Outline. The Hospital Readmissions Puzzle: Where Does Nutrition Fit? Participant Poll. Participant Learning Objectives 3/26/2018

Transcription

1 The Hospital Readmissions Puzzle: Where Does Nutrition Fit? JOY W. DOUGLAS, PHD, RD, CSG, LD ASSISTANT PROFESSOR DEPARTMENT OF HUMAN NUTRITION THE UNIVERSITY OF ALABAMA Outline CMS Readmissions Programs Overview: Hospital Readmissions Reduction Program (HRRP) Skilled Nursing Facility Value Based Purchasing Program (SNF VBP) The Readmission Nutrition Link Strategies for Clinicians Participant Learning Objectives Participant Poll Explain the differences between the Hospital Readmissions Reduction Program and the Skilled Nursing Facility Value Based Purchasing Program Describe the link between hospital readmissions and poor nutritional status Generate 2 strategies they can implement in their facility to reduce hospital readmissions What type of facility do you work in? Hospital Nursing Home Rehabilitation Facility Home Health Agency Academia/Research Other 1

2 The Hospital Readmissions Reduction Program 1,2 Result of the 2010 Affordable Care Act Goal: Improve quality of care and save taxpayer dollars by incentivizing providers to reduce excess readmissions Links payment to quality of hospital care Excess Readmissions = Poor quality of care Facilities can lose up to 3% of CMS reimbursement for all Medicare claims The Hospital Readmissions Reduction Program 1,2 WHAT IS A READMISSION? Admission to an applicable hospital within 30 days of being discharged with an eligible diagnosis Readmission diagnosis and facility can vary ELIGIBLE DIAGNOSES? Acute MI Heart Failure Pneumonia COPD Elective primary THA or TKA CABG surgery *Includes ICD 9 & 10 codes What s an Applicable Hospital? 1,2 General, acute care, short stay hospitals (Subsection D) Maryland hospitals participating in the All Payer Model, although financial penalties are not in place for FY 2018 Does not include: Long term care hospitals Children s hospitals Psychiatric hospitals PPS exempt cancer hospitals Rehabilitation hospitals and units Critical Access hospitals How Are 30 Day Readmission Rates Measured? 1,2 Over a rolling 3 year period for Medicare beneficiaries: July 1, 2013 June 30, 2016 Each hospital receives an Excess Readmissions Ratio (ERR), comparing actual readmissions to predicted ones Lower ratios are better (<1.0); higher are worse (>1.0) Adjusted for case mix and patient risk factors Determine Medicare payments to facilities See Hospital Compare website: reductionprogram.html 2

3 Participant Poll How familiar are you with the Skilled Nursing Facility Value Based Purchasing program? Not familiar at all Slightly familiar Moderately familiar Very familiar The Hospital SNF Relationship 3 20% of hospital Medicare patients D/C to SNFs 2017 Study: The SNF a patient is discharged to is a greater predictor of rehospitalization than the hospital they came from The SNF s operations directly impact their own finances, and those of the hospital Hospitals want to discharge patients to SNFs that have low rehospitalization rates establishing preferred provider networks with SNFs to partner in reducing readmissions The Skilled Nursing Facility Value Based Purchasing Program (SNF VBP) 4, Protecting Access to Medicare Act (PAMA) Takes effect in FY 2019 October 1, 2018 Measures all cause rehospitalizations from a SNF within 30 days of hospital discharge Impacts SNFs paid under the Prospective Payment System (PPS) *Will transition to measuring 30 day potentially preventable readmissions as soon as it is practicable The Skilled Nursing Facility Value Based Purchasing Program (SNF VBP) 4,5 2% of Medicare reimbursement will be withheld from SNFs and given as incentives for top performers Baseline period: January 1 December 31, 2015 Performance period: January 1 December 31, 2017 During the performance period, each facility will be compared to: Their own 2015 baseline period = Improvement score Other SNFs during the current period = Performance score 3

4 Facility Score Reporting 5 Confidential, quarterly facility updates available in QIES and CASPER Scores will range Higher = better and Education/Outreach/NPC/Downloads/ SNF VBP Presentation.pdf Public Reporting: Nursing Home Compare 5 What does this have to do with nutrition? 4

5 30 day Readmission Rate Most Common Readmission Diagnoses 6 30% 25% 20% 15% 10% 5% 0% 25% 20% *Condition has a direct connection to nutritional status 18% Heart Failure* Heart Attack* Pneumonia* Common Causes of Readmission Among Older Adults in Long Term Care 7 Lung disease (COPD)* Low body weight or low BMI* Pressure ulcers* Diabetes* Cognitive impairment Depression Swallowing difficulties* Presence of a urinary catheter or feeding tube* Urinary tract infections* Increasing number of medications taken daily* *Condition/factor has a direct connection to nutritional status The Readmission Nutrition Link: What Does All of This Mean? Nutrition is closely related to readmission risk Malnourished patients have higher readmission rates. 8,9 YOU can help reduce rehospitalizations! Reducing Readmissions: Strategies for Clinicians Establish a Nutrition Support Team Designate a Nutrition Champion Upon Admission During Inpatient/Nursing Home Stay Preparing for Discharge Appropriate Use of Palliative Care 5

