Transcript Reducing Readmissions, July 2012, Transcript [pptx]

Reducing Hospital Readmissions:
A Primer
July 2, 2012
S
Introduction
S June Quarterly Survey – Responses due June 27
S August 6, 2012 Webinar: Pressure Injuries
http://www.henlearner.org
S Affinity Groups – Open monthly calls led by Subject Matter
Experts –
S July 13 – 11 AM MT : Patient Falls and Immobility
S July 20 – 10 AM MT : Early Elective Inductions <39 Weeks
S For technical assistance, questions, requests e-mail:
[email protected]
S For resources, calendar of events, & archived materials go to:
http://www.henlearner.org
2
C.M.M.I. & H.E.N. Audacious Goals
•
Keep patients from getting injured or sicker. By the end of 2013,
preventable hospital-acquired conditions would decrease by 40%
compared to 2010.
S About1.8 million fewer injuries to patients with more than 60,000
lives saved over the next three years.
•
Help patients heal without complication. By the end of 2013, all
hospital readmissions would be reduced by 20% compared to 2010.
S
More than 1.6 million patients would recover from illness without
suffering a preventable complication requiring re-hospitalization
within 30 days of discharge.
Preventable Harms
3 First Focus Areas:
Obstetrical Trauma (E.E.D., Strong Start)
Patient Falls and ImmobilityOur hospitals selected this one!
Preventable Readmissions
Pressure Ulcers
Adverse Drug Events (A.D.E.)
Central Line Blood Stream Infections (C.L.A.B.S.I.)
Surgical Site Infections (S.S.I.)
Venous Thrombo-Embolism (V.T.E.)
Ventilator-Associated Pneumonia (V.A.P.)
Catheter-Associated Urinary Tract Infections (C.A.U.T.I.)
Preventable Readmissions
S Link to an article about a program at McKay-Dee Hospital
in Ogden, UT to reduce readmissions. While the webinar in
the story is past, the article is of interest.
S http://www.healthleadersmedia.com/content/FIN-
281620/Reducing-30day-Readmissions-Simply
Reducing Hospital Readmissions:
A Primer.
July 2, 2012
S
Disclosure
S The presenters of this webinar have no financial
interest in the content.
7
C.M.E. Statement
Written faculty disclosures have been made by all faculty members and financial support associated
with a C.M.E. activity, whether in the form of an educational grant or not, will be disclosed in
a brief statement either in conference materials or verbally at the beginning of the meeting by
the course director.
The Intermountain Healthcare Continuing Medical Education Department designates this live
activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. Intermountain
Healthcare C.M.E. fully complies with the legal requirements of the A.D.A. and the rules and
regulations thereof. If any participant of this program is in need of accommodation, please do
not hesitate to call and/or write to the C.M.E. office in order to receive service. A request for
accommodation can be made by calling 801.442.3930. Reasonable prior notice is required.
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Webinar Presenters
S Andrew Masica, M.D., M.S.C.I.
Baylor Health Care System – Vice President, Center for Clinical Innovation
S Brett Stauffer, M.D., M.H.S.
Baylor Health Care System – Director, Clinical Decision Support
Baylor Health Care System (B.H.C.S.) is a nonprofit delivery organization based in DallasFort Worth. B.H.C.S. is one of the nation’s largest integrated non-H.M.O. health care
providers, offering a full range of inpatient, outpatient, rehabilitation, and emergency
medical care in 8 contiguous counties in Texas. B.H.C.S. clinical sites include 26 hospitals
with more than 140,000 full admissions per year, and a large ambulatory practice system (the
Health Texas Provider Network, H.T.P.N.), in which there are over 1 million patient visits
annually.
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Webinar Presenters.
S Doug Koekkoek, M.D.
Providence Health & Services – Chief Medical Officer
Providence Health & Services (P.H.&S.) is a not-for-profit health system providing a
comprehensive array of services across five states, including Alaska, Washington, Montana,
Oregon and California. P.H. & S. includes 27 hospitals, more than 35 non-acute facilities,
physician clinics, a health plan, a liberal arts university, a high school, approximately 49,000
employees and numerous other health, housing and educational services. The Providence
Health Plan covers more than 200,000 lives, and throughout 5 states, Providence has more
than 400,000 hospital admissions, 1 million E.D. visits, and 2.2 million primary care visits
annually.
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Objectives
At the conclusion of today’s webinar, participants should
be able to:
1) Understand the importance of readmissions in the
current health care environment
2) Delineate metrics for performance improvement
3) Develop intervention strategies to reduce
readmissions
4) Identify and access resources to start or extend a
readmissions reduction program
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Reducing Readmissions:
Context
12
Scope of Problem
Frequent Medical Causes
of Rehospitalization
Frequent Surgical Causes
of Rehospitalization
30-Day Proportion
Condition at
Most Frequent 2nd Most Frequent
Rehosp.
of all
Discharge
(%)
(%)
Rate
Rehosp.
