West Valley and Central Valley Care Coordination Coalitions

Transcription

1 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 meeting, contact Cheryl Angotti cangotti2@hsag.com or call CVCCC WVCCC 2 1

2 Today s Agenda Welcome and Introduction West Valley and Central Valley Readmission and Adverse Drug Event (ADE) Data High-Risk Medication (HRM) Resources A Hospital s Readmission Reduction Journey Nursing Home Value-Based Purchasing (VBP) Update Home Health VBP and Conditions of Participation Update Readmission Assessment and Tools Behavioral Health Education and Updates Wrap up and Summary 3 CVCCC WVCCC 3 Your Meeting Feedback Is Important! Please help us exceed the 85% target! 2018 Evaluation Completion Rate % 85% 85% 85% QTR 1 QTR 2 QTR 3 QTR 4 4 CVCCC WVCCC 4 2

3 Road Map to Action West Valley and Central Valley Note the important takeaways from today s meeting on this Roadmap to Action. Share it with staff members and colleagues when you return to work. 5 CVCCC WVCCC 5 WVCCC/CVCCC 2018 Quarterly Meeting Schedule 6 CVCCC WVCCC 6 3

4 Social Determinants of Health Conference Tuesday March 27, :00 a.m. 3:30 p.m. Conference Cost: $25 per person Register Today! 7 CVCCC WVCCC 7 Community Introductions Who Is at Your Table? 8 CVCCC WVCCC 8 4

5 Data Update: Readmissions and ADEs Ettie Lande WVCCC/CVCCC How far are these care coordination coalitions from reaching the CMS readmission improvement target? Target RIR 1 = 12% RIR Goal is to reach or exceed this target by September 30, Relative Improvement Rate=RIR CVCCC WVCCC 10 5

6 Find Your Perfect 10 Challenge *Goal: 12% relative improvement rate in avoidable readmissions by September 30, CVCCC WVCCC 11 WVCCC Relative Improvement Rate (RIR): January 1, 2014 September 30, % 20.0% 15.0% 10.0% 5.0% WVCCC launched October % 4.15% 5.76% 6.72% 8.93% 11.46% 15.55% Desired Direction: Goal: 12% RIR* by Sept 30, % 18.07% 17.62% 16.82% 16.67% 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 Jul Jun 2017 Oct Sep 2017 Goal 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% Actual 3.64% 4.15% 5.76% 6.72% 8.93% 11.46% 15.55% 17.63% 18.07% 17.62% 16.67% 16.82% 12 Source: Medicare FFS Claims Data for beneficiaries residing within the ZIP codes of this community. *RIR is calculated based on the readmission rates per 1,000 beneficiaries and this formula: (Baseline Current)/Baseline. CVCCC WVCCC 12 6

7 WVCCC All-Cause Readmission Rates by Discharge Setting: October 1, 2016 September 30, 2017 Community Setting Discharged To 30-Day Readmission Rate 7-Day Readmission Rate West Valley CCC Home 12.9% 35.2% Skilled Nursing Facility (SNF) Home Health Agency (HHA) 21.4% 28.0% 19.2% 34.0% Hospice 2.3% 39.1% Other 18.1% 38.3% Total 15.1% 33.5% *Other: psychiatric hospital, long-term care hospital, acute rehab, intermediate-care, left against medical advise, based on hospital discharge disposition codes. 13 Data files provided to HSAG by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. CVCCC WVCCC 13 WVCCC Readmission Rates by Condition: October 1, 2016 September 30, 2017 Community Condition 30-Day Readmission Rate 7-Day Readmission Rate AMI 12.0% 48.8% HF 19.7% 30.6% West Valley CCC PNE 14.6% 31.3% COPD 20.2% 26.4% CABG 9.9% 50.0% THA/TKA 3.8% 37.2% 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 Data files provided to HSAG by the CMS were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. CVCCC WVCCC 14 7

