Re-Hospitalizations and the Bottom Line: What SNFs Can Do to Get Ready. Maureen McCarthy, RN, BS, RAC-CT, CPRA President & CEO Celtic Consulting

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1 Re-Hospitalizations and the Bottom Line: What SNFs Can Do to Get Ready Maureen McCarthy, RN, BS, RAC-CT, CPRA President & CEO Celtic Consulting

2 OBJECTIVES Define Rehospitalization and discuss current statistics Focus on the principles of prevention including interventions to protect patients and SNFs from rehospitalizations Discuss how to integrate interventions into everyday practice Identifying avoidable and unavoidable readmissions 2

3 HOW MANY OF YOU? Track your rehospitalizations? Know what your current rehospitalization rate is? Know what your referring hospital has for your rehospitalization rate?

4 RE-HOSPITALIZATIONS Measuring the rate of patients being re-admitted to the hospital Generally limited to a 30-day period But some hospitals are now looking at a 90-day episode of care. Studies have identified a system failure in the safety and stability of transitioning patients between care levels

5 WHY ARE RESHOSPITALIZATIONS SUCH AN ISSUE? Frequency o About 1 in 5 Medicare fee-for-service patients discharged from the hospital is rehospitalized within 30 days (Hansen, L.,Et. Al pg.520) o 20% of Medicare patients discharged to SNFs were readmitted within 30 days. The percentage increased to 27% if the patient was a nursing home resident prior to hospital readmission (Rahman, M, Et.Al.2013, pg.1899) 5

6 WHY ARE REHOSPITALIZATIONS SUCH AN ISSUE? Avoidable o 30% to 67% of hospitalizations among nursing facility residents could be prevented with welltargeted interventions (Jacobsen, et.al., 2010) I.E. Interventions based on the root causes, disease specific interventions o Appropriate interventions could save nearly $1.3-$2.9 billion a year 6

7 WHY IS THIS CMS FOCUS? 1. Cost $18 billion annually spent on Medicare covered readmissions within 30 days of hospital discharge $25 billion spent on all patients annually NEJM 2009

8 WHY IS THIS CMS FOCUS? 2. Frequency Too many readmissions, happening too often The 30-day period following discharge is a volatile period. 3. Easiest to control Threat of decreased funding SNFs are responsible for $4.34 billion in re-admissions

9 BEST PRACTICE STUDY Compares data at each level looking for effectiveness of interventions Nursing home, home health, community, hospital, etc. Determining the root causes of rehospitalizations from each setting How effective are providers at each level?

10 FOCUS OF STUDY Why is it happening? Epidemiology of avoidable rehospitalizations from each setting Root cause Service interventions Patient/family education, telemonitoring Disease specific interventions- CHF, COPD, Hip fractures If patients fell into multiple disease categories, the primary focus was used

11 BEST PRACTICES STUDY 4 areas of evidenced based interventions that reduced re-admits 1. Enhanced care & support 1. During care transitions 2. Improved patient education & selfmanagement support 3. Multidisciplinary team management 1. At least 2 disciplines 4. Patient-centered care at end-of-life

12 ENHANCED CARE & SUPPORT Improved discharge process Early post-discharge follow up Front-loaded home care visits Most effective with CHF patients Remote monitoring 14-55% reduction in all-cause re-admits 80% reduction with regular RN contact-chf pts Nurse-led transition care services

13 IMPROVED PATIENT EDUCATION & SELF-MANAGEMENT Providers that had improved the following processes seemed to have reduced rehospitalizations by 35-39% Family and Patient education and support to manage themselves and their illness Disease management or case management Either managing the specific disease, as in certain studies, or the patient themselves

14 MULTIDISCIPLINARY TEAM MANAGEMENT Care involving 2 or more disciplines Nursing, medical, rehab, nutrition, medication review, social work, specialty areas, etc.

