Transcript Hospital Readmissions - Quality and $ Target

Project BOOST
Reducing Readmissions
Mark V. Williams, MD, FACP, FHM
Professor & Chief, Division of Hospital Medicine
Northwestern U. Feinberg School of Medicine
Principal Investigator, Project BOOST
A Problem for a long time
Rosenthal, J. M. and D. B. Miller
"Providers have failed to work for
continuity." Hospitals 53(10): 79-83.
1979
Continuity of patient care between different
health care settings has been advocated for
nearly 20 years, but little has been done to
effect it. The study described here emphasizes
the current lack of effort by health care
providers in hospitals and nursing homes to
find a workable solution.
June 2007 MedPAC Report
 Medicare pays for ALL admissions regardless

Initial stay or readmission for same condition
 17.6% of admissions result in
re-admissions within 30 days (6% in 7 days)

= $15 billion in spending
 Future

“CMS proposes to require that all general acute
hospitals conduct a CARE assessment on every
Medicare beneficiary being discharged.”



Continuity Assessment Record and Evaluation
Public Disclosure of readmission rates
Lower case payments for readmissions
• 1 in 5 Medicare patients rehospitalized in 30 days
• Half never saw outpatient doc
• 70% of surgical readmissions–chronic medical
conditions
• Costs $17.4 billion
Rates of Rehospitalization within 30 Days after Hospital Discharge
Jencks S, Williams MV, Coleman EA. et al. N Engl J Med 2009;360:14181428
Health Affairs 2010; 29:57-64
Average LOS: US Hospitals
> 65 = 12.6 to 5.5 days
DeFrances et al, Adv data, 2007 Jul 12;(385):1-19
Harlan M. Krumholz, MD, SM research group
 Observational study of 6,955,461 Medicare FFS
hospitalizations for HF; 1993 and 2006, with 30-day f/u.






Mean age = 80
52% Htn, 38% DM, 37% COPD
LOS 8.8 days down to 6.3
In-hospital mortality declined from 8.5% to 4.3%
30-day mortality declined from 12.8% to 10.7%
Discharges to SNF increased from 13% to 20%

Discharge to home decreased from 74% to 67%
 30 day readmission increased from 17.2% to 20.1%

Post-discharge mortality increased from 4.3% to 6.4%
Preventable Admissions
 Hospital inpatient care is the most expensive
type of health care
 > 4 million Preventable Admissions
 Cost nearly $31 Billion
 Heart Failure and Pneumonia

Half of the $ problem
 COPD – 16%
 Diabetes – 13%
 Elderly – 2/3 of these hospitalizations
- 1 in 5 Medicare admissions
Care Coordination Failure?
 5 commercial disease management companies,
3 community hospitals, 3 AMCs, 1 integrated
delivery system, 1 hospice, 1 long term care
facility, 1 retirement community across U.S.
 No cost savings
 2 reduced hospitalizations
 Sickest patients benefited
HospitalCompare.gov
Readmission Reduction
CBO - $7.1B savings over 10 yrs
Hospital Quality & Performance Based
Payments
All DRG payment amounts in hospitals with
excess readmission are reduced by a
factor determined by the level of “excess,
preventable readmissions”
Effective 2013
 Excess = ratio of actual to expected (risk-adj)
 Reduction of 1%, 2%, and 3% first 3 years

Readmission Reduction
Program
 NQF endorsed measures


Initially AMI, HF, pneumonia
Expand in 2015 to 4 more conditions


Measures must have exclusions for readmissions
unrelated to prior discharge


COPD, CABG, PTCA, Other Vascular
e.g. transfers, planned readmissions
Readmission time window specified by Secretary

30 days in NQF measures
 Report all-payer readmission rates publicly
Measures – AMA PCPI
Care Transitions
Work Group
 Performance Measure Set

