Transcript Patient Safety Organization (PSO) Role

Reducing Patient
Readmissions
Keys to Improving Patient Care
Overview
• Impact of the Patient Protection and Affordable
Care Act (PPACA) on your facility
• Critical strategies to reduce readmissions
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Objectives
• Review the impact of PPACA
• Identify key strategies and tactics for
reducing readmissions that can be applied in
their organizations
• Describe actionable strategies for engaging
community organizations across the continuum
of care
• Strengthen patient involvement in their care
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Health Care Reform Legislation
• March 23, 2010=PPACA
 Paying for quality instead of quantity
 Financial penalties
 Community based care transitions program
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Affordable Care Act and
Reducing Readmissions
• §3026
 http://www.innovations.cms.gov/initiatives/Partnershipfor-Patients/CCTP/index.html?itemID=CMS1239313
• §3501
 http://www.ahrq.gov/qual/patientsafetyix.htm
• §399KK
 http://www.pso.ahrq.gov/
• §3025
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Patient Safety Organization (PSO) Role
• §399KK implementation
• ACA designates PSOs to help hospitals
 Department of Health and Human Services supports
the PSOs
• To find a PSO
 http://www.pso.ahrq.gov/listing/psolist.htm
• Eligible hospitals
 http://www.cms.gov/DemoProjectsEvalRpts/downl
oads/CCTP_FourthQuartileHospsbyState.pdf
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Readmission Reduction Program
• NQF endorsed measures
• Report all-payer readmission rates publicly
• Excess vs. expected
 For more information: www.QualityNet.org
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2012 Hospital-Specific Report Example
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The Reason Behind Readmissions
• Hospitals have responsibilities, but they
are not alone
• Readmissions occur when:
 Patients don’t understand or can’t comply
with discharge instructions
 Patients in some communities lack access to
primary care, post-acute care, pharmacies
 Patients have multiple diagnoses that make
them more vulnerable to complications
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Published Evidence
• Four broad categories
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Enhanced care and support during transitions
Improved patient education and self-management
Multidisciplinary team management
Patient-centered care planning at the end of life
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Key Strategies and Tactics (continued)
• Assess your risks
 Patient
 Hospital
 Financial
 http://rarereadmissions.org/
• Understand your readmission history
 Evaluate potential cause and appropriateness of
recent readmissions
 http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImpr
ovingTransitionstoReduceAvoidableRehospitalizations.aspx
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Key Strategies and Tactics (continued)
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Timely discharge summaries
Lengthen the handoff process
Provide medication on discharge
Make a follow-up plan before disharge
Telehealth
Identify frequent flyers
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Key Strategies and Tactics (continued)
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Understand what’s happening post-discharge
Provide home care on wheels
Consider physician medication reconciliation
Ensure patients understand
Focus on highest-risk patient
Listen to the patient
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Where the Gaps Are: Other Factors
• No longer does one practitioner typically take
responsibility for the discharge and follow-up
• Discharging practitioners may be unfamiliar
with the capacity to provide care in settings to
which they send patients
• Lack of a universal electronic health
information system
• The revolving door of skilled nursing facilities
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The Best Transition…
Is only as good as the reception
into the next setting of care.
Boutwell A and Johnson MB: STAAR Issue Brief: Reducing Barriers to Care
Across the Continuum–Working Together in a Cross-Continuum Team.
STAAR Issue Brief Series 2010 Number 3. Available at
http://www.ihi.org/offerings/Initiatives/STAAR/Documents/
STAAR%20Issue%20Brief%20-%20Cross%20Continuum%20Teams.pdf
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Cross-Continuum Teams (CCTs)
• Key component of the State Action on
Avoidable Rehospitalizations (STAAR) initiative
• Team composition
• Infrastructure
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Cross-Continuum Teams
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Multi-stakeholder team
Provides oversight and guidance
Known as the “STAAR Effect”
New competencies developed
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Key Changes
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Enhance assessment of post-hospital needs
Effective teaching and learning
Ensure follow-up
Real-time handovers
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide:
Improving Transitions from the Hospital to Community Settings to Avoid Rehospitalization.
Cambridge, MA: Institute for Healthcare Improvement; June 2012. Available at ww.IHI.org
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Transitions Home
Collaborative Getting Started
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Executive leader selected
Sponsor convenes the team
Opportunities for improvement identified
Aim statement developed
Kick-off meeting
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CCT Recommendations
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Meet regularly
Visit each other’s sites
Complete periodic diagnostic interviews
Add patients and family members
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Questions to Ask
• How can we get timely and relevant
information from community providers?
• Do we have universal patient-friendly
education materials for common conditions
in all settings?
• Are staff members competent in effective
teaching and facilitating learning?
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Questions to Ask (continued)
• Have we co-designed real-time
handover communications
• Do we utilize universal format for patient
care plans?
• Who is the best clinical provider to complete
follow-up phone calls?
• How do we collaborate with payers and
post-acute providers to determine eligibility
for certain populations?
