Transcript Document

THE MIAMI OPPORTUNITY
Care Transitions
2008-2011
Susan Stone, MSN, RN
Project Director – Care Transitions
January 30, 2009
The Medicare Quality Improvement Organization for Florida
Care Transitions Goals
• Improve 30-day rehospitalization rates
• Improve AMI, PNE, and HF readmission rates
• Improve the number of physician follow-up visits
among the patients who have been readmitted to the
hospital
• Improve hospital performance of patient satisfaction
(HCAHPS) for patients receiving information about
discharge and medications
• Test the use of the CARE Tool (improved care
coordination among providers)
The Medicare Quality Improvement Organization for Florida
Care Transitions Project
“Making the health care delivery system work
reliably for very sick Medicare beneficiaries
requires linking all clinical care providers and
ensuring that transitions are thoroughly
reliable. This work can only succeed when all
of the community is engaged and working
together, so the QIOs will serve to catalyze
and coordinate the work across all care
settings in the community.”
Barry M. Straube, M.D.
Director & Chief Clinical Officer
Office of Clinical Standards & Quality for CMS
The Medicare Quality Improvement Organization for Florida
The Problem: Target Community
About 1:5 Medicare patients are
rehospitalized within 30 days of discharge
• 73% of hospital admissions are through the ER
• 43% of the hospital discharges are to home
• 36% of the readmissions from HHAs
• 27% of the readmissions from Outpatient
Facilities
• 18% of the readmissions from SNFs
The Medicare Quality Improvement Organization for Florida
Project Measure: A Miami Community
31 Zip Codes
33146
33144
33197
33143
33126
33131
33145
33135
33256
33134
33186
33130
33133
33176
33165
33129
33193
33157
33156
33158
33125
Southern Miami County Area
33173
33114
33172
2007:
Beneficiaries: 139,831
Admissions: 25,456
Readmissions: 5,371 - 21.1%
State Rate: 17.5%
33149
33196
33177
33155
33183
33174
33122
The Medicare Quality Improvement Organization for Florida
What is Care Transitions?
Patient
ER
ICU
OUTPATIENT:
• Home
• PCP
• Specialty
• Pharmacy
• Other Services
• Care Giver
In-Patient
SNF
HHA
Patient
The Medicare Quality Improvement Organization for Florida
Problems Affecting Care Transitions
Poor
Discharge
Coordination
Patient
ER
ICU
OUTPATIENT:
• Home
• PCP
• Specialty
• Pharmacy
• Other Services
• Care Giver
Poor Discharge
Coordination
NO Medication
Reconciliation
NO Personal Health
Record
In-Patient
SNF
NO
Personal Health
Record
NO
Coordinated
Care Plan
Patient
HHA
Poor Care
Coordination
NO Medication
Reconciliation
NO Personal Health
Record
The Medicare Quality Improvement Organization for Florida
Care Transitions Solution
Medicare
Beneficiary
Hospital Discharge to
Self-Care
Management
Hospital Discharge to
Post-Acute Care Settings
•
•
Provider QI Activities
Cross-Setting Collaboratives
Community Partnerships
• Beneficiary Advocacy Groups
• Beneficiary Service Organizations
Outcomes:
1) Satisfied discharged (hospital) Medicare beneficiaries
2) Reduced # of care transitions associated with rehospitalizations
The Medicare Quality Improvement Organization for Florida
Best Practice Interventions
• Processes
– System wide
– Reason for readmissions
– Diagnoses specific
• Disparities
• Collaboratives
• Reshape public awareness
The Medicare Quality Improvement Organization for Florida
Proven Strategies to Reduce
Rehospitalizations
Care Transitions Interventions (CTI©)
• Medication reconciliation
• Personal health record
• Physician appointment scheduled within 7
days of discharge (visit within 2 weeks)
• Patient emergency plan
• Transition coaching
The Medicare Quality Improvement Organization for Florida
QIO Provided Care Transition Support
Root-Cause
Resolution:
Control Plan
Defining the
Problem
Lessons Learned:
Modifications to
the Action Plan
Discharge Process
Mapping
Hospital-Specific Provider
Community
Cause & Effect
Diagram
(Fishbone):
Action Plan for
Improvement
Root-Cause
Investigation Verifying with
Data
Cost-Benefit
Analysis
Recommended
Solutions
The Medicare Quality Improvement Organization for Florida
Hospital-Specific
Discharge-Process Findings
• Findings specific to the discharge process
–
–
–
–
–
Lack of D/C teaching instructions
Lack of discharge preparation checklist
Inconsistent discharge teaching process
Discharge to inappropriate settings
Failure to use full potential of discharge process software
system
– Inconsistent patient discharge follow-up calls process*
– Inconsistent medication reconciliation process (manual
system)*
