecessary
readmissions by 30%
 Has tools to help create an after hospital care plan for
each patient to prevent readmissions
 Detailed checklist for staff to follow during discharge
process
 Created the discharge advocate to create the care
plan
 Study was for 750 patients and half were taught by a
nurse and received a phone call from the pharmacist
after discharge
206
Project RED
 Some of the 11 steps included;
 Making the follow up appointments and giving them written
information on this
 Discussing test results and follow up results
 Confirming medications with reasons and their medication
plan
 Organizing post discharge services
 Getting discharge summary to the PCP timely
 Reviewing what to do if a problem arises
 Explain in their own words to make sure they understand
 Follow up call within 2 to 3 days to reinforce the plan
207
Project RED
 Patients also got a follow up call within 2 to 3 days
to reinforce the plan
 Patients got their own notebook with their
specialized care plan
 Staff got a training manual and workbook
 Louise is a computer animated character that
teaches hospital care plan information to patients
 Patients actually preferred Louise to a live human
for discharge education
 http://www.ahrq.gov/qual/pips/grants.htm#jack
208
http://www.ahrq.gov/news/kt/red/
209
http://www.bu.edu/fammed/projectred/
210
211
Taking Care of Myself Guide for Patients
 Taking Care of Myself: A Guide for When I Leave
the Hospital is a guide for patients to help them care
for themselves when they leave the hospital
 Easy-to-read guide can be used by both hospital
staff and patients during the discharge process
 Provides a way for patients to track their medication
schedules, upcoming medical appointments, and
important phone numbers
 Available at
http://www.ahrq.gov/qual/goinghomeguide.htm
212
213
Taking Care of Myself: Guide for …
214
Medication List
215
Appointments for Follow Up
216
Reducing Hospital Readmissions
 Academy of Health has a 12 page booklet out
entitled Reducing Hospital Readmissions
 Academy Health held a one day meeting to discuss
trends and identify best practices to prevent
unnecessary readmissions
 Supported by the Commonwealth Fund
 Representatives included CMS, AHRQ, NQF,
NCQA, IHI, TJC and others
 This report summarizes the information presented
217
Reducing Hospital Readmissions
 18% of Medicare patients discharged readmitted
within 30 days (1 in 5)
 29 to 47% of elderly HF patients are readmitted within 3-6
months after discharge
 66% are admitted within one year of discharge
 At a cost of $15 billion dollars
 Can occur from poor quality of care, discharging too
soon, discharge to inappropriate setting, or poor
communication
 Some readmissions are unavoidable (as many as
76% are thought to be preventable)
218
219
Reducing Hospital Readmissions
 65% of Medicare patients have two or more chronic
conditions which is challenging
 May have as many as 16 different physicians per
year which makes care coordination difficult
 Hospitalist may be unfamiliar with patient’s history
 PCP may be unfamiliar with care provided in
hospital
 Lack of communication is part of the problem
 Has recommendations which have been included
previously in strategies section
220
www.academyhealth.org/files/publications/R
educing_Hospital_Readmissions.pdf
221
Discharge Planning Screen
 Called the Blaylock Risk Assessment Index (Brass
or modified BRASS index)
 Tool to identify early in the hospital stay those who
will need specialized hospital discharge planning
services
 Tool can provide early identification to improve
timely delivery of appropriate hospital services
 www.nursing-researcheditor.com/authors/OMR/7/OMRManuscript.pdf
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1853085/?to
ol=pubmed
222
223
224
225
Sign Up for AHRQ PSNet
http://www.psnet.ahrq.gov/search.
aspx?searchStr=readmission
226
Rehospitalization and For Profit Hospitals
 Study published in the December 7, 2010 Annals of
Internal Medicine of 74,564 discharges (5% of Medicare
patients)
 Medicare patients are more likely to be rehospitalized at
a different hospital if they are initially treated at a forprofit hospital
 Looked at patients readmitted within 30 days of
discharge from January 2005 to November 2006
 Rehospitalization at a different hospital also occurred if
the discharging hospital was affiliated with a major
medical school or had a low volume of patients or the
patient had a Medicare defined disability
227
http://www.annals.org/content/153
/11/718.short?rss=1
228
Resources
 Jencks SF, Williams MV, Coleman EA.
Rehospitalizations among patients in the Medicare
fee-for-service program. N Engl J Med. Apr 2,
2009;360(14):1418-1428
 Coleman EA, Parry C, Chalmers S, Min SJ. The
care transitions intervention: results of a
randomized controlled trial. Arch Intern Med. Sep
25 2006;166(17):1822-1828.
