Transcript Preventing Readmissions - Lafayette Medical Education

Esteban Ramirez, D.O., F.A.C.O.I
Hospitalist Department
Indiana Univ. Health Arnett
Objectives
Why is reducing readmissions so
important
 CMS’ definition of a readmission
 Definition of Value Based Purchasing
 Become familiar with the measures that
CMS is looking at this year
 Familiarize yourself with the Projects
available to assist with minimizing
readmissions.

Why look at Readmissions
Deficit Reduction Act 2005: mandated the
Secretary of Health and Human Services
include measures of hospital outcomes and
efficiency in the Hospital Inpatient Quality
Reporting (IQR) program.
 Affordable Care Act: in 2010, Section
10303(a) of this Act directed the Secretary
of Health and Human Services to develop
additional outcome measures focused on
the five most resource-intensive conditions
as well as primary and preventive care.

Why look at readmissions?
The NEJM in 2009 and the Medicare
Payment Advisory Commission (MedPAC)
2005 reported that 18-20% of Medicare
patients are readmitted in 30 days.
 MedPAC estimated that 30 day
readmissions cost Medicare ~$15 Billion
dollars
 78% of readmissions are thought to have
been preventable.

 For example, >50% of pts readmitted within 30
days did not have on record a post
hospitalization visit (NEJM 2009)
What is a readmission per CMS

ANY diagnoses after being discharged within 30 days.
 Common misconception is that it has to be the same as the
discharge diagnosis
 Could be an admission to another hospital
 Observation visits , ED visits, and same day readmissions (to
the discharging hospital) do not count as a readmission
 AMI Exception: Planned PTCA, CABG within 30 days of
discharge

CMS has chosen to focus on 3 diagnoses at first to start
penalizing hospitals for higher than expected readmission
rates.
 Pneumonia
 Heart failure
 Myocardial Infarction
Value Based Purchasing


CMS is using it’s purchasing power to drive up the
quality of healthcare.
DRG payments for Fiscal Year 2013 will be based on
the organization’s Total Performance Score
 Items included in the calculation are:
○ 17 processes of care in:
 Pneumonia,
 Heart Failure,
 Acute myocardial infarction,
 Healthcare associated infections,
 Surgical care improvement
○ 8 measures in HCAHPS
 In following years, it is expected that the number of
measures will increase
Value Based Purchasing

Funding to these institutions will be
reduced by 1% 2013.
 In further years, it will be increased
 Money can be earned back by improving
your overall performance on the above
measures
How do we currently compare?

Using the data from Medicare claims over
the last 3 years CMS has determined the
national average of readmissions per
diagnosis.
 Rates of readmission vary by state which has
led Medicare to surmise that readmission rates
can be decreased by the lower performing
hospitals.
○ States with lower readmission rates:
 Idaho (13.3%), Oregon (15.7%), Utah (14.2%)
○ States with higher readmission rates:
 Illinois (21.7%), Louisiana (21.9%), New Jersey (21.9%)
How do we compare?

Using the above data, the hospitals are
being compared on 30 day readmission
rates for pneumonia, myocardial infarction
and heart failure:
 Better than US national rate of readmissions
 No different than US national rate of
readmissions
○ IUH Arnett and St. Elizabeth Hospitals
 Worse than US national rate of readmissions
○ This group will have 1% withheld from their DRG
payment
How do we compare?
** This data is available now on the
HOSPITAL COMPARE public website**
This site is managed by the Department
of Health and Human Services.
http://www.hospitalcompare.hhs.gov/
How do we compare?
 Recently released Hospital Compare data (7/2012):
○ Better than national average for readmissions:
 Citrus Memorial Hospital, in Inverness, FL and Sarasota Memorial Hospital,
in Sarasota, FL.
○ Worse than national average:
1. Beth Israel Deaconess in Boston, MA
2. Florida Hospital, Orlando, FL
3. Franciscan St. James Health, Olympia Fields, IL
4. Henry Ford Hospital in Detroit, MI
5. Mount Sinai Hospital, NY, NY
6. Olympia Medical Center, Los Angeles, CA
7. Tampa VA Medical Center, Tampa, FL
8. San Juan VA Medical Center, San Juan, Puerto Rico
Preventing Readmissions

Multiple organizations/groups have initiatives to address this
 Institute for Healthcare Improvement (STAAR) and American College of
Cardiology (H2H)
 INTERACT and Community Based Transition Programs from CMS
 National Priorities Partnership
 Hartford Foundation

Project RED- RED= Re-Engineered Discharge
 Designed by researchers at Boston Univ. and Boston Medical Center
 funded by Agency for Healthcare Research and Quality (AHRQ) and
National Institutes of Health (NIH)
 Showed significant decrease in utilization of ED visits and Hospital
Utilization. Trended toward reducing readmissions