Condition at
Discharge
30-Day
Proportion of Most Frequent 2nd Most Frequent
Rehosp.
all Rehosp.
(%)
(%)
Rate
All
21.0%
77.7%
Heart Failure
(8.6%)
Pneumonia
(7.3%)
All
15.6%
22.4%
Heart Failure
(6.0%)
Pneumonia (4.5%)
Heat Failure
26.9%
7.6%
Heart Failure
(37.0%)
Pneumonia
(5.1%)
Cardiac Stent
Placement
14.5%
1.6%
Cardiac Stent
(19.7%)
Circulatory D.X.S.
(8.5%)
Pneumonia
(29.1%)
Heart Failure (7.4%)
Major Hip/Knee
Surgery
9.9%
1.5%
Aftercare (10.3%)
Major Hip/Knee
Problems
(6.0%)
Other Vascular
Surgery
23.9%
1.4%
Other Vascular
Surgery
(14/8%)
Amputation
(5.8%)
Major Bowel
Surgery
16.6%
1.0%
G.I. Problems
(15.9%)
Post-Op. Infection
(6.4%)
Other Hip/
Femur Surgery
17.9%
0.8%
Pneumonia
(9.7%)
Heart Failure
(4.8%)
Pneumonia
20.1%
6.3%
C.O.P.D.
22.6%
4.0%
C.O.P.D.
(32.6%)
Pneumonia (11.4%)
Psychoses
24.6%
3.5%
Psychoses
(67.3%)
Drug Toxicity
(1.9%)
G.I.
Problems
19.2%
3.1%
G.I. Problems
(21.1%)
Nutrition-Related/
Metabolic Issues
(4.9%)
Adapted from Jencks et al, NEJM 2009
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Why now?
S Costly
S $17.4 billion in hospital payments from Medicare in 2004
S Substantial impact
S In some hospitals, 25% of all admissions are readmissions
S Readmissions major source of patient and family stress
S Remediable
S Commonwealth Fund report from 2006 estimated if national
readmission rates mirrored top-performing regions the savings to
Medicare would be $1.9 billion per year
14
Readmissions are often preventable
S Traceable causes of avoidable readmission established
S Hospital-acquired infection or other complication
S Premature discharge
S Failure to coordinate or reconcile medications
S Inadequate communication
S Poor planning for care transitions
S Given that interventions exist to reduce their occurrence,
readmissions are increasingly being seen as a measure of
hospital quality.
15
Readmissions affect all stakeholders
S While Medicare patients are at increased risk of
readmission, patients aged 18 to 64 have a readmission rate
only 20% less than that of patients over 65.
Rehospitalization rate is only weakly related to age.
S Readmissions are a problem for the entire spectrum of
patients and payors, and an issue that providers will
increasingly held be accountable for (e.g. effects on C.M.S.
reimbursement, A.C.O. care delivery models).
16
Readmission Metrics
17
Proposed H.E.N. Metrics
Outcome Measures
SOverall inpatient 30-day hospital readmission rate
(“all-cause all-payor”) being advocated for H.E.N.s
SMedicare inpatient 30-day hospital readmission rate
S Population characteristics different from privately insured
SHeart Failure inpatient 30-day hospital readmission rate
S 1 of 3 metrics used as a basis for F.Y.13 C.M.S. hospital payment
adjustments
18
N.Q.F.-Endorsed All-Cause
Readmission Metric
*Excerpt from NQF draft technical report (full version available at www.henlearner.org)
19
Additional Readmission Metrics
Other Outcome Measures
(tailor numerators/denominators according to group of interest)
SRationale for doing this is variation in readmission risk across the inpatient
population and to facilitate tracking of intervention effects (e.g. a program
targeting C.H.F. patients > age 65)
SMedicare inpatient 30-day hospital readmission rate
S Medicare as primary payor?
S Inclusion of dual eligibles (Medicare/Medicaid)?
SHeart Failure inpatient 30-day hospital readmission rate
20
Proposed H.E.N. Metrics
(Leading Indicator)
Process Measures
STransitional Care Bundle (Individual and Composite)
S Patient and caregiver education
S Medication management
S Transitional care planning and handoff
S Post discharge contact
21
Readmissions: Intervention
Strategies
22
Strategies for Intervention
S Singular interventions (particularly those lacking a
community outreach component) are not effective in
consistently reducing readmission rates.
