Transcript Reducing Readmissions through Transitions in Care

Reducing Unnecessary Hospitalizations:
Focus on Transitions
Amy Boutwell MD MPP
IHI-CMWF Reducing Re-hospitalizations Initiative
Institute for Healthcare Improvement
“The $15 Billion Dollar U-Turn”
• 17.6% of Medicare admissions are readmissions within 30 days
– Accounting for $15 B in spending
• Not all re-hospitalizations are potentially preventable, not all avoidable,
but many are (accounting for $12B in Medicare spending)
– HF, Pna, COPD, AMI lead the medical conditions
– CABG, PTCA, other vascular lead surgical conditions
• Disparities exist along racial and “burden of illness” lines
• Individual delivery systems and health services researchers have
demonstrated dramatic (40-85%) reduction of 30-day readmission rates
for certain patient populations (esp. CHF)
Why Readmissions? Why Now?
• MedPac June 2007 report highlights avoidable hospitalizations as an area
of high-cost, low-quality; recommends hospital-specific re-hospitalization
data be collected and publically reported
– Exploration of aligning payment to stimulate improvement in
performance on avoidable re-hospitalization rates
– Some health care systems want to “get out ahead” on this issue
– Some states are looking for immediate “wins” and cost savings
• CMS announcement of Care Transitions focus in the 9th SOW
– Approx. 12 -18 QIOs will be selected to identify *communities* in
which to coordinate care and improve transitions with the *specific
aim* to reduce re-hospitalizations (August 1, 2008)
Why Readmissions? Why Now?
• MedPAC June 2008 report outlines steps toward delivery system reform
that focuses on overcoming limitations of current FFS payments
– Vision of moving toward payment for care across provider types and time
• MedPAC June 2008 recommendations:
1. Confidentially report to hospitals and physicians readmission and
resource utilization rates to allow risk-adjusted performance
comparison with peers for 2 years and then make data publically
available
2. Reduce payment to hospitals with high readmission rates for a set of
conditions; allow hospitals and physicians to share in savings gained
from improved processes (gainsharing, or shared accountability)
3. Conduct a voluntary pilot to test bundled payments for
hospitalizations for a set of conditions
What can be done, and how?
• There exist a wealth of approaches to reduce unnecessary
readmissions that have been locally successful
Which are high leverage? Which can go to scale?
• Success requires engaging clinicians, providers across
organizational and service delivery types, patients, payers,
and policy makers
How to align incentives? How to catalyze coordinated effort?
Opportunities: Avoidable Hospitalizations
• Potentially preventable hospitalizations
– Ambulatory care sensitive conditions
• Hospitalizations occurring as a result of these conditions may have been
prevented by either timely access to quality outpatient care or adoption
of healthy behaviors
– Re-hospitalizations
• Process of discharge aims to establish care in a new setting
• Unplanned re-hospitalization usually signals failure of that process
• Methods exist to define “potentially preventable” re-hospitalizations
Prevalence and Drivers of Re-hospitalizations
• Preliminary 2007 Medicare data analysis finds:
– 20% beneficiaries are re-hospitalized at 30 days
– 35% are re-hospitalized at 90 days
– 67% are re-hospitalized or deceased at 1 year
• Among medical patients re-hospitalized at 30 days:
– 50% no bill for MD service between discharge and re-hospitalization
• Among surgical patients re-hospitalized at 30 days:
– 70% were re-hospitalized with a medical DRG
Source: Jencks, Williams, Coleman preliminary data pending peer-review
Evidence: Reducing Re-hospitalizations
• Growing evidence of the effectiveness of following:
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High quality in-patient care
Manage medical co-morbidities (in medical and surgical inpatients)
Early assessment of discharge needs
Enhanced patient and caregiver self-management engagement
Early post-acute follow up with MD or RN (home visit, phone call)
Hospital-based post-acute follow-up (phone calls, nurse visit)
Appropriate referral for home care services
Appropriate patient centered end of life/palliative care discussions
Remote monitoring
Improved transfer processes between acute hospitals and post-acute
facilities
Improving Care for Patients with Chronic Illness:
Evidence: Re-hospitalizations
• 81% of patients requiring assistance with basic functional
needs failed to have a home care referral
• 64% said no one at the hospital talked to them about
managing their care at home
Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based
Best Practices. Marblehead, MA: HCPro, Inc.; 2006.
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Evidence: Reducing Re-hospitalizations
• Excellent research and experience of innovators highlight the
effectiveness of enhanced care delivery during transitions:
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Transition coaching (Coleman)
Advanced NP coordination roles (Naylor)
Guided care model (Bolt)
Nurses that “wrap around” primary care for high –risk populations
(CMS demonstrations)
– Enhanced primary care coordination with home health (NYVNA)
– IHI Transforming Care at the Bedside (Ideal Transition Home for HF)
High-Leverage Opportunities for Action
1. Improved Transitions for All Patients
a) Transitions “out” of the hospital
b) Reception “in” to home (activated home health, office practice)
c) Reception “in” to skilled nursing (activated post-acute rehab, NH)
2. Proactively address the needs of “high risk” patients
a) Create inventory of evidence-based “wrap around” or enhanced services
b) State-specific assessment of plausibility of financing
3. Engage population in being active, informed consumers
a) Web-based tool, AARP campaign (medications), Partnership for Healthcare
Excellence campaign (consumer activation)
b) Consider focus on patients and families/caregivers in disease-specific advocacy
organizations to promote self-management, proactive role in care, esp at
transitions
Conditions to Support Systemic Improvement
• Create incentives to work across traditional settings of care
• Create incentives to coordinate between providers
• Create incentives to communicate with patients/caregivers
(HCAHPS)
• Encourage efficiencies in coordination and communication
(electronic records, email and phone interactions, group mgt)
• Decrease barriers to change (“carrot,” gainsharing)
• Implement catalyst to change (“stick,” transparency, payment
reduction)
• Finance low-cost community / outpatient services to avoid
expensive hospitalizations
Opportunities to Improve Care at Transitions
In-hospital
Transition out of Reception to
Hospital
SNF/NH
Reception
Home
Patients/
Caregivers
Evidence-based Enhanced
care (e.g. for
assessment
CHF)
Timely
Timely
Enhanced selfmanagement
Adverse-event
free
Enhanced
communication
Complete
(clinically
relevant)
Complete
(clinically
relevant)
Coaching /
navigating
Comprh. care
(e.g. medical
management
comorbidities)
Timely follow up
appointments/
check-in
Medication
management
Medication
management
Enhanced
clinical support
in new setting
End of life care
planning/
referral
Transfer
advanced
directives
End of life
planning/
Transfer info.
End of life
planning /
transfer info
Proactive,
informative
counseling