Central Valley/West Valley Care Coordination Coalitions. Quarterly Community Meeting
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1 Central Valley/West Valley Care Coordination Coalitions Ettie Lande, MS, RN Associate Director, Care Coordination (HSAG) Today s Agenda Welcome and Introduction Spotlight on Social Determinant of Health Spotlight on Behavioral Health Readmission Data Review High-Risk Medications Data Review High-Risk Medications Table Top Exercise Evaluations and Meeting Summary 2 1
2 Thank You! Today s breakfast is sponsored by Abrazo West Campus Thank you Stan Holm and Judy Butler If you would like to sponsor breakfast for a 2018 meeting, please contact Cheryl Angotti at cangotti2@hsag.com or call Introducing the HSAG Team Barb Averyt, Executive Director Cheryl Angotti, Project Coordinator Care Coordination/Adverse Drug Events Ettie Lande Associate Director / elande@hsag.com Jenna Burke Quality Improvement Specialist, EVCCC jburke@hsag.com Behavioral Health Dennette Janus Quality Improvement Specialist, Inpatient Psychiatric Hospitals djanus@hsag.com Nursing Home Quality Improvement/ C. diff/antibiotic Stewardship Keith Chartier Associate Director kchartier@hsag.com Nursing Home Quality Improvement Elaine Nelson Clinical Project Manager Buffy Lloyd Quality Improvement Specialist 4 2
3 Your Meeting Feedback Is Important! Please help us exceed the 85% target! 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 2017 Evaluation Completion Rates 96% 94% 85% 85% 85% 85% March, 2017 June, 2017 September, 2017 November, 2017 Meeting Target 5 Things I Will Share 6 3
4 At Our June Meeting, We Got Back to Basics Assess your organization for gaps in care coordination and care transition processes. Summarize your key findings. Prioritize key areas for improvement. Re-educate and/or reinforce expected behaviors. Implement best practice or an innovative solution to shore up the gap. Monitor performance, processes, and outcomes. 7 Our Challenge: Find Your Perfect 10 A community-wide effort engaging all providers To improve care coordination and transitional services For those at highest risk for an avoidable readmission To achieve a 12 percent relative improvement rate (RIR) in Central Valley and 20 percent in the West Valley By September 30,
5 Spotlight on Social Determinants of Health: Access to Medications Joanna Hale Business Operations Sr. Manager Banner Pharmacy Services Mimi Hoffman, NCRP Health System Manager Janssen Pharmaceuticals, Inc. 9 Network/Break: 20 Minutes
6 Spotlight on Behavioral Health Dennette Janus, LPC Quality Improvement Specialist Behavioral Health, HSAG Newest Statistics: WHO and NAMI World Health Organization (WHO) (March 2017) Depression is the leading cause of ill health and disability worldwide 18 percent increase between 2005 and 2015 National Alliance on Mental Illness (NAMI) 1 in 5 adults in America experience a mental illness Nearly 1 in 25 (10 million) adults in America live with a serious mental illness (SMI) Suicide is the 10th leading cause of death in the U.S. 12 Source Link: 6
