Transcript Development of an Outpatient Transfusion Program to

Development of an Outpatient
Transfusion Program to Reduce
Avoidable Hospitalizations
Zachary J. Palace MD CMD FACP
The Hebrew Home at Riverdale
Bronx, NY
2015 AMDA Foundation Quality Improvement and Health Outcome Award
Speaker Disclosures
Dr. Palace has disclosed that he has no relevant
financial relationships.
.
The Hebrew Home at Riverdale by RiverSpring Health
Bronx, NY
Established in 1917, an 855 bed not-for-profit skilled nursing facility, located on
a 32 acre campus on the Hudson River.
Twenty patient neighborhoods, including two 45 bed subacute units, and four
memory care units.
Services include PT, OT, ST, hydrotherapy pool and wellness center, LVAD care,
on-site peritoneal dialysis, hospice and palliative care.
On-site laboratory and satellite pharmacy.
Medical Department composed of 7 FT physicians, 2 NP’s and Optum©,
24/7 on-site physician coverage.
Learning Objectives
By the end of the session, participants will be able to:
• Appreciate the benefits of an innovative skilled
nursing facility-based quality improvement initiative in
reducing avoidable hospitalizations.
• Appreciate the role of an inter-institutional clinical
collaboration in addressing an unmet need.
• Recognize the benefits to the patient and the facility
by avoiding hospitalization.
• Recognize the reduction in healthcare costs
associated with outpatient transfusions.
5
Anemia Challenges
• Most patients with chronic anemia and a low
hemoglobin do not need to be admitted to
hospital
• Many can be managed on site (eg. iron, ESA)
• Some do need a blood transfusion
• Patients presenting to the emergency room for a
blood transfusion are ADMITTED
ESA=erythropoeitin-stimulating agent
6
Asking the Question…
• How can our facility send patients for a blood
transfusion without them getting admitted?
• Hematologists send their patients living in the
community to the blood bank for transfusions.
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Quality Improvement Initiative
• Objective: To develop a favorable alternative to the
unnecessary hospitalization of nursing home residents
requiring blood transfusion.
• The protocol was developed for the nursing home
resident who is evaluated for anemia and a clinical
decision is made for a blood transfusion without pursuing
an extensive diagnostic workup and an inpatient
admission.
• Through clinical collaboration with a geriatrician liaison at
a local hospital, the transfusion protocol transfer form was
developed.
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Exclusion Criteria
• Active bleeding
• Hemodynamic instability
• Family request for admission
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Intervention: Clinical collaboration to
provide outpatient transfusions
• Developed transfusion transfer form. This form
contains relevant patient demographic and clinical
data, including diagnoses, medications, allergies,
recent lab values, and previous transfusion history.
• Transfusion transfer form is completed by the SNF
physician/nurse practitioner and faxed to the
hospital-based geriatrician for further review.
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Intervention: Clinical collaboration to
provide outpatient transfusions
• Hospital-based geriatrician coordinates with the
hospital blood center for an out-patient transfusion
on the following day
• Patient is transported to the hospital blood center
for transfusion and returned to the nursing home
later that same day, avoiding an in-patient hospital
stay
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Consequences of the Elderly Being
Admitted to the Hospital
• Loss of physical function due to prolonged
immobility
• Development of new decubiti
• Nosocomial infections
• Acute adjustment reaction
• Financial impact (payer, facility)
Results
80
70
Anemia Transfers to Hospital
60
Outpatient Transfusions
50
40
30
74% reduction in
hospitalizations
for anemia
20
10
0
2009
2010
2011
2012
2013
2014
13
Results
• From 7/1/09 through 12/31/14 there was a 74%
reduction in patients transferred out to hospital for
a diagnosis of anemia.
• From 7/1/09 through 12/31/14 there were 232
outpatient transfusions.
2012 National Statistics - Outcomes for ICD-9-CM principal
procedure code 99.04 Packed Cell Transfusion
All discharges
Payer
Total number of
LOS (length of stay),
discharges
days (mean)
Charges, $ (mean)
700,235 (100.00%)
5.2
38,448
Costs, $ (mean)
10,419
448,050 (63.99%)
5.3
38,260
10,339
84,490 (12.07%)
5.6
42,706
11,484
119,720 (17.10%)
4.8
37,609
10,369
30,385 (4.34%)
4.1
32,122
8,632
16,215 (2.32%)
4.9
39,916
10,895
1,375 (0.20%)
4.6
30,578
8,650
Medicare
Medicaid
Private
insurance
Uninsured
Other
Missing
Weighted national estimates from HCUP National Inpatient Sample (NIS), 2012, Agency for Healthcare Research and Quality
(AHRQ), based on data collected by individual States and provided to AHRQ.(www.hcupnet.ahrq.gov, 2/6/2015)
Cost savings to Medicare
Hospitalization for transfusion
• Medicare mean cost for
inpatient transfusion:
$10,339
Outpatient transfusion
• Medicare APC payment for
outpatient transfusion:
CPT 36430
CPT P9010
Total:
$350
$217
$567
Cost savings per transfusion
$10,339 - $567 = $9772
For 2014, 71 outpatient
transfusions x $9772=
$693,812 saved
APC=Ambulatory Payment Classification
Cost savings to facility
• Mean inpatient length of stay = 5.3 days
• Average daily SNF rate approx. $300/d.
• For 2014, 71 outpatient transfusions.
• 71 inpatient stays avoided x 5.3 days/inpatient stay=
376.3 SNF days saved @ 300/day = $112,890.
• Facility transportation costs for 71 patients
@$170RT = $12,070.
• 2014 net cost saving to facility approx. $100K.
Conclusion
• Reduce avoidable hospitalization of the elderly
• Improve quality of healthcare delivery for patients
• Improve relationships with local hospital
• Realize cost savings to the facility and reduce
costs to the healthcare system
Credits
Special thanks to:
-HHAR staff physicians and NP’s
-Optum© NP’s
-Montefiore Medical Center Dept. of Geriatrics
Wanda Horn MD, Amy Ehrlich MD
-Montefiore Blood Bank
Contact info
Zachary J. Palace MD CMD FACP
Medical Director, Hebrew Home at Riverdale
[email protected]