S Observed successes have involved a multifaceted,
interdisciplinary approach (e.g. B.O.O.S.T., Project R.E.D.
among others).
S Targeting specific patients prior to discharge is difficult as
current models perform poorly in predicting readmissions in
a general hospital population.
Kansagara et al, JAMA 2011
23
Readmission Interventions Taxonomy
Hansen et al, Annals Int Med 2011
24
Data tracking/reporting as a core element
of any readmissions reduction program
Process Measure
Performance
Outcome Measure
Performance
Opportunity for
“measure-vention”
Data management and
transfer
Reports
Timely
Credible
Sustainable
Actionable
Stakeholder groups: physicians, administration, unit managers, pharmacy
25
Application of Intervention Strategies at
Providence Health & Services
S The tactics used at P.H.&S. aim to address the pre-discharge,
post-discharge, and transitional stages of the care
continuum:
S Multiple education interactions with patients/families
S Follow-up appointments within 3-5 days post-discharge
S Increased frequency of goals of care/end-of life conferencing
S Skilled Nursing Facility rounding
S Consistent performance reporting
S Prioritizing and testing new interventions on specific patient
subgroups
26
Preparing the Patient
Complex Case Management
S
Discharge Check List
a.
Follow up appointment with P.C.P 3-5 days after discharge.
b.
Education about medications, regime after discharge, and
disease process.
c.
Referrals: Does the patient need help with A.D.L., equipment,
or wound care
d.
Metric: % compliance with Discharge Check List being used
S
Discharge Phone Calls
S
Risk Assessment Tools
27
Early Follow-Up
S Patients need to be seen 3-5 days post discharge
S Include key information in dictated discharge summary
S Provide feedback to physicians
S Retrospective chart review to measure performance
28
Prompt Handoff to P.C.P.
(data obtained via chart review)
S
Dictated Discharge Summary: Average Number of Days Documented to see P.C.P. (n=563)
Conclusion: All four facilities decreased the number of days documented in the Dictated Discharge Summary
instructing patients when to see the P.C.P. after discharge.
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Communication
S Palliative Care
S Palliative care focuses on improving the quality of life ~
symptom control and management
S End of Life
S Conducting Family Meetings
S Goals of Care Discussions
S Completion of P.O.L.S.T. Forms
30
Facility Rounding (S.N.Fist Program)
S
“Virtual Team” of providers with geographically defined areas of service
S
Serving Specific Facilities: Based on quality and known high volumes of
Providence patients
S
Improve clinical quality outcomes and care transitions between healthcare facilities
S
Ease communication and care coordination for the primary care providers with the
facilities –improved provider satisfaction
S
Increase patient and family satisfaction
S
Reduced costs associated with hospital readmissions and reduced E.R. visits
31
Weekly Readmission Reporting
32
P.H.&S.: Readmissions
Performance
33
Getting Started
34
Improvement Team Members
S Care Coordination
S Social Work
S Pharmacy
S Nursing
S Physicians
S Administrative leadership
S Information technology and data management
S Patient advocates
35
Baseline Performance and Goal Setting
S Readmission comparison period for H.E.N.
participants is the 2010 calendar year.
S The Partnership for Patients initiative is targeting a
20% reduction in 30-day readmissions (relative to 2010
rate) by December 2013.
36
Establish Community Partners
S Readmission rates within health systems reflect the presence
of effective medical homes as the impact of purely hospitalbased interventions are very short-term.
S Within Baylor, patients with a medical home in one of our
affiliated outpatient practices (the Health Texas Provider
Network) have a 30-day readmission rate of 11% versus the
system-wide rate of 16.3%.
37
Establish Community Partners:
S Primary care providers
S Individual patient level (access, appointment scheduling)
S Population health management as a subsequent step
S Extended care facilities
S S.N.F.s/N.H.s
S L.T.A.C.s.
Other CMS initiatives
in development outside
of the HEN program
S Home health providers
S Nursing visits, therapy
S Community health workers
38
Mechanism for Information Exchange
S Ideal situation is a fully integrated, health system with a
universal E.H.R....
S Summary document with essential patient information
S Diagnoses, medication list, allergies, specialists, pending tests
S Electronic portals
S Paper based (example in Appendix A)
S Information needs to be broadly accessible across care
delivery sites
39
Begin with a Subgroup
S Identify a high utilization population or a specific hospital
unit closely aligned with system operational goals
S C.H.F. patients
S Geriatrics unit
S Deploy an intervention targeting that subgroup as a pilot
S Will often require a reallocation of existing resources
S Survey your system/individual hospital for overlap
S Share findings (successes, failures, and lessons learned)
40
Baylor N.P. C.H.F. Pilot study
• Model being replicated at several other Baylor hospitals
• Allowance for tailoring to local environments/workflow
41
Performance Tracking: Process
Patient #
Education
Medication
Management
Discharge
Planning
Post-D/C Appt.