7 Mental Health America (MHA) 2017 Report: Overall Ranking by State Arizona s Ranking 50 of 51 (2013) Rank State 1 Connecticut 2 Massachusetts 3 Iowa Rank State 18 Wisconsin 19 Texas 20 Virginia Rank State 35 Nebraska 36 Missouri 37 Ohio 42 of 51 (2014) 7 measures for adult ranking Lower rankings indicate higher prevalence of mental illness and lower rates of access to care 4 New Jersey 5 Hawaii 6 Maryland 7 Delaware 8 Maine 9 Illinois 10 South Dakota 11 Pennsylvania 12 Vermont 13 New York 14 North Dakota 15 California 16 Florida 21 Oklahoma 22 Alabama 23 Kansas 24 Michigan 25 Colorado 26 Wyoming 27 North Carolina 28 Arkansas 29 Alaska 30 New Hampshire 31 South Carolina 32 New Mexico 33 Kentucky 38 Montana 39 Louisiana 40 Georgia 41 Washington 42 Arizona 43 West Virginia 44 District of Columbia 45 Tennessee 46 Mississippi 47 Indiana 48 Idaho 49 Oregon 50 Utah 17 Minnesota 34 Rhode Island 51 Nevada 13 Source: Mental Health America. Downloaded08/18/17 Adult Prevalence of Mental Health: Arizona Rank and Percentage Compared to National Adult Prevalence of Mental Illness Adults With Any Mental Illness (AMI) 18.29% of adults struggle with mental health problems annually. This equals to 43.7 million Americans. Rank % The state prevalence of mental illness ranges from: (Florida) 16.03% Highest Ranked 22.66% (Oregon) Lowest Ranked 14 Source: The State of Mental Health in America, 2017 Report 7
8 Adults With Dependence or Abuse: Arizona Rank and Percent Compared to National Adults With Dependence or Abuse of Illicit Drug or Alcohol 8.47% of adults in America report having a substance use or alcohol problem. Rank % The state prevalence of adult alcohol and substance use ranges from: (Tennessee) 7.18% Highest Ranked 12.51% (DC) Lowest Ranked 15 Source: The State of Mental Health in America, 2017 Report Adults With Serious Thoughts of Suicide: Arizona Rank and Percent Compared to National Adults With Serious Thoughts of Suicide Rank % The percentage of adults reporting serious thoughts of suicide is 3.94%. The estimated number of adults with serious suicidal thoughts equals 9.4 million individuals. The state prevalence of adult with serious thoughts of suicide ranges from: (Connecticut) 3.34% Highest Ranked 4.85% (Utah) Lowest Ranked 16 Source: The State of Mental Health in America, 2017 Report 8
9 Arizona Inpatient Psychiatric Facility (IPF) Readmission Data: Q Q Arizona 30-day Hospital Readmission Rates After Discharge from Inpatient Psychiatric Facilities CY * 2014 (Baseline) Q Q Q Q Q Q % 21.4% 19.4% 21.5% 19.9% 20.5% 17 *CY: Calendar Year. Source: Medicare Fee for Service Claims Data Arizona IPF: Hospital Readmissions by Discharge Setting Q Q Group Setting Discharged To 30-Day Readmit Rate Discharges Readmits Within 30 Days 30-Day Readmits to Different Hospital 7-Day Readmits to Different Hospital N % N % Home 20.6% 4, % % ICF % % % SNF % % % Arizona HHA % % % AMA % % % Other 19.6% % % Totals 20.5% 5,345 1, % % 18 Source: Medicare Fee for Service Claims Data. Key: 1. Intermediate care facility (ICF), 2. Skilled nursing facility (SNF), 3. Home health agency (HHA). 4. Against medical advice (AMA). Other: Any other hospital entered discharge setting code than the one s listed. 9
10 HSAG Behavioral Health Projects Increase depression and alcohol misuse screenings in primary care settings Reduce hospital readmissions after discharge from IPF Education: Six-session webinar series, to continue in 2018 Monthly top 10 intervention series, through 2018 Statewide behavioral health strategy meeting in Top 10 Readmission Reduction Interventions Series One readmission reduction intervention in detail, monthly Series continues through 2018 Integrating behavioral health into each community coalition meeting and readmission reduction strategies 20 10
11 Explore a New World in 2017 Session 6: Medication and Medical Issues November 3 21 Readmission Data Review Barb Averyt HSAG 11
