Transcript Hospital Guide to Reducing Medicaid Readmissions

Designing & Delivering Whole-Person Transitional Care:
The Hospital Guide to Reducing Medicaid Readmissions
National Launch Webinar
September 9, 2016
Our Speakers
H. Joanna Jiang, Ph.D.
Senior Social Scientist
Agency for Healthcare Research
and Quality
Amy Boutwell, M.D., M.P.P.
President
Collaborative Healthcare Strategies
Our Agenda
• Introduction to the AHRQ Reducing Medicaid
Readmissions Project
• Testing and Evaluation of Version 1 of the Guide
• Overview of The Hospital Guide to Reducing
Medicaid Readmissions and the ASPIRE framework
• Q&A welcome via chat
Objectives
• Understand the purpose of the AHRQ Hospital
Guide to Reducing Readmissions
• Understand the focus on Medicaid as the catalyst
for promoting “whole-person”care for all high-risk
patients
• Understand the Guide’s ASPIRE framework as
intended to support a data-informed, strategic
redesign of readmission reduction efforts
Why Medicaid?
30-Day All-Cause Readmission Rate, 2013
Medicare
Medicaid
29.1
24.5
23.7
20.6
Congestive heart
failure
Chronic obstructive
pulmonary disease
17.8
17.7
Acute myocardial
infarction
Source: Trends in Hospital Readmissions for Four High-Volume Conditions, 2009-2013, HCUP Statistical Brief #196.
Nonmaternal Adult Medicaid Patients
At High Risk of Readmission
30-Day All-Cause Readmission Rate, 2013
Medicare
Medicaid
21.6
21.2
19.2
16.2
Private
9.9
Age 65+ Age 21-64
years
years
NonOB
NonOB
adults age adults age
21-44
45-64
years
years
10.8
NonOB
NonOB
adults age adults age
21-44
45-64
years
years
Source: All-Cause Readmissions by Payer and Age, 2009-2013, HCUP Statistical Brief #199, AHRQ
Top 5 conditions with the largest
number of readmissions
Medicare
• Congestive heart failure
• Septicemia
• Pneumonia
• Chronic obstructive
pulmonary diseases
• Cardiac dysrhythmias
Private insurance
• Cancer chemotherapy, radiotherapy
• Mood disorders
• Complications of surgical procedures
or medical care
• Complication of device, implant or
graft
• Septicemia (except in labor)
Medicaid
• Mood disorders
• Schizophrenia & other
psychotic disorders
• Diabetes w/ complications
• Complications of
pregnancy
• Alcohol-related disorders
Uninsured
• Mood disorders
• Alcohol-related disorders
• Diabetes w/ complications
• Pancreatic disorders (not
diabetes)
• Skin and subcutaneous
tissue infections
Source: HCUP Statistical Brief #172: Conditions With the Largest Number of Adult Hospital Readmissions by Payer, 2011
AHRQ Reducing Medicaid
Readmissions Project
•
•
•
•
•
2011-2012: Identify factors at the patient, provider, and system
levels that contribute to Medicaid readmissions
2012-2013: Explore whether the best practices to reduce
readmissions apply to the Medicaid population as well
2013-2014: Create a guide for hospitals to increase awareness
and address unique issues in reducing Medicaid readmissions
(Version 1.0, released in August 2014)
2014-2016: Test and evaluate the guide through dissemination,
use in collaboratives, and direct implementation with safety net
hospitals
2016: Update and disseminate Version 2.0 of the guide
Reducing Medicaid Readmissions
Project Team
Amy Boutwell, MD, MPP
Collaborative Healthcare Strategies
James Maxwell, PhD
Angel Bourgoin, PhD
Katie DeAngelis, MPH
Sarah Genetti
Michelle Savuto
John Snow, Inc.