Project BOOST- Better Outcomes for Older Adults through Safe
Transitions led by the Society of Hospital Medicine and includes Joint Commission,
CMS, CDC, IHI, Blue Cross and Blue Shield, AHRQ, Kaiser Permanente
 6 sites that have utilized this have produced 21% reduction in
readmissions
Project RED

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Education about the diagnosis
Make the follow up appointment for the
patient using input from the patient
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Give purpose for visit
Coordinate with needed labs and studies
Review transportation to appointment and
if needed set it up for the patient
Discuss test results and if any are
pending who is responsible for following
up on these
Project RED
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Organize post discharge services
Confirm medication plan
Reconcile discharge plan and
medications with national guidelines
(heart failure, acute MI, etc…)
Review what should be done if a
problem arises (redevelop chest pain,
increased fevers, etc.)
Project RED

Expedite the discharge summary
 Components to DC summary:
○ Reason for hospitalization/diagnosis
○ Significant findings
○ Procedures performed
○ Condition at discharge
○ Comprehensive medication list including allergies
○ Pending tests/labs and medical issues that require
follow up

Assess understanding of the above
 May require a translator, different literacy level,
involving caregivers
Project RED
Provide hard copy of the discharge plan
when leaving
 Provide telephone reinforcement at 2-3
days.

 Re-assess understanding
 Intent on following up with appointments
 Assess need for second call by:
○ Pharmacist and/or
○ Nurse and/or
○ Physician
Project BOOST
Geared primarily to patients greater than 65 year of age.
 Encourages identifying high-risk patients and providing the
intervention solely to this population
 TARGET tool to assess risk
○ Includes GAP (General Assessment for Preparedness)assess potential barriers
○ 8P tool: done at admission
 Problem medications: warfarin, digoxin, aspirin, insulin in
combination with clopidogrel
 Hx of psychiatric disorders
 Problem Diagnoses: COPD, heart failure, cancer, stroke,
diabetes/glycemic complication
 Polypharmacy (>5 medications)
 Poor health literacy
 Poor social support
 Prior (unplanned) hospitalizations in the last 6 months
- Has been identified as the single most predictive risk
factor of readmissions (NEJM 2009)
 Palliative Care
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Project BOOST
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Educating patients on their conditions and possible side
effects of medication- Utilization of the Teach Back Method
Scheduling follow-up physician appointments within 7 days
Medication reconciliation at discharge to ensure that drugs
prescribed at discharge don't harmfully interact with
previously prescribed drugs
Discharge instructions should be in at least 14 font. Avoid all
capitals and jargon.
 Include diagnoses, possible side effects from medications,
what to look for to get further care/ER visit, list of appts.
Discharge summary to PCP <48 hours
Direct communication with PCP for these high risk patients.
Telephone contact with patient within 72 hours
*There is a training and mentoring program available for this
project*
Take Home Points

Communicate better with our patients
 May require repetition or discharge instructions in a different
language/interpreter or involvement of family/caregivers

Communicate better between inpatient to outpatient
providers
 Quick turn around of DC summaries <48hrs
 Better quality DC summaries that include pending tests/labs
 Phone calls to PCPs office for high risk patients
Make appointments for patients before DC
 Provide follow up phone call to patient 2-4 days to ensure
understanding and address unexpected issues
 Must use a multidisciplinary approach

Readmission Risk Calculators
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Center for Outcomes Research and
Evaluation (CORE) has an application
that is free that could be downloaded on
iPhone.
What will the future look like
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Improved electronic discharge process that incorporates EBM check off
lists that must be completed prior to DC
More availability for quicker turn around on DC summaries (including
weekends and holidays)
Improved access to post hospitalization care within 7 days
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Medical Home Model (e.g. extended hours, weekend avail.)
Use of physician extenders and/or
Semi-retired physicians
Improved collaboration between inpatient, outpatient and SNF/ECF
healthcare workers
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Gather representatives from each area
Analyze the process
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Inpatient to outpatient, inpatient to SNF/ECF, SNF/ECF to Outpatient
LEAN methodology
Projects are currently under way to address specifically the high
readmissions for Heart Failure, Pnemonia and Acute Myocardial
Infarction
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Perhaps a future lecture series on these?
Champions for each?
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Questions or Comments?
References
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Readmission Measures Overview. www.QualityNet.org
(established by CMS)
Jencks S, Williams M, Coleman E. Rehospitalizations
among Patients in the Medicare Fee-for-Service
Program. N Engl J Med 2009; 360:1418-1428
Medicare Payment Advisory Commission (MedPAC).
Promoting greater efficiency in Medicare. June 2007.
Project Boost Website:
www.hospitalmedicine.org/BOOST/
Project RED website
https://www.bu.edu/fammed/projectred/
Voss R, Gardner R, Baier R, Butterfield K, Lehrman S,
Gravenstein S. The care transitions intervention:
translating from efficacy to effectiveness. Arch Intern Med.
Jul 25 2011;171(14):1232-1237.