– Inconsistent readmission review process*
* Occurring frequently
The Medicare Quality Improvement Organization for Florida
Hospital-Specific
Discharge-Process Findings
• Findings specific to patient education
– Lack of education patient/caregiver to play active
role in their care post-discharge*
– Inconsistent medication reconciliation instructions*
– Lack of caregiver understanding of patient’s
condition (ALF only and home)*
* Occurring frequently
The Medicare Quality Improvement Organization for Florida
Hospital-Specific
Discharge-Process Findings
• Findings specific to staff education
– Lack of coordination of care among providers (inconsistent
communication)*
– Lack of awareness by hospital staff of importance of
reducing rehospitalization rate
– Inconsistent readmission review*
– Discharge plan not communicated timely fashion to
pharmacy to adequate anticipation of medication
reconciliation
– Inconsistent performance improvement communication
* Occurring frequently
The Medicare Quality Improvement Organization for Florida
Analysis – Primary Diagnoses
FL Top 5 Discharge Primary Diagnoses
FL Top 5 Readmission Primary Diagnoses
Rate
R
a
n
k
HF
6.26
1
Symptoms, ill-defined (780-789)
5.46
2
4.43
Diagnosis Group
Other diseases of urinary system
(590-599)
PNE
COPD
Diagnosis Group
Rate
R
a
n
k
HF
Other diseases of respiratory system
(510-519)
7.76%
1
4.04%
2
3
Other psychoses (295-299)
3.74%
3
4.20
4
3.10%
4
3.54
5
CKD
Pneumoconiosis and other lung
diseases due to external agents
(500-508)
1.57%
5
The Medicare Quality Improvement Organization for Florida
Analysis – Primary Diagnoses
Miami Top 5 Discharge Primary Diagnoses
Miami Top 5 Readmission Primary Diagnoses
Rate
R
a
n
k
HF
6.09
1
Symptoms , ill-defined (780-789)
4.82
2
4.66
3
4.11
4
3.90
5
Diagnosis Group
Other diseases of urinary system (590599)
PNE
COPD
Diagnosis Group
Rate
R
a
n
k
HF
Other diseases of respiratory system
(510-519)
25.71%
1
12.00%
2
10.35%
3
8.19%
4
5.33%
5
CKD
Other psychoses (295-299)
Pneumoconiosis and other lung
diseases due to external agents
(500-508)
The Medicare Quality Improvement Organization for Florida
Discharges with
Multiple 30-Day Readmissions
•
•
•
•
•
Discharges with “1” readmissions – 16.55%
Discharges with “2” readmissions – 2.97%
Discharges with “3” readmissions – 0.70%
Discharges with “4” readmissions – 0.37%
Discharges with “5+” readmissions – 0.17%
Top 5 Discharge Diagnosis of
Beneficiaries with Multiple
Readmissions
Percent
Top 5 DRGs of Beneficiaries with
Multiple Readmissions
Percent
HF
7.99
Heart Failure W MCC
3.78
PNE
6.19
Pulmonary edema & Respiratory Failure
3.21
COPD
5.59
Psychoses
3.12
5.39
Heart Failure & Shock W CC
2.74
4.60
COPD W MCC
2.55
Other diseases of respiratory system (510519)
Complications of surgical and medical
care, not elsewhere classified (996-999)
The Medicare Quality Improvement Organization for Florida
Discharge Status by Race
Discharge Status
To Home
SNF
Discharge status by Race (% Claims)
African
Caucasian
American
34.86
48.03
24.96
13.16
Hispanic
Other
39.04
25.96
28.57
34.29
Home Health
19.80
18.42
19.62
22.86
Intermediate Care Facility
11.62
3.95
7.88
2.86
Inpatient Rehab Hospital
4.73
2.63
2.31
2.86
Left Against Medical Advice
1.43
5.92
4.23
8.57
Long Term Care Hospital
1.15
2.63
0.38
.
Psychiatric Hospital
0.86
1.32
0.38
.
Hospice
0.29
1.32
0.19
.
Transfer
0.29
1.32
.
.
.
1.32
.
.
Other
The Medicare Quality Improvement Organization for Florida
Readmission Source by Providers
Hospital
Discharge Source:
Provider Type
Hospital
Readmission Source:
Provider Type
Home Health Agency
18.2%
36.0%
Home (Outpatient Hospitals)
43.1%
27.1%
Skilled Nursing Facility
15.8%
18.4%
Other
22.9%
3.3%
Miami Community: Claims
Distribution
The Medicare Quality Improvement Organization for Florida
Readmission Source by Physician
Associated Providers
Physician-Associated Provider Sources of
Readmissions
Rates
Inpatient Hospital
22.8%
Office (place of practice in the community)
17.0%
Emergency Room
10.8%
Skilled Nursing Facility
8.7%
Outpatient Hospital
8.0%
Total
67.3%
The Medicare Quality Improvement Organization for Florida
Questions?
Contact:
Susan Stone, MSN RN
FMQAI Care Transitions Project Director
Office: 813-865-3526
Email: [email protected]
This material was prepared by FMQAI, the Medicare Quality
Improvement Organization for Florida, under contract with the
Centers for Medicare & Medicaid Services, an agency of the U.S.
Department of Health and Human Services. The contents
presented do not necessarily reflect CMS policy.
FL2009T2F72T20611018
The Medicare Quality Improvement Organization for Florida