H. Joanna Jiang, PhD
Program Officer and Senior Social Scientist
Agency for Healthcare Research and Quality
Acknowledgements
Field Testing Hospitals
• Northwest Hospital, Baltimore MD
• St Agnes Hospital, Baltimore MD
• Univ. of Maryland-Midtown Hospital,
•
•
•
•
•
•
•
•
•
•
Baltimore MD
Presence St Mary-St Elizabeth, Chicago IL
Norwegian American Hospital, Chicago IL
St Bernard Hospital, Chicago IL
Temple University Hospital, Philadelphia PA
Baystate Medical Center, Springfield MA
Olive View Medical Center, Sylmar CA
University Health System, San Antonio TX
Frederick Memorial Hospital, Frederick MD
Huntsville Hospital, Huntsville AL
Medical University of South Carolina,
Charleston SC
Partnering Organizations
• Maryland Hospital Association and Virginia
Health Quality Partners (Maryland QIO)
• South Carolina Hospital Association and
Carolinas Center for Medical Excellence
(SC QIO)
• Illinois Hospital Association and Telligen
(IL QIO)
Acknowledgements
Advisory Panels (2012-2016)
• Stephanie Calcasola, RN-BC, M.S.N.,
•
•
•
•
•
•
•
•
Baystate Health
Judith Chamberlin, M.D., Aetna Medicaid
Larry Gage, J.D., National Association of
Public Hospitals
Sheryl Garland, M.H.A., Virginia
Commonwealth University
Anne Gauthier, M.S., National Academy for
State Health Policy
Liza Greenberg, RN, M.P.H., Medicaid
Health Plans of America
Michael Hochman, MD., AltaMed Health
Services
Wendy Jameson, M.P.H., M.P.P., California
Health Care Safety Net Institute
Karen Joynt, M.D., MPH., Office of the
Assistant Secretary for Planning and
Evaluation, Department of Health and
Human Services
• David Kelley, M.D., M.P.A., Pennsylvania Office of
Medical Assistance Programs
• Deborah Kilstein, J.D., M.B.A., Association of
Community Affiliated Plans
• Sarah Levin, M.D., Contra Costa Health System
• Enrique Martinez-Vidal, M.P.P., AcademyHealth
• Maureen Milligan, Ph.D., Texas Health and Human
Services Commission
• Erica Murray, M.P.A., California Association of Public
Hospitals and Health Systems
• Joseph Ouslander, M.D., principal investigator,
INTERACT
• Karen Rago, RN, M.P.A., University of California, San
Francisco
• Jeff Richardson, M.B.A., LCSW-C, Community of
Behavioral Health Association of Maryland
• Nancy Vecchioni, RN, M.S.N., Michigan Peer Review
Organization (retired)
• Bryan Weiner, PhD., UNC Gillings School of Global
Public Health
Insights from Field Testing Version 1
Testing and Evaluation of Version 1 of the Guide
• Analyzed stages of implementation based on implementation science &
organizational change theory
–
–
–
–
Knowledge
Readiness
Adoption
Institutionalization
• Eight domains of readmissions work
1.
2.
3.
4.
5.
6.
7.
8.
Have a specific readmissions reduction goal
Have a portfolio of readmission reduction strategies
Collect and analyze quantitative data
Collect and analyze qualitative data
Implement standard hospital-based transitional care
Implement enhanced services for high-risk patients
Implement ED-based strategies
Collaborate with cross-continuum partners
Adoption of Strategies - Results
Knowledge= recognize value
readiness = prepare to test
adoption = at least 1 test
institutionalization = hardwire
 Baseline is first dark blue bar; mid-point (7 months) is medium blue
 Most change occurred during mentored implementation coaching period
 Most “Institutionalization” occurred after midpoint (7-13 months)
Findings
•
High-volume Medicaid / safety net hospitals are willing and able to test multiple
strategies to reduce readmissions
•
Change can occur quickly
–
–
•
Teams were able to recognize the need, prepare, test, and institutionalize a number of readmissionsrelated activities within the span of 13 months
5 of 6 teams changed their baseline to endpoint activity dramatically
Change can occur in multiple domains in parallel
–
–
3 or more of the 6 teams tested use of quantitative data, qualitative data, developing Medicaidrelevant cross-setting partnerships; improve inpatient care; deliver enhanced services
4 of 6 teams consistently work with Medicaid-relevant cross setting partnerships, use qualitative
data, implement strategies in the ED to reduce readmissions
Implementation Challenges
Major challenges included:
• Leadership turnover
• Ability to run straightforward data analysis
• Ability to produce monthly readmission data
• Ability to interpret data to inform efforts
• Preference for delivering targeted enhanced services rather than
improving standard care processes
• Lack of tracking intervention implementation
Feedback on the Guide
• Very positive reactions to the relevance and utility of the Guide and Tools
– The Guide – “For someone like me who walked in with very little idea of what to do, it
was very helpful, because it is methodical and organizes an approach. We have worked
the booklet here in a systematic way, and I think that is part of the reason we are having
good results.” – Hospital C
– Portfolio Development Tool – “This tool assists me in putting our readmission reduction
efforts on paper… We probably don’t take credit for the things we do every day, so this
tool allows me to put things in perspective and present a total readmission package.” –
Hospital B
• Recommendations for improvement
– More actionable formats (e.g. slide templates that can be presented to senior
management, work plans)
– More guidance on coordinating who uses the tools and what should be done with the
results
Table of Contents
• Introduction
• Why focus on Medicaid Readmissions?
