Care Transitions in Michigan

Transcription

1 Care Transitions in Michigan Nancy D. Vecchioni, RN, MSN, CPHQ Haggerty Road, Suite 100, Farmington Hills, MI

2 22670 Haggerty Road, Suite 100, Farmington Hills, MI

3 State Variation: Hospital Admissions Indicators Best State All States Median Worst State Michigan Medicare beneficiaries readmitted to hospital within 30 days Long-stay nursing home residents admitted to hospital Nursing home residents readmitted to hospital within 30 days Home health patients admitted to hospital DATA: Medicare readmissions Medicare 5% SAF Data; Nursing home admission and readmissions 2006 Medicare enrollment records and MEDPAR file; Home health admissions 2007 Outcome and Assessment Information Set SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009

4 Michigan Medicare Patient 30-Day All Cause Readmission Rates (%) by County, 2010 Statewide Medicare Patient Readmission Rate= 19.9% Readmission Rates are Greatest in Southeast Michigan

5 Post Acute Care Readmission Rates 10/1/2010 9/30/2011 Discharges Number of 30 Day Readmissions Rates Geographic Region Setting Total (A) To Setting (B) % to Setting (B/A) Total (D) From Setting (E) % from Setting (E/D) % of discharges readmitted (D/A) % of discharges to setting readmitted (E/B) HHA 445,924 90, % 88,368 21, % 19.82% 23.62% State of Michigan Home 445, , % 88,368 39, % 19.82% 17.20% Hospice 445,924 13, % 88, % 19.82% 2.44% SNF 445,924 86, % 88,368 21, % 19.82% 24.79% 5

6 Medicare Readmissions Rates by Physician Follow-Up and among Hot Spotters CY 2010 MI Statewide Population Segment Total Discharges Eligible for Readmission Readmission Within 30-days of Discharge N % N % Physician Follow-up within 30 days of discharge No Yes # of Admits in prior 3 months > Total

7 Report of 30-Day All-Cause Readmission Rates for: Statewide Time Period: 2010Q1-2010Q4 Payers: Medicare FFS, Medicaid FFS, BCNM, BCBSM, HAP, Priority Health, Health Plus (Managed Care Data are reported by these payers) See Data Definitions for Column Descriptions a b c d e f g h I PRODUCT Line Type of Index Discharges at RA to the Same Hospital RA to a Different Hospital RA to Any Hospital AGE GROUP Admission Risk N N % N % N % M 77,402 8, % 2, % 11, % Adult S 81,427 4, % 1, % 5, % O 38, % % 1, % M 8, % % % Pediatric S 3, % % % Commercial O % 2 0.5% % Post-neonatal M 1, % % % S % 9 2.2% % Neonatal M 35, % % % S % 0 0.0% 5 5.8% Total 248,518 15, % 4, % 19, % M 87,502 11, % 3, % 14, % Adult S 30,616 3, % 1, % 4, % O 58,039 2, % % 2, % M 13,537 1, % % 1, % Pediatric S 4, % % % Medicaid FFS O 2, % % % Post-neonatal M 5, % % % S 1, % % % Neonatal M 50, % % 1, % S 3, % % % Total 257,064 20, % 5, % 26, % M 3, % % % Adult S 1, % % % O 5, % % % M % % % Pediatric S % 3 1.0% % Medicaid Managed Care O % 1 0.4% % Post-neonatal M % 5 1.3% % S % 1 2.9% 3 8.8% Neonatal M 3, % % % S % 0 0.0% 0 0.0% Total 15, % % 1, % M 19,025 2, % % 3, % Medicare Managed Care (reported by Adult S 10, % % 1, % payers) O % 0 0.0% 0 0.0% Total 29,769 3, % 1, % 5, % Medicare (FFS) Adult M 344,416 56, % 15, % 71, % S 138,493 11, % 3, % 14, % U 2, % % 1, % Total 485,651 68, % 18, % 87, % Total by Age Group Adult 899, , % 28, % 133, % Pediatric 34,822 3, % % 3, % Post-neonatal 9, % % % Neonatal 92,767 1, % % 1, % Grand Total 1,036, , % 29, % 139, %