Reconciled medication list
Transition record
Timely transmission
 Discharge Planning/Post-Discharge Support
for Heart Failure Patients
Hospital Discharge
- currently
“Random events connected to highly
variable actions with only a remote
possibility of meeting implied
expectations.”
Roger Resar, MD
Agent of Tremendous Change and Global Innovation Seeker
Luther Midelfort – Mayo Health System
Senior Fellow, IHI
Dangers of Discharge
•19% of patients had a post discharge AE
Ann Intern Med 2003;
- 1/3 preventable and 1/3 ameliorable
•23% of patients had a post discharge AE
- 28% preventable and 22% ameliorable
Vol. 138
CMAJ 2004;170(3)
Dangers of Discharge
Ann Intern Med
2005;143(2):121-8

1095 of 2644 (41%) inpatients discharged with test
result pending



- 191 (9.4%) potentially required action
- Survey of MDs involved: almost 2/3 unaware of results
- Of these: 37% actionable and 13% urgent
Dangers of Discharge
Arch Intern Med. 2007;167:1305-1311
 ¼ of discharged patients require additional
outpatient work-ups
 > 1/3 not completed
 Increased time to post-discharge f/u
associated with lack of work-up completion
 Availability of discharge summary increased
likelihood of work-up being done
Hospitalist to PCP
Info transfer and communication deficits at
hospital discharge are common
Direct communication 3-20%
 Discharge summary availability at 1st postdischarge appt 12-34%; 51-77% at 4 weeks
 Discharge summaries often lack info

Dx test results (33-63%), hospital course (7-22%),
discharge meds (2-40%), pending test results (65%)
 Follow-up plans (2-43%), Counseling (90-92%)

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW
JAMA 2007;297:831-41.
Discharge Summary
J Gen Intern Med 2009;24:1002-6
“Discharge summaries are grossly inadequate at
documenting both tests with pending results and
appropriate f/u providers.”
Northwestern Solution
Journal of Hospital Medicine 2009;4:219
 Significantly improved the quality and timeliness.
 Better documentation of f/u issues, pending tests, and
info provided to patients and/or family.
 PCPs more satisfied with timeliness and quality
 >95% of discharge summaries completed in < 1 week
Discharge Planning
- is it THE answer?
 21 RCTs: 4509 medical, 2285 med-surg; 440 Ψ






LOS: mean decrease -0.91 (95% CI: -1.55 to -0.27)
Readmission rates: RR 0.85 (0.74 to 0.97)
Elderly medical pts: mortality RR 1.04 (0.74 to 1.46)
Discharged to home: RR 1.03 (0.93 to 1.14)
Improved patient satisfaction
Subset analysis: improved functional status
Cochrane Database of Systematic Reviews 2010;1
 Randomized 363 patients age > 65
 “Comprehensive discharge planning” and home
follow-up with APNs
 ~70% completion rate
 Readmissions at 24 weeks 20% vs 37%



Reduced multiple readmissions 6.2% vs 14.5%
Prolonged time to first readmission
Medicare reimbursements cut in half
Arch Intern Med 2006;166:1822-1828
 Elderly patients transitioning to SNF/home
 Randomized: Intervention group paired with
“Transition Coach” vs. standard care
 Empowerment and education: 4 pillars




Facilitate self management/adherence
Maintain a personal health record
Timely follow-up
Knowledge and management of complications
 Education during hospitalization

including meds and med reconciliation
 Phone calls and personal visits by TC post discharge
 Reduced rehospitalization and costs
Arch Intern Med 2006;166:1822-1828
Results
Rehospitalization
Within 30d
Within 90d*
Within 180d*
Interv
8.3
16.7
25.6
Cont
11.9
22.5
30.7
P(adj) OR (95%CI)
0.048 0.59 (0.35-1.00)
0.04
0.64 (0.42-0.99)
0.28
0.80 (0.54-1.19)
*Also significantly improved for
“Rehospitalization for same diagnosis as index admission.”
Costs($)
At 30d
At 90d
At 180d
Interv
784
1519
2058
Cont
918
2016
2546
Unadj Log Transformed
0.048 0.06
0.02
0.02
0.04
0.049
Or should it be a Pharmacist?
Am J Med 2001;111(9B):26S-30S
 N=221 randomized at UCSF
 All receive pharmacist facilitated discharge
 110 got 2 day phone call by pharmacist:



Check on clinical status
Remind about follow-up
Check on medications (did they obtain them; any
problems taking them; any side effects; did they know
which to take and how; etc…)
Results
 Contacted 79 or 110








25% had questions about their meds
11% had questions about their care
11% had questions about follow-up
19% had been unable to get their meds
15% reported new problems
Greater satisfaction in intervention group:
86% vs. 61% very satisfied (p=0.007)
10% vs. 24% patients came to ED at UCSF at 30d
(p=0.005)
15% vs. 25% rehospitalized at 30d (p=0.07)
Pharmacy Literature
 Schnipper et al:


N = 178 medical patients randomized
Intervention:





Med reconciliation done at d/c by Pharmacist
Pharmacist counseling at d/c and 3day follow-up call
At d/c, pharmacist recommended med changes in 60%
At 3d call, unexplainable discrepancies between d/c meds
and reported home meds in 29%
At 30d




Fewer preventable ADEs: 1% vs. 11% (p=0.01)
Fewer preventable med related ED visits: 1% vs. 8% (p=0.03)
49% had med discrepancies!
No difference in total ADEs, health care utilization, patient
satisfaction, or med adherence
Arch Intern Med 2006;166:565-71
Pharmacists Work!
Arch Intern Med. 2009;169(9):894-900
Swedish ward-based pharmacists
 16% reduction in hospital visits
 47% reduction in ER visits
 Drug-related readmissions reduced 80%
 Intervention group cost < control
Project RED
RCT of 749 hospitalized adults
Intervention

Nurse Discharge Advocate
F/U appt, Medication Reconciliation
 Patient education

Individualized instruction booklet
 Pharmacist call 2-4 days post-discharge


Review medications
Limitations

Urban, academic, safety net hospital
Project RED Outcomes
Intervention
Control
(n = 370)
(n = 368)
16.5%
24.5%
Rehospitalization**
15%
21%
PCP f/u in 30 days*
62%
44%
Prepared for Discharge*
65%
55%
ER Visits*
*p < 0.05
**p = 0.09
Low-cost Intervention
JGIM 2008
“user-friendly” Patient Discharge Form
Telephone outreach from a nurse postdischarge
Improved outpatient follow-up
Reduced ER visits and rehospitalizations
from historical controls
1.
2.
3.
4.

Med Rec by PharmD
RN Care Coordinator D/C Planning
Phone Follow-up
PHR, Supplemental Discharge Form
Reduced ER visits, Reduced Readmission
SHM Initiatives
Discharge Checklist
Halasyamani L et al. Transition of care for hospitalized elderly patients
--development of a discharge checklist for hospitalists. J of Hosp Med 2006:354.
Resource Room
Safe STEPs
Project BOOST
Better Outcomes for Older adults through
Safe Transitions
 John A. Hartford Foundation $1.4 million

Safe STEPs
Safe and Successful Transitions for
Elderly Patients
John A. Hartford Foundation Grant
Safe STEP Interventions
Medication reconciliation
Pharmacy reviews: admission and d/c
 Geriatric friendly medication forms

Education
Patients: pre-d/c appointment
 Providers: geriatric h&p

PCP communications

“Fast facts”
Safe STEPs
 237 elderly patients at three hospitals

Academic, community
 5 component intervention





Admission form with geriatric cues
Fax to PCP
Interdisciplinary worksheet
Pharmacist-physician medication reconciliation
Pre-discharge planning appointments
 Reduced ED visits and readmissions
by 1/3
Project BOOST Team
• Tina Budnitz, MPH
• Eric Coleman, MD, MPH
• Jeff Greenwald, MD
• Eric Howell, MD
• Lakshmi Halasyamani, MD
• Mark V. Williams, MD
• Janet Nagamine, MD
• Dan Dressler, MD, MS
• Kathleen Kerr
• Greg Maynard, MD
• Arpana Vidyarthi, MD
Advisory Board
Chair: Eric Coleman, MD, MPH
Co-Chair: Mark V. Williams, MD
with organizational representatives from:








Social work
Case management
Clinical pharmacy
Geriatric medicine
Geriatric nursing
Health IT
Blue Cross/Blue Shield
United Health






Health systems
NQF
AHRQ
TJC
CMS
National Consumer’s
League
 Other content experts
www.hospitalmedicine.org/BOOST
What is BOOST Today?
 Intervention

Tailored clinical Tools:








Comprehensive Risk Assessment
Team-based care
Patient centered discharge process
72 Hour follow-up call for “high-risk” patients
Scheduled outpatient follow-up visits
Standardized PCP Communication
Tailored processes, work-flow
Project management tools
BOOST components (cont)
 Technical Support




Mentors calls, email, resources
Teleconferencing across sites
Education (webinars, newsletters)
Enduring Materials (Teachback DVD)
 Peer Support



Listserv
Document sharing
Moral support
 Infrastructure Development



Train the trainer curricula
Mentor Guides
Mentor University
Teach Back
NEW CONCEPT: Health
information, advice,
instructions, or change
in management
Assess patient
comprehension /
Ask patient to
demonstrate
Explain new concept /
Demonstrate new skill
Clarify and tailor
explanation
Patient recalls and
comprehends /
Demonstrates skill mastery
Adherence /
Error reduction
Re-assess recall and
comprehension / Ask
patient to
demonstrate
Modified from Schillinger, D. et al. Arch Intern Med 2003;163:83-90
Life-Cycle Project BOOST
Baseline
Data
Peerlearning
Project
Planning
Mentor
reviewed
action plan
Staff
education
Tailor tools
Develop
policies,
procedures,
order sets
Implement
intervention
Keep
stakeholders
informed
Monitor core
elements
Surveillance
Assemble
Team
Teach-back
Training
Redesign
care
processes
Intervention
Institutional
Support
Intervention
Toolkit
Individualized Mentoring
Implementation
Analyze
processes
2 Day Training
Planning
Training & Preparation
Analyze data
Adjust
intervention
components
Report to
stakeholders
Spread
gains
Evaluation
Plan
Training-6months
6-9 months
9-12 months
BOOST Network
BOOST eNewsletter
Key milestones
 BOOST updates
 Site status reports, aggregate outcomes
 Forum for sharing ideas, challenges, mini
studies

BOOST Network
E-mail, call between sites
 BOOST listserv

End-Result
Network of Institutions using the
guide and interventions
Understanding Impact of
Interventions
Understanding Implementation
facilitating factors and barriers
BOOST Mentor Sites
Projected Growth
Cohort 1: 9/08
Cohort 2: 3/09
MI Collaborative 5/10
Tuition pilot 5/10
6 sites
24 sites
14 sites
2 sites
CA Collaborative
20 sites
Fall 10 Tuition Cohort 15 sites
Online in 2010 =
81 sites
So what happens to readmission rates?
12/08
6/09
Cohort 1
(n=6) kickoff
12/09
Implementation
Survey
Cohort 2
(n=24)
kickoff
12/10
Hierarchical time
series analysis of
readmission rates
(one year prior to
kick-off through one
year post kick-off)
12/10
Prelim Results
Across all sites overall readmission rates
decreased from 13% to 11%.
BOOST Intervention Units
 6 months post “go live”

Readmission rates rose in non-BOOST
units by 2%
Marked increased patient satisfaction
at some sites.
A Hospital Nurse
“Project BOOST brings me back to what I
thought nursing was really about.
BOOST helps patients and families
understand what they need to do to go
home. This is why I went into nursing.”
THANKS!!!
The John A. Hartford Foundation