• How to Use This Guide
• Analyze Your Data
• Survey Your Current Readmission
Reduction Efforts
• Plan a Multi-Faceted Data-Informed
Portfolio of Strategies
• Implement Whole-Person Transitional
Care for All
• Reach Out to Collaborate With CrossContinuum Providers
• Enhance Services for High-Risk Patients
List of Tools
The guide comes with 13
customizable tools to be used
in hospital teams’ day-to-day
operations.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Data Analysis
Readmission Review
Hospital Inventory
Community Inventory
Portfolio Design
Operational Dashboard
Portfolio Presentation
Conditions of Participation Handout
Whole-Person Transitional Care Planning
Discharge Process Checklist
Community Resource Guide
Cross Continuum Collaboration
ED Care Plan Examples
The ASPIRE Framework
Analysis
Reduce Medicaid
Readmissions
Action
A
• Analyze Your Data
S
• Survey Your Current Readmission Reduction Efforts
P
• Plan a Multi-faceted, Data-Informed Portfolio of Strategies
I
• Implement Whole-Person Transitional Care for All
R
• Reach Out and Collaborate with Cross-Continuum Providers
E
• Enhance Services for High-Risk Patients
Why Medicaid Readmissions?
6 Foundational Message from CMS
• Reducing readmissions pays – or at least inaction hurts
• Hospitals must improve standard “discharge planning” processes
• Reducing readmissions is a cross-continuum effort
• Attend to non-clinical needs for post-hospital supports & services
• Shared learning is an valuable improvement tool
• Reducing readmissions requires better data
 All of this is true and helpful! Has it helped Medicaid patients?
Why Medicaid?
• Medicaid patients have high readmission rates
– Medicaid all-cause readmission rates for patients aged 21-44 (19.2%) and 4564 (21.6%) are higher than Medicare all-cause readmission rates (17.3%)
– Medicaid heart failure readmission rates are higher than Medicare rates:
29.1% versus 23.7%
• Strategies developed for Medicare patients may need to be
adapted to better address Medicaid patients’ needs
– In Massachusetts 40% of all hospitalized adults had a behavioral health
condition; among Medicaid patients, the prevalence was 61%
– In South Carolina, the diagnosis leading to the highest number of readmissions
among Medicaid adults was sickle cell; this was not a top cause for Medicare
Medicare Penalty Focus Has Created Blinders
• Medicare Focus
– Medicare patients are not the only patients at risk of readmission
– Older adults are not the only adults at high risk of readmission
 Patients with readmission risks are not limited to Medicare
• Limited, Diagnosis-Specific Focus
–
–
–


Heart failure, heart attack, pneumonia, COPD, hip/knee replacement
These are not the most frequent diagnoses leading to readmissions
These are not the diagnoses with the highest rates of readmissions
Patients with readmission risks are not limited to the “penalty condition” list
A “case-finding” approach has limited improving standard care processes
Whole-Person Approach
Analyses highlight the multi-factorial causes of readmissions:
– Patient interviews
– Root cause analysis
Experience in the field has found success with transitional care
models that address clinical, behavioral, and social needs
– Interdisciplinary, social work, social service models appear effective
– Several “clinical” approaches have been adapted to include social
work, navigation, advocacy, resources to address basic needs
Whole-Person Approach
• Successful readmission reduction teams state:
– “We look at the whole person, the big picture”
– “We always address goals and ask what the patient wants”
– “We meet the patient where they are”
– “First and foremost it’s about a trusting relationship”
– “You can’t talk to someone about their medications if there is no food
in the fridge”
– “We do whatever it takes”
Why Take A Data-Informed Approach?