8 Integrate Care for Populations & Communities - Objectives and Outcomes Improve the quality of care for Medicare beneficiaries who transition among care settings through a comprehensive community effort Coordinate community-wide adoption of improved practices Facilitate Community Coalition Charters Yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries 8

9 Integrate Care for Populations & Communities Project Goals Reduce 30-Day Hospital Readmissions by 20% Communities participating in formal Care Transitions (CT) Program (e.g. ACA 3026 Community CT demo, AAA CT grants) Eligible entities CBOs, high-readmission hospitals Community-level coalition building, data analysis, action plan development Recruit at least four communities Northern Southeast Michigan Western Southeast Michigan Calhoun County Ingham County Detroit High-level of CBO involvement especially AAAs 9

10 Integrate Care for Populations & Communities Project Goals Communities not accepted in a formal CT Program Continue to provide technical assistance 7% reduction in readmissions Part of statewide CT learning network MI STA*AR 2% reduction in readmissions 10

11 Integrate Care for Populations & Communities Provide Technical Assistance Community Coalition Formation Materials to use as models for community coalition formation Consultative support for convening a community coalition Technical support to create an initial strategic plan for organization, intervention, monitoring, and decisionmaking that articulates how the community proposes to achieve the aims 11

12 Integrate Care for Populations & Communities Provide Technical Assistance Recruit and educate provider groups and communities to participate in formal Care Transitions Initiatives Data analysis and reports Community and individual hospital Root cause analysis readmission drivers Evidence-based intervention selection & implementation process Provide intervention measurement strategies 12

13 Medicare All-Cause Re-Hospitalization Within 30 Days of Discharge from a Michigan Hospital, 1C Service Area, 1/1/08 12/31/10 Population Segment Race Age Sex Physician Follow-up within 30 days of discharge Diagnosis Length of Index Admission # of Admits in prior 3 months Time^ MI Statewide Total Discharges Eligible for Readmission Readmission Within 30- days of Discharge Total Discharges Eligible for Readmission Zip Code Region Readmission Within 30- days of Discharge N % N % N % N % White Black Other < > M F No Yes CHF AMI PNE COPD OTHER < 4 days days > 8 days > Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr

14 Integrate Care for Populations & Communities Provide Technical Assistance Ongoing QIO assistance if not accepted into a formal Care Transitions Program in the following areas: Monthly or Quarterly Readmission Metrics Intervention measurement strategies 14

15 Current CCTP Participants 15

16 Integrate Care for Populations & Communities Statewide CT Learning and Action Network Bring together groups of quality-minded providers, consumers, physicians and stakeholders to focus on improving care delivery and outcomes Shared goal to improve quality of care as patient transition between setting types Rapid, wide-scale improvement Action-based May 1 st kick-off with 350+ attendees MISTA*AR platform for LAN Future webinars and conference calls Affinity groups 16

17 Integrate Care for Populations & Communities Progress Recruitment Have formally recruited five communities Three have applied for and two successfully received 3026 funding; one awaiting review One submitting application in May 2012 Actively assisting three additional communities 17

18 Statewide Summit May 1, 2012 How to Guides expanded to all healthcare settings Transformation of MI STA*AR steering committee to Care Transitions Coalition Development of Care Transition Initiatives Crosswalk Development of affinity groups Expansion of ReWaRD report to post acute care settings 18

19 Frequent User System Engagement CSH (cross continuum, community) Advanced Care Planning Lisa Ashley (Cross Continuum) ReWaRD Harolyn Baker, MPRO Care Link & Coordination MPRO (Cross Continuum) Payor/ Payment Policy Robert Yellan Facilitator Medication Management MPRO (Cross Continuum) Hospital to Physician Coordination MHA

20 Individually, we are one drop. Together, we are an ocean." A TSUNAMI Ryunosuke Satoro & Nancy Vecchioni