Transitioning Care to Reduce Admissions and Readmissions. Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH

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1 Transitioning Care to Reduce Admissions and Readmissions Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH

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6 Disclaimer: Potential for Error Type One Error Rejecting the null hypothesis when it is true Saying there is a meaningful difference between drugs when there is not Type Two Error Accepting the null hypothesis when it is false Saying there is not a meaningful difference between drugs when there is Type Three Error The unintentional error of solving the wrong problems precisely Type Four Error The intentional error of solving the wrong problems

7 Objectives Discuss policy and future trends related to hospital readmissions and their role in value-based purchasing Understand the evidence for and against readmission reduction strategies Describe care transition best practices Understand regulatory and payment support for care coordination

8 Why?

9 Cost For 31 of the past 40 years, health care costs have increased at a greater rate than the economy as a whole Health care costs constitute 18% of U.S. GDP 30% increase in personal income over the past decade effectively eliminated by a 76% increase in health care costs $765B in waste

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12 Comparisons Health expenditures per capita (US$PPP)

13 Comparisons Life expectancy at birth

14 Comparisons

15 Missed Opportunities The U.S. Health Care System Today

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23 Challenges lead to readmissions Representative timeline of a patient s experiences in the U.S. health care system

24 Lack of coordination leads to costly care 90% of readmissions are unplanned Limited access to post-hospitalization follow-up care Usually related to poor care coordination and continuity <50% see a provider prior to the readmission Preventable transition errors (mostly medication related) Most patients are on 6+ medications at time of discharge Cost $25B annually Readmitted patients more costly with prolonged LOS Preventable readmissions could save $12B/year Heart disease and stroke lead the way, followed by diabetes

25 The situation Growing population with progressive disabilities requiring long-term services and supports 6M receive home, community or nursing home care in US Frequent changes in health Multiple transitions among providers 15% Medicare beneficiaries have chronic illness and long-term care needs 1/3 of Medicare spending Much of this spending and associated care is unnecessary

26 The response Hospital Compare Partnership for Patients Shared savings initiatives Affordable Care Act Section 3023, National Pilot Program on Payment Bundling Section 3025, Hospital Readmissions Reduction Program Section 3026, Community-Based Care Transitions Program National Quality Strategy

27 Partnership for Patients Funds hospital-level improvements 3500 hospitals 700,000 (75% of) index admissions among FFS Medicare beneficiaries Goal: 20% reduction in readmission rate by the end of 2013 through improving transitions of care

28 Section 3025 Hospital Readmissions Reduction Program Penalties for hospitals with excessive rehospitalization $280M in ,000+ hospitals penalized (1,910 less than 1%) Increase to 2% in 2013 and 3% in 2014 Targets heart failure, pneumonia and acute MI Applies to additional conditions beginning in 2015 Quality improvement programs through patient safety organizations to eligible hospitals with high severity-adjusted rehospitalization rates

29 Section 3025 Hospital Readmissions Reduction Program Motivates providers to focus on preventable rehospitalizations Provides incentives for behavior that could lead to improvements in outcomes for all beneficiaries Promising interventions have effectively reduced rehospitalizations among older chronically ill adults

30 Section 3026 Community-Based Care Transitions Program $500 million available to community-based organizations, in combination with one or more hospitals with high rehospitalization rates Provide transitional care services proven to improve outcomes and reduce costs Designed to reduce fragmentation

31 National Quality Strategy Aims and Priorities

32 Discussion

33 Getting to specifics The term transitions of care refers to a patient leaving one care setting and moving to another as their condition or healthcare needs change. The care transition often involves multiple persons including the patient, family or other caregivers An optimal transition should be well planned with the involvement of the patient and family, and adequately timed. More often, however, the communication between settings and the coordination among caregivers, patients and healthcare professionals fail to provide all the information needed for optimum quality of care

34 Care transition strategies and processes Patient Engagement Care Coordination/Communication Successful Transitions

35 Key Elements to Improving Transitions Ensure patient is the central member of the healthcare team Accuracy of information: comprehensive medication reconciliation on admission & transitions Literacy level of information given Provision of patient education with teach back Determination of patient s confidence prior to discharge Creation of comprehensive follow-up plan for those at risk Collaboration with community resources

36 Patient Engagement Activities Find safe, decent care Communicate with health professionals Organize health care Pay for health care Make good treatment decisions Participate in treatment Promote health Get preventive care Plan for end of life Seek health knowledge

37 The Patient at The Center Take patient and family preferences into account in deciding needs after discharge Diagnose patient preferences Clear concise advance directives Ensure patient has a good understanding of responsibilities for managing own health at discharge Ensure patient understands the purposes for taking medications at discharge

38 Ensuring Patient is an Active Team Member Increase physician visibility on patient units Health care team rounds at bedside Written daily care plan for patient/family Disease education with teach back Discharge instruction and medication education at discharge with teach back New medication education by pharmacy Measure and address patient s confidence at managing the medical plan Comprehensive follow-up post-discharge for high risk patients with telephone coaching and monitoring of community resources

39 Care coordination Begins in hospital before discharge Out of hospital services aligned with patient s needs Home health, rehabilitation services, outpatient ancillary follow-up with dieticians/counseling, etc. Ensure patient is an active team member The team is key to readmission reduction and patient quality of life optimization Relay of information to outside entities is key