• Many readmission reduction efforts have been launched in direct
response to Medicare readmission penalties
• The discharge diagnoses in the penalty program are not the top reasons
for readmissions in the Medicare population
• There are many high risk patients that go without improved transitional
care when the focus is just on penalty conditions
• Focusing on those diagnoses only will not reduce hospital-wide
readmission rates
Data-Informed Approach
• Articulate your hospital’s readmission reduction goal
• Analyze your own hospital’s data to identify patients at high risk and
unique readmission patterns
• Understand root causes of readmissions among your patients
• Implement an approach that is designed to effectively meet the
transitional care needs of your patients
• Track implementation and outcome data to continuously improve
processes to reach your goal
Table of Contents
• Introduction
• Why Focus on Medicaid Readmissions?
• How to Use This Guide
• Analyze Your Data
• Survey Your Current Readmission
Reduction Efforts
• Plan a Multi-Faceted Data-Informed
Portfolio of Strategies
• Implement Whole-Person Transitional
Care for All
• Reach Out to Collaborate With CrossContinuum Providers
• Enhance Services for High-Risk Patients
List of Tools
The guide comes with 13
customizable tools to be
used in hospital teams’
day-to-day operations.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Data Analysis
Readmission Review
Hospital Inventory
Community Inventory
Portfolio Design
Operational Dashboard
Portfolio Presentation
Conditions of Participation Handout
Whole-Person Transitional Care Planning
Discharge Process Checklist
Community Resource Guide
Cross Continuum Collaboration
ED Care Plan Examples
All Payer and Payer-Specific Readmission Analysis
Why Analyze Your Own Data?
Your hospital-specific readmission patterns may differ in important
ways from national patterns: especially true for safety net hospitals.
Look at:
• Readmission rates by payer
• Top 10 diagnoses leading to the most readmissions
• Proportion of all readmissions with a behavioral health comorbidity
• Readmissions by discharge disposition
• Readmissions for frequently hospitalized patients
• Timing of readmissions
Discharge Disposition
Top 10 Medicare Dx:
1.
CHF
2.
Sepsis
3.
Pneumonia
4.
COPD
5.
Arrythmia
6.
UTI
7.
Acute renal failure
8.
AMI
9.
Complication of device
10.
Stroke
Top 10 Medicaid Dx:
1.
Mood disorder
2.
Schizophrenia
3.
Diabetes complications
4.
Comp. of pregnancy
5.
Alcohol-related
6.
Early labor
7.
CHF
8.
Sepsis
9.
COPD
10.
Substance-use related
Medicare
(% discharges)
Medicaid
(% discharges)
Discharge to Home
55%
84%
Discharge to SNF/IRF/LTAC
24%
5%
Discharge to Home with Home Health
14%
8%
15-Point Analytic Plan: All Payer and Payer-Specific
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Total discharges (exclude deaths and transfers to inpatient care settings)
Total readmissions
Readmission rate
Proportion of discharges and readmissions, by payer
Days between discharge and readmission, <4 days, <10 days, 11-30 days
Top 10 diagnoses resulting in highest number of readmissions
Percent of all readmissions accounted for by the top 10 diagnoses
Proportion of all discharges with any behavioral health (including substance use) condition
Proportion of all readmissions with any behavioral health condition
Discharge disposition (home, home with home health care, skilled nursing facility)
Readmission rate by discharge disposition
Number of patients with a personal history of high utilization (4 or more admissions / year)
Number of discharges among this group (“high utilizers”)
Number (and percent of total) of readmissions among this group (‘high utilizers”)
Readmission rate among high utilizers
Data Analysis Tool
Ask your patients “Why”
Elicit the story behind the chief complaint; identify root causes
Review readmissions from “whole person” view
• 41 woman with longstanding HIV never hospitalized in past; hospitalized
for pneumonia, started on HIV medications and antibiotics and told to
follow up with HIV and PCP providers. Readmitted 8 days later.
• 61 man with 8 hospitalizations this year for shortness of breath returns to
the hospital 10 days after discharge with shortness of breath.
“Billing data aren’t going to tell you whether a patient needed
a pharmacy intervention, needed a place to live, or couldn’t
afford their medications.”
Readmission Review Tool
Purpose:
• To understand patient perspective
• To understand root causes
• To understand there are multiple factors
• To identify opportunities for improvement
• To develop a better plan for the patient
• To develop better services to offer
Recommendation:
• Conduct at least 5 during planning
• Review all readmissions
Using Data to Identify Your High Risk Populations
Table of Contents
• Introduction
• Why Focus on Medicaid Readmissions?