 Reducing Hospital Readmissions with Enhanced
Patient Education, Krames, free publication but
must register at
http://www.fiercehealthcare.com/offer/reducing_readmission?source=femrspon
229
230
Resources
 Naylor MD, Brooten DA, Campbell RL, Maislin G,
McCauley KM, Schwartz JS. Transitional care of
older adults hospitalized with heart failure: a
randomized, controlled trial. J Am Geriatr Soc. May
2004;52(5):675-684
 Leff B, Reider L, Frick KD, et al. Guided care and
the cost of complex healthcare: a preliminary report.
Am J Manag Care. Aug 2009;15(8):555559Coleman EA. Encouraging Patients and Family
Caregivers to Assert a More Active Role
231
Resources
 A Reengineered Hospital Discharge Program to
Decrease Rehospitalization: A Randomized Trial
Jack et al. ANN INTERN MED 2009;150:178-187.
 Hospitalists And Care Transitions: The Divorce Of
Inpatient And Outpatient Care
Pham et al.
Health Aff (Millwood) 2008;27:1315-1327.
 MedQIC has care transition project with 9th scope of
work and resources at www.qualitynet.org and listen to
recorded session and go to Care Transitions QIOSC at
http://www.cfmc.org/caretransitions/
232
233
234
Resources
 During Care Hand-Offs: The Care Transitions
Intervention
http://www.caretransitions.org/documents/CTI_Sum
mary.pdf
 Marsteller J. Guided Care: Better Care for Older
People with Chronic Conditions. 2010
http://www.guidedcare.org/pdf/Guided%20Care%20
summary%20and%20results.pdf
 ADRC-TAE. Evidence-Based Care Transitions
Models 2010
235
Resources
 Wolff JL, Giovannetti ER, Boyd CM, et al. Effects of
Guided Care on Family Caregivers. Gerontologist.
Aug 26 2009
 US Department of Health & Human Services.
Implementing the Affordable Care Act: Making it
Easier for Individuals to Navigate Their Health and
Long-Term Care through Person-Centered Systems
of Information, Counseling and Access. Program
Announcement and Grant Application Instructions:
Administration on Aging and Centers for Medicare &
Medicaid Services; 2010.
236
Resources
 The incidence and severity of adverse events affecting
patients after discharge from the hospital. Forster AJ,
Murff HJ, Peterson JF, Gandhi TK, Bates DW. Ann
Intern Med. 2003;138:161-167
 Adverse drug events occurring following hospital
discharge. Forster AJ, Murff HJ, Peterson JF, Gandhi
TK, Bates DW, J Gen Intern Med. 2005 Apr;20(4):31723.
 Transition of care for hospitalized elderly patients—
development of a discharge checklist for hospitalists.
Halasyamani L, Kripalani S, Coleman E, et al. J Hosp
Med. 2006;1:354-360
237
Resources
 Greenwald JL, Denham CR, Jack BW. The hospital
discharge: a review of high risk care transition with
highlights of a reengineered discharge process. J
Patient Saf 2007 Jun;3(2):97-106.
 Forster AJ, Murff HJ, Peterson JF, et al. The incidence
and severity of adverse events affecting patients after
discharge from the hospital. Ann Intern Med 2003 Feb
4;138(3):161-76.
 Strunin L, Stone M, Jack B. Understanding
rehospitalization risk: can hospital discharge be
modified to reduce recurrent hospitalization? J Hosp
Med 2007 Sep;2(5):297-304.
238
Resources
 Anthony D, Chetty VK, Kartha A, et al. Reengineering the hospital discharge: an example of
a multifaceted process. In: Advances in patient
safety: from research to implementation [online].
AHRQ 050021 (2). Agency for Healthcare
Research and Quality. Available from Internet:
http://www.ahrq.gov/downloads/pub/advances/vol
2/Anthony.pdf
 Commonly referred to as the RED Project
239
Patient Resources
 For extensive list of patient resources go to
www.cfmc.org/caretransitions/patient_resources.ht
m
 National Transition of Care Coalition
 How to Avoid the Round Trip Visit to the Hospital
 Ask Medicare
 Next Step in Care
 Taking Charge of Your Healthcare: Your Path to Being an
Empowered Patient
 Be Prepared for Medical Appointments, Navigating the
Healthcare System, Taking Care of Myself etc.
240
Resources
 Coleman EA, Parry C, Chalmers S, et al. The care
transitions intervention: results of a randomized
controlled trial. Arch Intern Med 2006 Sep
25;166(17):1822-8.
 Halasyamani L, Kripalani S, Coleman E, et al.
Transition of care for hospitalized elderly patients—
development of a discharge checklist for
hospitalists. J Hosp Med 2006 Nov;1(6):354-60.
 Influence of language barriers on outcomes of
hospital care for general medicine inpatients.