40 Care Coordination by Patient-Centered Medical Homes Process to identify patients with hospital admissions and ED visits Process to share clinical information with hospital/ed Process to obtain patient discharge summaries Process to contact patients for follow-up care after discharge Process to exchange patient information with hospital Collaboration with patient/family to develop written care plan for transitions from pediatric to adult care Electronic exchange of key clinical information with facilities Provides electronic summary of care for more than 50% of transitions of care

41 Strategies strong evidence Re-Engineered Discharge Discharge advocate (specially trained nurse) Education throughout hospitalization Calls to reinforce discharge plan and offer problem solving Transitional Care Model Pre- and post-discharge coordination of care for high-risk, elderly patients with chronic illness by APNs Consistency of provider across entire episode of care

42 Strategies strong evidence Care transition program Medication self management Patient-centered record Follow-up with physician Knowledge of red flags and how to respond Evercare Care Model Enhanced primary care and care coordination by NPs and care managers NP care in nursing home setting Development and coordination of personalized care plans with all health providers

43 Potential Strategies Engage patients in planning quality improvements Patient education steering committee After hospital care plans Discharge planning checklists Leverage technology Enable connectivity across critical people, services, and information Active engagement with patient-generated information Web-based surveys Remote monitoring

44 More strategies Care partners support active engagement of informal caregivers (e.g., friends, family, volunteers) Embedded Case Management 400% increase in case managers embedded in primary care offices from 2011 to 2012 Top care sites for ECMs: Primary care practice (58%) Clinic (13%) Community (15%) Hospital (52%)

45 Results

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50 Hospital Readmissions Reduction Program Readmission penalities in West Virginia FY /30 hospitals had no penalty 4/30 hospitals had maximum penalty (1.00%) FY /30 hospitals had no penalty 4/30 hospitals had penalties greater than 1.00%

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52 Unanticipated Consequences

53 Payment Bundling Incentivizes care delivery in the lowest-cost setting Creation of limited referral networks Market segmentation Withholding or denying services, shifting costs to postbundle period Excludes long-term services Little incentive to coordinate care before or beyond the episode Fails to integrate acute, postacute, and primary care services with community and institutionally based long-term services and supports

54 Section 3023 Barriers and Consequences Excludes long-term services Little incentive to coordinate care before or beyond the episode Fails to integrate acute, postacute, and primary care services with community and institutionally based long-term services and supports Incentivizes creation of limited referral networks and market segmentation Withholding or denying services, shifting costs to post-bundle period

55 Hospital Readmissions Reduction Program Barriers Many other health conditions commonly require rehospitalization (e.g., stroke, hip fracture, sepsis, UTI) Accounting for physical and cognitive deficits Chronic conditions + functional limitation = 2x cost Only high severity-adjusted rehospitalization rate hospitals eligible for QI services Excludes postacute and long-term care organizations High costs associated with preventing or reducing rehospitalization (e.g., electronic transfer of information)

56 Hospital Readmissions Reduction Program Unanticipated Consequences Ability of hospitals to offset relatively small losses from rehospitalization penalties with larger income earned from rehospitalization Penalty caps may incentivize hospitals to bear the penalties rather than the costs for prevention-related rehospitalization reduction strategies Availability of coding that could obscure or avoid measurement of some rehospitalizations (e.g. observational care)

57 Community-Based Care Transitions Program Hospitals serve as the hub of care transitions Program excludes patients not hospitalized or not living in geographic regions served by participating communitybased organizations Definition of high risk Medicare beneficiary Excludes those with low risk score but high functional impairment Not aligned with Medicaid or private payors Potential for duplication of services

58 It is not just about reimbursement

59 Or is it?

60 Financing Care Transitions

61 Getting Paid Discharge Encounter Discharge encounter Face-to-face examination Medication reconciliation Paperwork preparation/form completion Discharge summary dictation Time for completion is additive and must be documented Discharge summary Completion must be timely, even for observation services Succinct but complete Some musts Pertinent tests that were negative or positive Procedures restated with findings Medication list with medication changes from admission summarized Needed follow-up tests, office visits, or other appointments

62 Discharge care billable codes Inpatient care services (<30 minutes of time involved) (>30 minutes of time involved) Observation (outpatient) care services observation discharge (no time) admit/discharge same day Nursing home admission is separately billable even if performed on the same day

63 Getting Paid Transition Care Management Transition Care Management TCM codes mainly apply to primary care practices to help cover non face-toface services they offer Provided to patients discharged from Inpatient or observation status hospital care Skilled nursing facilities Partial hospitalization programs TCM Service: 99495/99496 Time period is 30 days (date of discharge and for next 29 days) Additional E/M visits outside of the one required are billed separately Documentation: date of d/c, date of dialogue to secure/confirm appointment, minimal content to address hospital course, subsequent correspondence, the E/M note associated with the f/u care, medication reconciliation no later than initial office visit

64 Transition Care Management (cont d) MDM of moderate complexity, face to face visit within 14 calendar days of discharge MDM of high complexity, face-to-face visit within 7 calendar days of discharge NOT to be used Unless physician or NPP accepts the care of patient post-discharge without a gap and accepts responsibility for the patient s care By surgeons in post-hospital global surgical period (90d) By hospitalists who do a one-time f/u visit By RHC and FQHCs In hospital hospital or hospital SNF transfer For TCM codes to be successfully used need partnerships: Hospital Hospital based physician Primary care physician Working as a team

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