• How to Use This Guide
• Analyze Your Data
• Survey Your Current Readmission
Reduction Efforts
• Plan a Multi-Faceted Data-Informed
Portfolio of Strategies
• Implement Whole-Person Transitional
Care for All
• Reach Out to Collaborate With CrossContinuum Providers
• Enhance Services for High-Risk Patients
List of Tools
The guide comes with 13
customizable tools to be used
in hospital teams’ day-to-day
operations.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Data Analysis
Readmission Review
Hospital Inventory
Community Inventory
Portfolio Design
Operational Dashboard
Portfolio Presentation
Conditions of Participation Handout
Whole-Person Transitional Care Planning
Discharge Process Checklist
Community Resource Guide
Cross Continuum Collaboration
ED Care Plan Examples
“We run the care coordinator pilot; I think nursing is working
with IT on getting a high-risk flag in the record. I don’t know
how that is coming.…”
Inventory Hospital-Based Efforts & Resources
• Readmission reduction activities have proliferated over time
• Some efforts may have developed in isolation from one another
• Resources or assets may exist that could be leveraged
– Readmission flags, high risk flags in EMR
– Post-discharge follow up calls
– Centralized appointment scheduling
– Pharmacists or pharmacy technicians
– ACO, bundled payment teams
Hospital Inventory Tool
Use this tool to:
•Identify readmission reduction efforts
across departments
•Identify whether efforts are coordinated
•Identify whether there is duplication
•Identify gaps
“You don’t understand, there are just no resources in the
community”
Inventory Community Efforts & Resources
• Post-acute and community providers may offer services and supports
hospital staff are unaware of
• Health plans may offer high risk patients transitional care and/or care
management
• Resources or assets may exist that could be leveraged
– Practices that are patient centered medical homes: care manager
– Home health agencies that specialize in behavioral health
– Health homes offering outreach, engagement, case management
– Housing agencies with case management services
Community Inventory Tool
Use this tool to identify:
• Peer supports?
• Navigators?
• Medical-legal advocates?
• Behavioral health providers
• Medicaid MCO care managers?
• Formal partnerships?
• Informal arrangements?
• Optimizing available resources?
• Is linkage as easy as it needs to be?
• Gaps in services and supports?
Bon Secours Baltimore Health System
Internal Inventory
•
•
•
•
•
•
•
Peer recovery coaches in the ED
Outcomes Management
Social Work
Behavioral Health Program
Clinics provide post-discharge follow
up <7-10 days for anyone
IT: ACO patients flagged
IT: Use CRISP for notifications
Community Inventory
•
•
•
•
•
•
•
•
Health Enterprise Zone
The Coordinating Center
Homeless Outreach Program
Transitional Housing Providers
Home Health Agencies
Skilled Nursing Facilities
Baltimore Area Agency on Aging
Collaboration w UM Midtown
What’s needed next:
•Care coordination model for high risk patients
•Create care plans for high utilizers
•Integrate medical and behavioral health care clinical information
•Continue to innovate to meet need of patients
Source: presentation to HSCRC Care Coordination workgroup, Dec 2014
Reflect on Findings to Date
•
Which high-risk populations are and are not being currently served?
•
Do the strategies offered for the current target population effectively address the
transitional care needs and root causes of readmissions? How do you know?
•
Have the strategies offered for the current target population reduced readmissions
for the target population? How do you know?
•
Are there opportunities to better serve the current target population and reduce
readmissions even more?
•
Are there opportunities to serve new target populations? Which populations?
With what services, process improvements, and/or partners?
Table of Contents
• Introduction
• Why Focus on Medicaid Readmissions?
• How to Use This Guide
• Analyze Your Data
• Survey Your Current Readmission
Reduction Efforts
• Plan a Multi-Faceted Data-Informed
Portfolio of Strategies
• Implement Whole-Person Transitional
Care for All
• Reach Out to Collaborate With CrossContinuum Providers
• Enhance Services for High-Risk Patients
List of Tools
The guide comes with 13
customizable tools to be used
in hospital teams’ day-to-day
operations.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Data Analysis
Readmission Review
Hospital Inventory
Community Inventory
Portfolio Design
Operational Dashboard
Portfolio Presentation
Conditions of Participation Handout
Whole-Person Transitional Care Planning
Discharge Process Checklist
Community Resource Guide
Cross Continuum Collaboration
ED Care Plan Examples
Take a Data-Informed Approach
1. What is our aim?
2. What does our data show?
3. Who should we focus on?
4. What should we do?
Many teams start in the reverse order!