Made/Kept
Post-D/C
Call
Information
Transferred
Bundle
met
1
Yes
Yes
Yes
Yes/No
Yes
No
No
2
Yes
Yes
Yes
Yes/Yes
Yes
Yes
Yes
3
No
Yes
No
No/No
No
Yes
No
4
Yes
Yes
Yes
Yes/Yes
Yes
Yes
Yes
5
Yes
Yes
Yes
Yes/Yes
Yes
Yes
Yes
• Need to define what constitutes a completed process
• In most health care systems, this would currently require chart review
• Configurable in an E.H.R.
• Assessing outpatient follow-up will be challenging in non-integrated settings
• 10 randomly selected charts per month would provide an adequate sample for trending
• Amenable to roll-up and presentation in a dashboard format (units, physicians)
42
Performance Tracking: Outcomes
43
Expectations for HEN Members
S Quarterly data sharing/metrics reporting on readmissions
S First request –submit these by end of July 2012:
S
Baseline data for calendar 2010 and 1st quarter 2012
S
All-cause all-payor
S
Medicare patients
S
CHF patients
NQF Endorsed Specifications
S Metric details can be found at: www.henlearner.org
S Instructions on how to submit data will be forthcoming soon
S Deployment of readmission reduction interventions and
collaborative learning with use of H.E.N resources
44
More About Metrics
S Parameters of the “ideal” metrics surrounding readmissions
are evolving
S Multiple viewpoints (including C.M.S. response ) available in
N.Q.F. materials posted on our H.E.N. website
S Need for a broadly feasible (and meaningful) process
measure, as well as a “balance” measure (L.O.S., E.D. visits,
23 hour obs. stays)
S Process and balance measures for our H.E.N. will be
established by 9/2012; these metrics will become part of the
quarterly reports
45
What can I do tomorrow?
S The Affordable Care Act requires establishment of a hospital
readmissions reduction program-the financial lever (in the form of
payment reductions by C.M.S.) can be applied starting in 10/2012.
S C.M.S. has calculated excess readmission ratios for A.M.I., C.H.F., and
P.N.A., which will determine payment adjustment for hospitals.
S C.M.S. will be reporting these ratios in the F.Y.13 Inpatient Prospective
Payment System Final Rule (8/2012) and also on Hospital Compare
(10/2012).
S Until July 19, 2012, hospitals can review their reports and submit
corrections on the information used to calculate excess readmission
ratios through QualityNet.
S Further details can be found at http://www.qualitynet.org (go to
Hospitals-Inpatient section, then click on the Readmissions Reduction
46
tab).
Reducing Readmissions: Closing Thoughts
S Reducing preventable hospital readmissions has been
prioritized as a patient safety and health care quality issue,
and will have implications on reimbursement.
S Evidence indicates that multifaceted approaches crossing
care delivery sites (particularly those entailing some form of
a medical home) are the most effective types of interventions.
S An adaptable improvement approach with a team of invested
stakeholders, goal setting, and systematic performance
measurement and reporting will be required to “move the
needle.”
47
H.E.N. Readmissions Task Force...we’re here to help!
48
H.E.N. Resources
S Subject Matter Experts/Implementation Advisors
S Affinity Group Calls
S Tools found on http://www.henlearner.org
S
Evidence (Literature Review)
S
Project Boost
S
Project R.E.D.
S
N.Q.F.-endorsed readmission metric definitions
S
Methodology for the Excess Readmission Ratio
49
Keeping the Conversation Going!
S Reducing readmissions is a long-term investment
S Monthly conference calls for discussion of data, troubleshooting,
and exchange of best practices
S Subject matter experts from the H.E.N. sites will participate in
these calls
S The calls will focus on the H.E.N. collaborative’s needs as
indicated by your responses on the webinar evaluation form
S Schedule for these affinity group calls will be established soon
50
H.E.N. Resource Link
S
Hospital Engagement Network
8 http://www.henlearner.org/additional-resources/
S
Lynette Savage, R.N., Ph.D. – Providence Health & Services, Quality
Management & Medical Staff Services
* [email protected]
S
( 503.215.3421
Gina Honermann-Garinger, M.B.A. – Baylor Health Care System, Center for
Clinical Innovation
* [email protected]
( 214.265.3631
Technical & Website inquires:
S
Amyanne Wuthrich, M.S. – Intermountain Hospital Engagement
Network
* [email protected]
( 801.213.3742
51
Appendix A (Patient Summary Document Example)
Accessible at: http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/PASS.pdf
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