6 Establish A Nutrition Support Team 10 Interdisciplinary Nutrition Support Teams (NSTs) have been associated with improved nutrition related outcomes. Advocate for the creation of an active interdisciplinary NST for the patients/residents in your facility. Include representatives from pharmacy, nursing, the therapies, etc. Designate Champions Designate A Nutrition Champion 10 a Nutrition Champion at the facility to provide increase awareness of the importance of nutrition, and to provide training to other disciplines. can be nutrition specialist physicians, dietitians, and/or nurse leaders. Champions Champions would advocate, model, teach, and reinforce best practice nutrition. Upon Admission 11,12 Aggressively identify and treat malnutrition/undernutrition Use evidence based, validated screening tools Mini Nutritional Assessment (MNA) Malnutrition Screening Tool (MST) Malnutrition Universal Screening Tool (MUST) Nutrition Risk Screening 2002 (NRS 2000) Short Nutritional Assessment Questionnaire (SNAQ) Upon Admission 11,12 Implement interventions promptly Consider nutritional protocols that nursing staff can immediately implement upon admission, when indicated Study by Sulo et al (2017): Nurses screened patients using the MST upon admission If score 2, oral nutrition supplements were automatically ordered in EMR Estimated readmissions cost savings of $310,061 for 769 patients ($403 per patient), and reduced hospital length of stay by 0.6 days per patient 6

7 During Inpatient/Nursing Home Stay 13 Try innovative approaches to improve oral intake Hydration Programs To reduce readmissions for dehydration and UTIs Hydration stations with fruit and herb infused beverages, served in clear dispensers Display in common areas and serve during activities During Inpatient/Nursing Home Stay 13 Try innovative approaches to improve oral intake Appetizing pureed foods To combat poor intake among those with dysphagia Use food molds and piping sets to make food visually appealing One Michigan facility saw unplanned wt. loss decrease from 3.7% to 1.3% after implementing a pureed foods program During Inpatient/Nursing Home Stay 13 Fortified Foods Program To reduce readmissions related to weight loss, anorexia, pressure ulcers, and debility Replace liquid nutrition supplements with fortified menu items Examples: fortified smoothies, super cereal, fortified mashed potatoes, etc. Will also help to reduce nutrition supplement costs Preparing for Discharge Coordination of Care Address food insecurity before discharging patients/residents back into the community 7

8 Coordination of Care 10 Malnutrition is a risk factor for readmission, so providing for adequate nutrition care after discharge is essential. Discharging individuals without planning for how to continue their interventions and plan of care causes fragmented care. Fragmented care wastes as much as $25 45 billion annually, and leads to increased readmission rates, complications, and decreased independence and functional ability for patients. Fragmented care example: A complicated tube fed patient with documented intolerances to multiple formulas is transferred to a rehab facility. Rehab facility RD receives no nutrition information about the patient upon admission. Rehab RD then spends 7 days trying various feeding formulas and regimens to find something that the patient can tolerate. Coordination of Care 10 Things to think about: Where is this patient going after discharge? Are your nutrition interventions appropriate and realistic for the patient to continue after leaving your facility? Does the facility they are going to next have a dietitian? Can the next facility continue your nutrition care plan? Can you communicate with the healthcare team who will be caring for this patient after discharge? Addressing Food Insecurity 14,15 As of 2010, an estimated 5.6 million older adults either lived below the poverty level, or were considered near poor (<125% of the poverty level) Food insecurity is associated with hospital admissions Greatest risk: older minorities and older females Before discharge home, assess whether patients have access to adequate food to meet their needs Addressing Food Insecurity 14 Food Insecurity Programs Healthy Food Prescriptions MD rx provides vouchers to pay for healthy food options, primarily fruits and vegetables Multiple programs in pilot stages in the U.S. Funded by health systems, or by community agencies Medically Tailored Meals Dx specific meals planned by RDs, delivered to the patient s home Funded by Medicaid as part of the waiver program Nutrition champion: advocate for your facility to participate in programs that connect at risk patients with community resources to ensure adequate nutrition. 8