Karliner LS, Kim SE, Meltzer DO, Auerbach AD. J
Hosp Med. 2010;5:276-282
241
Resources
 Do patient safety events increase readmissions?
Friedman B, Encinosa W, Jiang HJ, Mutter R. Med
Care. 2009;47:583-590
 Impact of a pharmacist-facilitated hospital discharge
program: a quasi-experimental study.
Walker PC, Bernstein SJ, Tucker Jones JN, et al.
Arch Intern Med. 2009;169:2003-2010
 Effect of hospital follow-up appointment on clinical
event outcomes and mortality.
Grafft CA, McDonald FS, Ruud KL, Liesinger JT,
Johnson MG, Naessens JM. Arch Intern Med.
2010;170:955-960
242
Resources Recommended by H2H
 REPORT: Structured Telephone Support or
Telemonitoring Programmes for Patients with
Chronic Heart Failure
 AUTHORS' CONCLUSIONS: Structured
telephone support and telemonitoring are
effective in reducing the risk of all-cause mortality
and CHF-related hospitalizations in patients with
CHF; they improve quality of life, reduce costs,
and evidence-based prescribing.
 http://www.ncbi.nlm.nih.gov/pubmed?term=%22Cochrane+database+of+systematic+re
views+%28Online%29%22%5BJour%5D+AND+2010%5Bpdat%5D+AND+Inglis%5Bfir
st+author%5D&cmd=detailssearch
243
Resources Recommended by H2H
 GUIDE: Taking Care of Myself: A Guide for
When I Leave the Hospital
 This easy-to-read guide can be used by both hospital staff
and patients during the discharge process, and provides a
way for patients to track their medication schedules,
upcoming medical appointments and important phone
numbers.
 http://www.ahrq.gov/qual/goinghomeguide.htm)
 ARTICLE: The Bounceback Problem: Why
Patients Can’t Stay Out of Hospitals
 http://www.slate.com/id/2262319/pagenum/all/#p2
244
Resources
 Forester A, et al. The Incidence and Severity of
Adverse Events Affecting Patients After Discharge
from the Hospital. Ann Intern Med. 2003; 138: 161167.
 Makaryus AN and Friedman EA. Patients
understanding of their treatment plans and di-agnosis
at discharge Mayo Clin Proc. Aug 2005;80(8):991994.
 Coleman, Eric et al. Preparing Patients and
Caregivers to Participate in Care Delivered Across
Settings: the care Transitions Intervention, J Am
Geriatr Soc Nov. 2004; 52:1817-1825.
245
Resources
 Kripalani S, et al. Deficits in Communication and
Information Transfer Between Hospital-Based and
Primary Care Physicians, JAMA Feb 2007;
297(8):831-841
 Kripilani S et al. Promoting effective transitions of
care at hospital discharge: A review of key issues
for hospitalists. Journal of Hospital Medicine
2007;2:314-323.
 Moore C et al. Tying up loose ends: discharging
patients with unresolved medical is-sues. Arch
Intern Med 2007; 167:1305-1311
246
Transitional Care Model (TCM) Naylor
 Naylor M, Brooten D, Jones R, Lavizzo-Mourey R,
Mezey M, Pauley M. Comprehensive discharge
planning for the hospitalized elderly. Ann Intern Med.
1994;120:999-1006.
 Naylor MD, Brooten D, Campbell R, Jacobsen BS,
Mezey MD, Pauley MV, Schwartz JS. Comprehensive
discharge planning and home follow-up of hospitalized
elders: a randomized clinical trial. JAMA. 1999;281:613620.
 Naylor MD, Brooten DA, Campell RL, Maislin G,
McCauley KM, Schwartz JS. Transitional care of older
adults hospitalized with heart failure: a randomized,
controlled trial. J Am Geriatr Soc. 2004;52:675-684
247
Resources
 Patient Satisfaction and the Discharge Process
Evidence-Based Best Practice, by Paul Clark, Press
Ganey , HCPro , Marblehead Ma,2006
 CMS Checklist at www.medicare.gov
 Best Practices Intervention Package (BPIP) at
http://dnssearch.rr.com/?q=www.homehealthquaqlit
y.org&con=nxd
 Interact at interact.geriu.org and this is
communication tools, clinical paths, and advanced
care planning
248
LTC Resources on Transitions in Care
 The American Medical Directors Association has a
number of excellent resources for LTC facilities on
transitions in care
 www.amda.com
 Includes Transitions of Care in the Long Term Care
Continuum Practice Guidelines
 http://www.amda.com/tools/clinical/TOCCPG/index.html
 Articles are available
 Can listen to presentation including work done with
the QIO
249
www.amda.com/tools/clinical/TOCCPG/index.html
250