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Where the Gaps Are: Health Literacy
• “Health (il)literacy”: Nearly half of adults
have trouble understanding simple health
information (procedure consent, prescriptions,
oral instructions)
• Less than half of patients discharged from
academic general medicine know their
diagnoses, treatment plans, or side effects of
prescribed medications
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The High-Risk Patient
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History of readmission
Failed teach-back
Longer stay than expected
High-risk conditions
Poor, disabled, or on dialysis
Late follow-up after discharge
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Engaging the Patient: Health Literacy
• Red flags:
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Elderly
Low income
Unemployed
Minority
Did not finish high school
Immigrant
Born in U.S. but English second language
Noncompliance
Can’t name meds
“Forgot my glasses…will read later”
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Engaging the Patient: Communication
• Eight steps for oral communication:
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Slow down
Plain language
Pictures
Limited information
Repeat
Teach-back
Provide oral and written information
Shame-free environment
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High-Level Opportunities for Action
• Execute an effective transition from the
hospital to post-acute care settings
 Early assessment of discharge needs
 More intensive management of chronic medical
conditions during hospitalization
 Evidence:
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Transition coaching
Nursing phone call follow-up
Hospital-generated phone call and coaching
Collaboration between sending and receiving facilities
on what data is needed during transfers
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High-Level Opportunities (continued)
• Facilitate timely follow-up care in the
post-discharge setting
 Work with outpatient providers to schedule
appointments prior to discharge
 Consider early follow up for “high-risk” patients,
which may be hospital-generated call
 Increase referral to home health when indicated
 Consider enhanced outpatient support
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High-Level Opportunities (continued)
• Engage patients and caregivers as active
participants and managers of their care
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Include medications
How to monitor for and act on clinical deterioration
Use of hospital-based enhanced assessment
Early and repeated teaching opportunities
during hospitalization
 Assess patient’s understanding
 Condition, diet/medications, and symptoms
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Readmission Is an Opportunity
• Fragmentation of care lies behind many
failed transitions
• Improving transitions will necessarily
reduce fragmentation
• If we succeed, we have established a
precedent for fixing other broken parts of
the health care system
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Real World Success Stories
• Improved transitions out of the hospital
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Project RED
BOOST
IHI’s Transforming Care at the Bedside
Hospital to Home “H2H” (ACC/IHI)
• Supplemental transitional care between settings
 Care Transitions Intervention (Coleman)
 Transitional Care Intervention (Naylor)
 Missouri Department of Health and Human Services
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Patient and Family Engagement
• Patient-Centered Care
 http://www.ipfcc.org/tools/Patient-Safety-Toolkit-04.pdf
• Promotion
 http://www.ahrq.gov/qual/engagingptfam.htm
• Principles
 http://www.gwumc.edu/healthsci/departments/nursing/n
aqc/documents/Patient_Engagement_Guiding.pdf
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Community Engagement
• Know where your patients are coming from
• Know where your patients are going to
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Boston University Experience
Testing the
Re-Engineered Discharge
Brian Jack, MD, Principal Investigator
Associate Professor and Vice Chair
Department of Family Medicine
Boston Medical Center
Boston University School of Medicine
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BOOST Toolkit: Primary Components
• Tool for identification of high-risk patients
• Patient and family/caregiver preparation
• Enhanced communications
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Discharge summary
Provider to provider
Patient contact
Patient resource
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Institute for Healthcare Improvement
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Hospital to Home (H2H)
• H2H is a national quality improvement initiative
• Goal is to reduce all-cause readmission rates in
heart failure and acute myocardial infarction
• Uses a three-question framework
Available at: http://h2hquality.org
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The Care Transitions Intervention
• 750 community-dwelling adults 65 years or
older admitted to the study hospital with one
of 11 selected conditions
• Intervention:
 Tools to promote cross-site communication
 Encouragement to take a more active role in
their care
 Guidance from a “transition coach”
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention:
results of a randomized controlled trial. Arch Int Med. 2006;166(17):1822-8.
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Transitional Care Model
• Nurse practitioners provide inpatient assessment
• NPs review medications and goals
• Design and coordinate care with patients
and providers
• Attend first post-discharge MD office visit
• Direct home care for one to three months
• Conduct home interviews
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS.
Transitional care of older adults hospitalized with heart failure:
a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675-84.
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Available at: http://web.mhanet.com/aspx/articles.aspx?navid=111&pnavid=4&articleid=143
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AHRQ Web Resource
• Implementing Re-Engineered Hospital
Discharges (Project RED)
 Training manual
 After-hospital care plan samples
 Tool kit
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Various forms
How-to ideas
Evaluation
Cost and implementation
www.ahrq.gov/news/kt/red/redfaq.htm
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Some Practical Tools
• Ideal discharge checklist: Society of Hospital
Medicine–Quality Improvement Tools:
 www.hospitalmedicine.org
• Care Transitions Program
 www.caretransitions.org
• “Getting Ready to Go Home”–simple checklist for
patients and families at admission to help think
about discharge issues:
 www.hospitalmedicine.org
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Questions?
“It is not the answer that enlightens,
but the question.”
–Eugene Ionesco
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Mission Statement
[email protected]
(800) 421-2368, ext. 1134
Our Mission Is to
Advance, Protect, and Reward
the Practice of Good Medicine
For additional information,
go to www.thedoctors.com
and click on Patient Safety.
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