12 Hospital Readmission Reduction Program (HRRP): FY 2017 and FY 2018: Arizona FY2017 FY2018 Hospital Readmission Reduction Program (HRRP) Hospitals with No Penalty Hospitals with Penalty 0.01% 0.50% % 0.99% % 1.99% % 3.0% 2 3 Average Penalty 0.583% 0.589% HRRP Year 6 Maximum payment reduction cut by 3.0 percent Payment cuts applied to all DRG (inpatient) claims FY2018 performance period: July 1, 2013 June 30, 2016 Six conditions assessed: AMI, HF, PN, COPD, Elective THA/TKA, CABG Effective Oct. 1, 2017 Sept. 30, Under Trump, Hospitals Face Same Penalties Embraced By Obama, Jordan Rau, 8/3/17. Readmission Relative Improvement Rates (RIR)*: January, 2014 March, % Community Launch October, 2014 Desired Direction: Goal: 20% RIR* by Sept 30, % 16.18% 19.40% 19.57% 18.81% 15.0% 10.0% 5.0% 3.62% 4.20% 5.78% 6.74% 9.12% 11.83% 0.0% Jan Dec 2014 Apr Mar 2015 Jul Jun 2015 Oct Sep 2015 Jan Dec 2015 Apr Mar 2016 Jul Jun 2016 Oct Sep 2016 Jan Dec 2016 Apr Mar 2017 Goal 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% Actual 3.62% 4.20% 5.78% 6.74% 9.12% 11.83% 16.18% 19.40% 19.57% 18.81% 24 Source: Medicare FFS Claims Data for beneficiaries residing within the ZIP codes of this community. *The RIR is calculated based on the readmission rates per 1,000 beneficiaries and this formula: (Baseline Current)/Baseline. 12
13 All Cause Readmission Rates By Setting: Q Q Community Setting Discharged To 30-day Readmission Rate 7-day Readmission Rate Home 14.5% 34.5% Skilled Nursing Home 21.4% 31.0% Home Health 18.9% 35.8% Hospice 2.5% 30.8% Other 20.2% 36.5% Total 16.2% 34.1% Source: Medicare Fee for Service Claims. *Other: psychiatric hospital, long-term care hospital, acute rehab, intermediate-care, left against medical advise, based on hospital discharge disposition codes. 25 Readmission Rates by Condition: Q Q Community Condition 30-day Readmission Rate 7-day Readmission Rate AMI 13.8% 49.5% HF 21.7% 32.6% PNE 17.6% 31.6% COPD 22.1% 27.0% CABG 9.0% 57.1% THA/TKA 2.7% 39.6% Source: Medicare Fee for Service Claims. AMI: Acute Myocardial Infarction, HF: Heart Failure, PNE: Pneumonia, COPD: Chronic Obstructive Pulmonary Disease, CABG: Coronary Artery Bypass Graft Surgery, THA/TKA: Total Hip Arthroplasty/Total Knee Arthroplasty Surgery
14 Readmission Relative Improvement Rates (RIR)*: January, 2015 March, % 12.0% 10.0% Community Launch November, 2015 Desired Direction: Goal: 12% RIR by Sept 30, % 6.0% 6.93% 5.95% 4.0% 3.14% 2.0% 0.0% -2.0% -1.71% -2.47% 0.41% -4.0% Jan 2015 Dec 2015 Apr 2015 Mar 2016 Jul 2015 Jun 2016 Oct 2015 Sep 2016 Jan 2016 Dec 2016 Apr 2016 Mar 2017 Goal 12.0% 12.0% 12.0% 12.0% 12.0% 12.0% Actual -1.71% -2.47% 0.41% 3.14% 6.93% 5.95% 27 Source: Medicare FFS Claims Data for beneficiaries residing within the Zip codes of this community. *The RIR is calculated based on the readmission rates per 1,000 beneficiaries and this formula: (Baseline Current)/Baseline. All Cause Readmission Rates By Setting: Q Q Community Setting Discharged To 30-day Readmission Rate 7-day Readmission Rate Home 15.3% 35.3% Skilled Nursing Home 19.3% 30.0% Home Health 19.4% 36.5% Hospice 2.1% 44.0% Other 23.4% 41.2% Total 16.8% 35.1% 28 Source: Medicare Fee for Service Claims. *Other: psychiatric hospital, long-term care hospital, acute rehab, intermediate-care, left against medical advise, based on hospital discharge disposition codes. 14
15 Readmission Rates by Condition: Q Q Community Condition 30-day Readmission Rate 7-day Readmission Rate AMI 14.0% 43.6% HF 22.7% 30.5% PNE 18.3% 34.8% COPD 21.7% 28.7% CABG 9.2% 50.0% THA/TKA 4.0% 49.2% 29 Source: Medicare Fee for Service Claims. AMI: Acute Myocardial Infarction, HF: Heart Failure, PNE: Pneumonia, COPD: Chronic Obstructive Pulmonary Disease, CABG: Coronary Artery Bypass Graft Surgery, THA/TKA: Total Hip Arthroplasty/Total Knee Arthroplasty Surgery. Beneficiaries on High-Risk Medications (HRMs) Data Review 15