9 Appropriate Use of Palliative Care 16,17 Palliative care is: A team based approach, focusing on improving the patient s overall quality of life through: Symptom management Clarifying the priorities of the patient Matching treatments to the patient s goals Appropriate for any age and any stage of serious disease Compatible with curative treatment, and can be provided at the same time Appropriate Use of Palliative Care 16,17 Palliative care is NOT: Limited to those with a life expectancy of < 6 months Hospice care Giving up on a patient; rather, it focuses on identifying and meeting the needs and wishes of the patient Appropriate Use of Palliative Care 16,17 Active palliative care programs are associated with: pa ent quality of life pa ent and family sa sfac on with care hospital readmission rates health care costs Without palliative care, older adults with terminal conditions are subjected to: hospital readmissions Medical interven ons and procedures that quality of life Palliative Care: How Do We Get There? 16,17,18 Designate a Palliative Care Champion at your facility Train staff members on the components and purpose of palliative care Educate family members on palliative care Use a team approach to clearly define the patient s goals of care Improve communication between the patient, their family members, and the health care team members Collaborate with palliative care teams at local hospitals 9

10 Figure 1 from Tappenden et al (2013) Figure 3 from Tappenden et al (2013) References 1. Centers for Medicare & Medicaid Services. Hospital Readmissions Reduction Program Frequently Asked Questions Fiscal Year QualityNet website. er2&cid= Accessed February 22, Centers for Medicare & Medicaid Services. Hospital Readmissions Reduction Program: Fiscal Year 2018 Fact Sheet. QualityNet website. er2&cid= Accessed February 22, Rahman M, McHugh J, Gozalo PL, Ackerly DC, Mor V. The contribution of skilled nursing facilities to hospitals readmission rate. Health Services Research. 2017;52(2): Centers for Medicare & Medicaid Services. The Skilled Nursing Facility Value Based Purchasing Program (SNF VBP). Centers for Medicare & Medicaid Services Website. Initiatives Patient Assessment Instruments/Value Based Programs/Other VBPs/SNF VBP.html Last updated December 20, Accessed February 22, Medicare Learning Network. Skilled Nursing Facility (SNF) Value Based Purchasing (VBP) Program Fiscal Year (FY) 2018 Final Rule. and Education/Outreach/NPC/Downloads/ SNF VBP Presentation.pdf Presented November 16, Accessed February 22, References 6. Dharmarajan K, Hsieh AF, Krumholz HM, et al. Diagnoses and timing of 30 day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. Journal of the American Medical Association. 2013;309(4): Dwyer R, Stoelwinder J, Gabbe B, Lowthian J. Unplanned transfer to emergency departments for frail elderly residents of aged care facilities: a review of patient and organizational factors. Journal of the American Medical Directors Association. 2015;16(7): Agarwal E, Ferguson M, Isenring E, et al. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in hospital mortality: Results from the Nutrition Care Day Survey Clinical Nutrition. 2013;32: Fingar KR, Weiss AJ, Barrett ML, Elixhauser A, Steiner CA, Guenter P, et al. All cause readmissions following hospital stays for patients with malnutrition, HCUP Statistical Brief #218. December Agency for Healthcare Research and Quality, Rockville, MD. Accessed March 21, Rosen B, Maddox P, Ray N. A position paper on how cost and quality reforms are changing healthcare in America: focus on nutrition. Journal of Parenteral and Enteral Nutrition. 2013;37(6): Sulo S, Feldstein J, Partridge J, Schwander B, Sriram K, Summerfelt W. Budget Impact of a Comprehensive Nutrition Focused Quality Improvement Program for Malnourished Hospitalized Patients. American Health & Drug Benefits. 2017;10(5):

11 References 12. Tappenden K, Quatrara B, Parkhurst M, Malone A, Fanjiang G, Ziegler T. Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition. Journal of the Academy of Nutrition and Dietetics. 2013;113(9): LaVecchia Ragone G. Using nutrition to battle readmissions. Long Term Living: For The Continuing Care Professional. 2014;63(1): Swinburne M, Garfield K, Wasserman A. Reducing Hospital Readmissions: Addressing the Impact of Food Security and Nutrition. Journal Of Law, Medicine & Ethics. 2017;45(S1): Bernstein M, Munoz N. Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults: Promoting Health and Wellness. Journal of the Academy of Nutrition and Dietetics. 2012;112(8): Silvers A, Rogers M. Minimizing Readmission Penalties with Palliative Care. Hfm (Healthcare Financial Management) [serial online]. March 2018: Giuffrida J. Palliative Care in Your Nursing Home: Program Development and Innovation in Transitional Care. Journal Of Social Work In End Of Life & Palliative Care. 2015;11(2): References 18. Cherlin E, Brewster A, Curry L, Canavan M, Hurzeler R, Bradley E. Interventions for Reducing Hospital Readmission Rates: The Role of Hospice and Palliative Care. American Journal Of Hospice & Palliative Medicine. 2017;34(8): Questions? 11