Create a Data-Informed Strategy
1. Specify the goal and target population
– The goal should be data-informed and specify what will be achieved
for whom, by how much, and by when
2. Identify 3-4 primary ways by which the aim will be achieved, such as:
– Improving hospital-based transitional care processes
– Collaborations with cross-setting partners
– Delivering enhanced services
Example 1: Baltimore Hospital
Intervene in ED prior to
(re)admit
Real-time identification
ED staff available to coordinate
Use individualized care plans
Needs assessment
Reliably deliver inpatient
transition of care practices
Reduce
hospital-wide
readmissions
by 20%
Engage caregiver/”learner”
Customized instructions & teach back
Arrange for follow up & services
Follow up phone calls
Provide or link to
transitional care services
Bedside delivery of medications
Time-limited transitional care
Link to community support
Develop cross-setting
partnerships, norms &
protocols
Monthly cross-continuum meetings
Cross-setting readmission reviews
Warm handoffs, “receiver” oriented
Share use of common tools, eg INTERACT
Example 2: Chicago Hospital
Regular review of readmission data
Create structures and
capacity to drive
continuous
improvement
Reduce
readmissions
hospital-wide
by 20%
Regular review of patient/provider identified root causes
Engage physician leadership
Team meetings 2x/week to support rapid-cycle
improvement
Deploy Social Worker in ED 40h/wk to link to services
Improve & enhance
hospital-based services
Deploy CM in ED 40h/wk to support (re)admit avoidance
Interview all readmitted patients to inform ToC planning
Provide bedside medication delivery
Follow up calls to patients and to home health agencies
Ensure linkage to follow
up and services
Schedule follow up <7 days in [hospital owned] clinics
Coordinate with on-site behavioral health providers
Provide transportation assistance
Driver Diagram Tool
Analyze Your Strategy: Is it Complete?
 Are all readmission reduction related activities captured?
 Will this strategy address the root causes of readmissions for your target population?
 What target populations have & have not been prioritized? Why?
 What strategies have & have not been prioritized? Why?
 Are the following data-informed or high-leverage elements included? If not, why not?







Medicaid adults
Behavioral health
Social support needs
High utilizers
High risk diagnoses based on your data (sepsis, renal failure, sickle cell, etc)
Discharges to post-acute care settings
Collaborations with: MCOs, BH providers, clinics, social services, housing services
 Does this strategy align with value based /alternative payments and other incentives?
 Medicare readmission penalties? Medicare value-based purchasing (total cost)?
 Medicaid readmission penalties? Medicaid MCO at-risk contracts? DSRIP goals?
 Board-level goals relating to quality, patient experience, disparities, or stewardship?
Operational Dashboard Tool
Portfolio Presentation Tool
Table of Contents
• Introduction
• Why focus on Medicaid Readmissions?
• How to Use This Guide
• Analyze Your Data
• Survey Your Current Readmission
Reduction Efforts
• Plan a Multi-Faceted Data-Informed
Portfolio of Strategies
• Implement Whole-Person Transitional
Care for All
• Reach Out to Collaborate With CrossContinuum Providers
• Enhance Services for High-Risk Patients
List of Tools
The guide comes with 13
customizable tools to be
used in hospital teams’
day-to-day operations.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Data Analysis
Readmission Review
Hospital Inventory
Community Inventory
Portfolio Design
Operational Dashboard
Portfolio Presentation
Conditions of Participation Handout
Whole-Person Transitional Care Planning
Discharge Process Checklist
Community Resource Guide
Cross Continuum Collaboration
ED Care Plan Examples
Understand evolving guidance and requirements
Use these as your blueprint to improve standard care
Excerpts from Recent CMS Guidance and Proposal
•
Have a written discharge process approved by governing body
•
Analyze and track readmissions
•
Review readmissions and look for patterns
•
Regularly review and improve the discharge processes
•
Every patient in inpatient or observation needs a discharge plan
•
Actively solicit the preferences of the patient and family/friends/support person
•
The plan must be able to be realistically implemented
•
Address behavioral health follow up as part of the discharge plan
•
Provide customized education
•
Provider verbalized instructions, using the teach-back technique
•
Know capabilities community based providers – including Medicaid home and community based services
•
Know options for Medicaid long term services and supports or have a contact at Medicaid who can help
•
Provide patients with data to inform their choice of post-acute providers
•
Transmit discharge summaries within 48 hours of discharge
•
Follow up with patients at high risk of readmission
Source: CMS May 2013 and November 2015
Improving Standard Processes for All Patients
•
•
•
•
•
•
Identify all patients at high-risk of readmission
Assess all patients for clinical, behavioral and social needs
Communicate with patients simply and effectively
Link patients to follow-up and post-hospital services
Provide real-time information to receiving providers
Ensure timely post-discharge contact
AND
• Have a process
• Track, trend and review readmissions
• Continuously improve the process to better meet needs
Improving Transitional Care for All Tool
Whole-Person Transitional Care Planning Tool
Discharge Checklist Tool
Table of Contents
• Introduction
• Why focus on Medicaid Readmissions?