15 END OF LIFE CARE Patient-centered care planning for end of life Generally 6 months or less life expectancy Hospice referrals

16 WHAT ARE HOSPITALS DOING? Better care and support for the patient Getting the patient more involved with the discharge process Scheduling follow up appointments for the patient (make them as soon as possible after discharge) Homecare (Tele-monitoring) Nurses following up with patients after discharge

17 HOSPITAL RE-ADMISSIONS Now we know why. Let s talk about HOW we can reduce our numbers What other considerations?

18 CONSIDERATIONS Over 50% of readmissions within 30 days did not have a claim for physician services in between readmissions 70% of surgical patients were readmitted within 30 days for medical reasons NEJM 2009

19 FAMILY CAREGIVERS Consider what happens when patients are discharged to home: 46% of family members performing nursing tasks (includes spouses) 75% performing medication management 33% performing wound care 66% get no home services AARP

20 AFTER CARE Emergency Room visits account for 40% of post-discharge hospital care Wall Street Journal Return Patients Vex Hospitals January 23, SNFs will start to see more admission direct from the ER Some may qualify for Medicare, some may be managed

21 SNFS ARE PART OF THE SOLUTION Need to develop a plan to improve care across ALL settings All care providers need to work together Bundling services/shared savings Hospitals being penalized up to 3% Medicare reduction SNF providers are next CMS is looking at a 2% in FY 2019

22 WHERE DO WE START? There is no 1 single solution CMS 3 pronged approach Improved health Improved patient experience Reduce costs

23 WHERE DO WE START? Focus on reducing costs Eliminate unnecessary or duplicative services, work with other care providers Labs Diagnostic tests Screenings Encourage physicians to get on board

24 KNOW YOUR NUMBERS Keep track of your discharges Review data to identify trends Know what you are tracking CMS focus CHF, PNA, AMI (Congestive Heart Failure, Pneumonia, heart attack) Most hospitals track: all cause readmits Any reason for returning within 30 days

25 TRACKING READMITS CMS focus diagnoses Most common readmissions came from 3 diagnoses, so the focus started there 25% of CHF patients readmitted within 30d 20% of MI patients readmitted within 30d 18% of PNA patients readmitted within 30d

26 TRACKING DATA Knowing your numbers may not be enough If tracking only CMS diagnoses May still see decreasing referrals You may have increased readmits for other diagnoses Readmits cost, regardless of diagnosis or reason

27 WHAT CAN SNFS DO? Building a partnership with a Hospital o Frequent referrals to the same SNF In a study conducted between it was determined that re- Hospitalization rates are lower in SNFs that take a majority of their patients from a single hospital 27

28 WHAT CAN SNFS DO? Building a partnership with a Hospital o Frequent communication between SNF and hospital Information sharing Continuity of care Care plan exchanges o Adoption of common clinical protocols 28

29 HOW CAN SNFS HELP? Take care of avoidable re-admissions in-house Avoidable (not all inclusive) Hydration Monitoring Diagnostic testing that can be handled inhouse Examples UTI, dehydration, medication management

30 UNAVOIDABLE READMITS Unavoidable (not all inclusive) Emergent care Suturing Surgical intervention, etc. Examples Falls with closed head injury Major lacerations Compromised airway Absence of vital signs

31 QA TO MONITOR RESULTS What happens if I sent an avoidable readmit to the hospital? Interact Tools-Transfer Check List, or other system to monitor What happened before the transfer? What actions were taken before the transfer? What factors affected the transfer decision? Could this transfer have been avoided? What improvement can be made for the next situation?

32 IN-HOUSE TREATMENT Assess situation for probable vs. possible injury Can this situation be treated in-house? Do you have the resources to treat this type of situation? Are there contract services available to assist? IV starts, FEES tests, physician extenders

33 WHAT CAN SNFS DO? Medication Monitoring o Over medication Monitor for side effects of medication, especially new medications) Collaborate with physicians about smaller dosage 33

34 WHAT CAN SNFS DO? o Medication Monitoring o Medication Adherence Studies have shown that poor med adherence causes 10-20% of rehospitalizations Monitor medication refusal trends and reasons for refusal Evaluate nurses med pass efficiency Medication reconciliation part of the admission process 34