16 Arizona 30-Day Readmissions Among Medicare FFS Beneficiaries: Q Q Day All-Cause Readmission Rate 15.7% 30-Day High Risk Medication (HRM) Readmission Rate 18.8% Readmissions among beneficiaries on HRMs are much more frequent than the general population. Percent of 30-day readmits with an anticoagulant or diabetes agent ADE are much higher than the percent of readmits with an opioid ADE. 31 Based on CMS Medicare FFS Parts A and D claims data for Q Q Arizona Readmission Rates for HRM Beneficiaries: Q Q by Quarter Category Q Q Q Q Q Q Anticoagulants 19.9% 19.4% 19.3% 19.3% 19.5% Diabetic Agents 19.9% 19.1% 20.0% 20.9% 20.0% Opioids 18.9% 20.3% 19.6% 20.2% 19.7% All 3 HRMs Combined Arizona s All Cause Readmission Rate 18.9% 18.7% 18.5% 19.2% 18.8% 15.9% 16.1% 15.7% 15.3% 15.7% 32 Source: Medicare Claims Data. HSAG Arizona ADE Report of Medicare Fee for Service(FFS) claims for beneficiaries on one or more HRM and the Arizona State Medicare FFS Readmission Report for Q Q
17 Arizona Adverse Drug Event Rates Per 1,000 Beneficiaries by HRM: Q Q HRM Category # of ADEs Unique Beneficiaries Rate per 1,000 Beneficiaries Change From Q Q Anticoagulants 4,544 18, Better Diabetic Agents 1,941 16, Better Opioids , Worse Overall 7,337 46, Same 33 Source: HSAG Arizona ADE Report of Medicare Fee for Service Claims. Tabletop Activity: Best Practices for Patients on High-Risk Medications (HRMs) 17
18 How Is Your Organization Addressing High-Risk Medication Management? 35 Table Exercise Break up into 6 teams. Select a spokesperson for your team to report out at the end of the exercise. Review the page of the tool assigned to you and discuss the information together. Identify the top 3 areas of your assignment you want everyone to know. Spokesperson reports out to the larger group
19 Table Top Team Assignment 1: Opioid Prescriber Tips Page 1 2: Opioid Prescriber Tips Page 2 3: Diabetic Agent Prescriber Tips Page 1 4: Diabetic Agent Prescriber Tips Page 2 5: Anticoagulant Prescriber Tips Page 1 6: Anticoagulant Prescriber Tips Page 2 37 HSAG Contacts for Additional Support on These Topics For additional support on: Conducting organizational assessment, contact: Ettie Lande, elande@hsag.com Reducing readmissions specific to behavioral health, contact: Dennette Janus, djanus@hsag.com Developing HRM and ADE strategies, contact: Jenna Burke, jburke@hsag.com
20 Evaluation Completion Followed by Meeting Summary Barb Averyt Your Meeting Evaluation Feedback Is Needed Target: at least 85% of you will complete a meeting evaluation form. Please complete the evaluation before you leave today (fold in half and leave on the center of the table). Your feedback is very important to us and highly valued
21 Meeting Summary Connecting all the moving pieces 41 Questions? 42 21
22 Thank you! Ettie Lande, MS, RN This material was prepared by, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-11SOW-C
West Valley and Central Valley Care Coordination Coalitions
West Valley and Central Valley Ettie Lande, MS, BSN, ACM-RN February 08, 2018 Thank You! For sponsoring today s breakfast AstraZeneca and Cyndi Black If you can sponsor breakfast at an upcoming community
3+ 3+ N = 155, 442 3+ R 2 =.32 < < < 3+ N = 149, 685 3+ R 2 =.27 < < < 3+ N = 99, 752 3+ R 2 =.4 < < < 3+ N = 98, 887 3+ R 2 =.6 < < < 3+ N = 52, 624 3+ R 2 =.28 < < < 3+ N = 36, 281 3+ R 2 =.5 < < < 7+
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