• How to Use This Guide
• Analyze Your Data
• Survey Your Current Readmission
Reduction Efforts
• Plan a Multi-Faceted Data-Informed
Portfolio of Strategies
• Implement Whole-Person Transitional
Care for All
• Reach Out to Collaborate With CrossContinuum Providers
• Enhance Services for High-Risk Patients
List of Tools
The guide comes with 13
customizable tools to be used
in hospital teams’ day-to-day
operations.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Data Analysis
Readmission Review
Hospital Inventory
Community Inventory
Portfolio Design
Operational Dashboard
Portfolio Presentation
Conditions of Participation Handout
Whole-Person Transitional Care Planning
Discharge Process Checklist
Community Resource Guide
Cross Continuum Collaboration
ED Care Plan Examples
“We would be thrilled if someone from the hospital
called us”
Cross-Continuum Collaboration: Who’s Job is It?
• It’s the hospital’s job!
• CMS policies signal that hospitals are expected to lead delivery system
transformation to more effectively deliver care across settings
• Hospitals that do reach out to post-acute and community based providers
and agencies find those partners are very receptive
“There are many resources in the city, but it can be hard to
find them. We need to inventory them and collect this
information in one place.”
Identify Medicaid-Relevant Partners
Medicaid-Relevant Clinical Providers
Medicaid-Relevant Service Agencies
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Behavioral Health Centers
Community Health Centers
Behavioral Health Homes
Resident Physician Clinics
Patient Centered Medical Homes
Substance Use Treatment Centers
Adult Day Care Centers
Medicaid Managed Care Plans
Health Homes
Group Homes
Housing Authority
Transportation Providers
County Health Departments
Food Assistance
Legal Advocacy Assistance
Peer Support
Look for Care Management Resources
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Accountable care organizations
Patient-centered medical homes
Bundled payment initiators
Health homes
Behavioral health homes
Medicaid managed care organizations
CMS demonstration initiatives
State Innovation Model initiatives
Duals-demonstration programs
Medicaid Delivery System Reform Incentive Payment (DSRIP) programs
Medicaid Delivery System Transformation Initiatives (DSTI) programs
Local or national foundation grant-funded initiatives
State agency funded initiatives
State behavioral health agency
Housing authority or housing agencies
Peer support programs
Faith-based organizations
Volunteer organizations
Community Resource Guide Tool
Develop “Referral Pathways”
Make doing the right thing the easy thing for staff
Cross Continuum Coordination – Getting Started
If you are just getting started:
•Hold regularly scheduled monthly meetings
•Start with a “coalition of the willing” – doesn’t need to be perfect
•Invite new partners/ agencies as you learn about them
•Allow 3-4 months for the group to gel
•Start with common agenda items:
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Readmission data
Readmitted patient stories
Readmission stories from “receiver” perspective
Handoff communication
What information do “receivers” need that they frequently don’t have?
Cross-Continuum Collaboration Tool
Table of Contents
• Introduction
• Why focus on Medicaid Readmissions?
• How to Use This Guide
• Analyze Your Data
• Survey Your Current Readmission
Reduction Efforts
• Plan a Multi-Faceted Data-Informed
Portfolio of Strategies
• Implement Whole-Person Transitional
Care for All
• Reach Out to Collaborate With CrossContinuum Providers
• Enhance Services for High-Risk Patients
List of Tools
The guide comes with 13
customizable tools to be used
in hospital teams’ day-to-day
operations.