35 BUILDING TRUST Build your program in step increments Nurses must collect the data the physician needs Interact III tools are helpful Give the right information at the right time The physician must trust that the SNF can handle the situation safely and effectively Different forms based on diagnosis, or any Communication is imperative! Make sure all initial information is shared between caregivers

36 PLAN DEVELOPMENT Ease of program use may ensure compliance When to report How to report Why interventions were taken and the results or effect on resident

37 BUILDING SKILLS Education for nursing staff is crucial Training to handle clinical situations Invest in your team Opportunity to partner with hospital or other care setting Keeping nurses current with skills Assessment skills will be key

38 BUILDING SKILLS Identify and document resident changes Communicate changes to other staff Identify opportunities to avoid hospitalization What could have been done differently? Give the program importance Make it important enough to follow up on

39 BUILDING SKILLS Improved documentation in the medical record will enable staff to go back and evaluate all signs, symptoms and changes May want to use results of the root cause reviews to train on facility specific case studies What to do, what not to do

40 BUILDING SKILLS Interact tools offer systems to assist staff nurses List of signs and symptoms allowing nurses to become more familiar with potential changes in condition so they can be comfortable compiling data Helps to determine whether the observed S/S need to be reported immediately or whether they are non-immediate

41 BUILDING SKILLS Don t for get the CNA staff! Largest amount of direct time per pt. Many times recognize slight changes Consistent staffing could help with learning the resident s baseline Consider a documentation system to assist with communication to nurses

42 COORDINATION Better coordination of discharged residents Medicare residents discharged within 30 days from SNF Simple 1 st measure.make a call! Recommend using a nurse so that they can address clinical issues 20% of hospital readmissions are SNF residents Even if 20% of discharges return, nice increase in census

43 COORDINATION Identify which residents are high risk of complications Criteria Diagnosis Previous complications Multiple admits over a period of time JEN Frailty index Availability of resources at home

44 WHAT NEXT.. How do I turn this into a program at my facility? Pulling it all together

45 IMPROVE ASSESSMENT SKILLS Identify residents at high risk for complications/change in condition Identify the root cause for the change Improve monitoring in order to identify changes early and treat quickly

46 ENHANCE STAFF TRAINING Improve assessment skills for nurses Performing timely and accurate clinical assessments Utilize partners, vendors, collaboratives, QIO, other care settings for their expertise

47 IMPROVE COMMUNICATION Between physicians and extenders (APRNs, PAs) and facility nursing staff Provide timely meaningful information to the physician Update physician on changes

48 RE-EVALUATE EFFECTIVENESS Timely follow up Go back and assess resident condition Re-assess treatment plan Not care plan, just the immediate treatment for the compromised condition Clinical and/or medical evaluation

49 CARE LEVEL COORDINATION Meet with local referring hospitals, home health agencies, or others in your collaborative to see if there is anything you can be doing now to assist in transitioning your residents between their care level and yours.

50 THANK YOU!!! Additional References Boutwell, A. Hwu, S. Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence. Cambridge, MA: Institute for Healthcare Improvement: 2009 Jencks, S., Williams, M., & Coleman, E. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360 (14), doi: /nejmsao Rahman, M., Foster, A., Grabowski, D., Zinn, Jacqueline., & Mor, V. (2013). Effect of Hospital-SNF Referral Linkage on Rehospitalization. Health Service Research, 48(6 Pt 1), Thirty Day Readmission Rates for Heart Attack Failure and Pnuemonia at Cedars-Sinai Hospital. (2014). Retrieved on April 13, 2014 at Pnuemonia-at-Cedars-Sinai.aspx. Kessler, B., & Arrellano, M. (2013). 15 Ways To Attack Readmissions. Retrieved on March 15, 2014 from 0readmissions%20FINAL%20(2).pdf

51 QUESTIONS? Maureen McCarthy, RN, BS, RAC-CT President & CEO of Celtic Consulting Office: x22 Cell: South Road, Suite 3 Farmington, CT

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