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Data Analysis
Readmission Review
Hospital Inventory
Community Inventory
Portfolio Design
Operational Dashboard
Portfolio Presentation
Conditions of Participation Handout
Whole-Person Transitional Care Planning
Discharge Process Checklist
Community Resource Guide
Cross Continuum Collaboration
ED Care Plan Examples
Enhanced Services
• Additional services and supports in the time following hospitalization
• Services not provided to all patients as part of routine care
• Offered to subgroups identified as “high risk” of readmission
• Delivered prior to and after discharge, often for 30 days
• Deployed at provider expense so as to reduce readmissions
• Delivered by hospital staff or by contracted staff from other entities
 Specific section on strategies to improve care for patients with a history of
recurrent hospitalizations (“high utilizers”)
 Specific section on Emergency Department-based strategies
“Our [navigators] are flexible, proactive, and persistent;
they address all needs. Each of them has incredible
interpersonal skills.”
“Whole-Person” Adaptations to Transitional Care
• Navigating
• Hand-holding
• Arranging for….
• Providing with….
• Harm reduction
• Meet “where they are”
• Patient priorities first
• Relationship-based
Adapt Transitional Care Models to Better Address
Whole-Person Needs
In Practice: Social Workers
In Practice: Community Health Workers
The social worker calls the high-risk patient within
two days of discharge, and first focuses on
developing rapport with the patient or their
caregiver. The social worker identifies problems
to be addressed, with about three-fourths of
these problems not becoming apparent until after
discharge. The three most common problems are
difficulty coping with change, caregiver stress,
and problems managing medical care, including
medications. Other common issues include
trouble
obtaining
community
services,
communication breakdowns between providers,
trouble managing a new treatment or diagnosis,
and difficulty understanding the discharge plan.
The hospital assigns a CHW to all patients with
three or more readmissions in the past year. The
CHWs meet with patients as early as possible
during the hospitalization and try to meet with the
patient multiple times before discharge. This
connection while in the hospital makes it much
easier to continue the relationship in the posthospital setting. By design, CHWs meet with
patients independently of doctors and nurses.
CHWs have noted that patients feel more
comfortable telling them about psychosocial and
economic problems that may prevent them from
adhering to their care plan, such as being unable
to afford heat in their home or not understanding
what the doctor said.
The Bridge Model of social worker-led transitional
care reduced all-cause any-hospital 30-day
readmissions by 20%, as published in the Journal
of the American Geriatrics Society (May 2016).
Adapt Transitional Care Models to Better Address
Whole-Person Needs
Principles to Guide High Utilizer Programs
• Identify the patient in real-time
• Engage the patient while they are on-site
• View utilization as a symptom of unmet needs
• Prioritize engagement
• Deploy an interdisciplinary team
• Be proactive in post-hospital follow up
• Be patient and persistent
• Have resources to deploy to meet short term needs
• Use care plans to improve care across settings and over time
Care Plans Improve Care Across Settings and Over time
• Longitudinal Care Plan
– A comprehensive plan to achieve health-promoting goals and objectives. Specific goals
regarding clinical, behavioral, and/or functional status are often included, and are
measured via serial assessments over time. Longer term; care management over time.
• Transitional Care Plan
– Identifies post-hospital needs, patient priorities, and readmission risks and the plan to
address those needs, priorities and mitigate risks in the 30 days post discharge. Focus on
ensure linkage to providers and services within the 30 day transitional period.
• ED Care Plan (examples)
– Summary information for the ED provider to inform safe, effective, and consistent care
in the ED and facilitate discharge with team-based follow up, as appropriate.
ED Care Plan Tool
“In previous times, the path would’ve been to simply admit the
patient, and we’ll sort it out 5 days later. We’re becoming more
accustomed to having resources in the ER to help us discharge
patients from the ED. That’s a culture change.”
Reducing Readmissions from the ED
1.
Create a 30-day return flag on the ED Tracker Board
2.
Use the 30-day return flag to notify the high risk care team
3.
Use care plans and care teams’ involvement in the ED
4.
Consider developing “treat and return” pathways
5.
Engage hospitalists in decision to admit
Summary
• The AHRQ Hospital Guide to Reducing Medicaid Readmissions encourages
hospitals to:
– Expand readmission reduction efforts to all patients
– Adapt strategies to better serve Medicaid patients
– Employ a data-informed approach to designing efforts
– Implement a whole-person approach to identifying and addressing
patients’ transitional care needs
• The ASPIRE Framework:
– Supports an updated strategic planning process
– Recommends improving care in 3 domains: improve hospital-based
care, collaborate across settings, deliver enhanced services
Thank you for your commitment to reducing readmissions
Amy E. Boutwell, MD, MPP
Collaborative Healthcare Strategies
[email protected]
Angel Bourgoin, PhD & Jim Maxwell, PhD
John Snow, Inc.
[email protected]; [email protected]