8 CVCCC RIR: January 1, 2015 September 30, % 12.0% 10.0% 8.0% 6.0% CVCCC launched November 2015 Desired Direction: Goal: 12% RIR by Sept 30, % 4.93% 4.84% 5.64% 4.0% 2.0% 0.0% -2.0% -1.81% -2.66% 0.00% 1.90% -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 Jul 2016-Jun 2017 Oct 2016 Sep 2017 Goal 12.0% 12.0% 12.0% 12.0% 12.0% 12.0% 12.0% 12.0% Actual -1.81% -2.66% 0.00% 1.90% 5.46% 4.93% 4.84% 5.64% 15 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. CVCCC WVCCC 15 CVCCC All-Cause Readmission Rates by Discharge Setting: October 1, 2016 September 30, 2017 Community Setting Discharged To 30-Day Readmission Rate 7-Day Readmission Rate Home 12.8% 37.6% SNF 19.0% 32.5% Central Valley HHA 17.6% 37.8% Hospice 1.8% 56.3% Other 20.1% 37.1% Total 14.7% 36.6% *Other: psychiatric hospital, long-term care hospital, acute rehab, intermediate-care, left against medical advise, based on hospital discharge disposition codes. 16 Data files provided to HSAG by the CMS were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. CVCCC WVCCC 16 8

9 CVCCC Readmission Rates by Condition: October 1, 2016 September 30, 2017 Community Condition 30-Day Readmission Rate 7-Day Readmission Rate AMI 15.9% 43.9% HF 21.9% 35.3% Central Valley PNE 16.8% 35.5% COPD 20.7% 29.8% CABG 13.3% 44.8% THA/TKA 2.9% 39.8% 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. 17 Data files provided to HSAG by the CMS were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. CVCCC WVCCC 17 WVCCC/CVCCC Readmissions to a Different Hospital: October 1, 2016 September 30, % Go to a Different Hospital on the Readmission How does this impact your internally tracked readmission rates? What impact does this have on the patient s experience and the cost and quality of care? 18 Source: Data files provided to (HSAG) by the Centers of Medicare and Medicaid Services (CMS) and include Part-A claims for Medicare Fee-For-Service beneficiaries. CVCCC WVCCC 18 9

10 ADE Data Ettie Lande anticoagulants diabetic agents opioids HRM Resources: Implementation Update Kari Evans 10

11 HRM Resources: Implementation Timeline November 2017 Introduced 6 of the 7 HRM interventions during November s all community quarterly meeting and participant interest list established January Coaching Calls Completed on January 9 11 via webinar. Reviewed interventions, tools, and developed next steps for the individual interventions. Asking participants to share findings and lessons learned for future coaching sessions 11/14/17 1/9/18 2/15/18 January 2018 HRM #5 Anticoagulants: Coumadin and Anticoagulation Clinics resource completed and distributed via on 1/9/18 to participants that signed up for the intervention February Coaching Calls Calendar invites sent out for February combined coaching calls: Opioids Feb. 15 at 1 p.m. Anticoagulants Feb. 21 at 1 p.m. Diabetic Agents Feb. 21 at 2 p.m. 21 CVCCC WVCCC 21 New HRM Resource: Anticoagulant Clinics in Maricopa County 22 CVCCC WVCCC 22 11

12 HRM Resource: Spotlight on Diabetic Hypoglycemia Data files provided to (HSAG) by the Centers for Medicare & Medicaid Services (CMS) April 2016 March 2017.The data files include Part-A and Part-D claims for Medicare Fee-for-Service beneficiaries 3. Home Health Quality Institute. CVCCC WVCCC 23 HRM Resource Next Steps Review HRM intervention tools Implement HRM interventions in your setting by collaborating with key stakeholders Develop audits and action items around interventions Analyze through internal audits and adjust interventions as needed to facilitate improvement 24 CVCCC WVCCC 24 12

13 Solution-based Strategy A Hospital s Readmission Reduction Journey Matt Wekell Mark Roberts St. Joseph s Hospital and Medical Center Phoenix, Arizona CVCCC WVCCC Network and Break: 20 Minutes 26 CVCCC WVCCC 26 13

14 Nursing Home Value-Based Purchasing Update Lisa Leveque Vice President Strategic Alignment & Care Transformation Bandera Healthcare CVCCC WVCCC Home Health Value-Based Purchasing and New Home Health Conditions of Participation Marie Fredette, CAE Executive Director Arizona Association for Home Care (AAHC) CVCCC WVCCC 14

15 Readmissions Assessment and Tools Barb Averyt HSAG CVCCC WVCCC Preventing Hospital Readmissions What Is CMS Looking For? December 2017, CMS revised the State Operating Manual (SOM) Guidance to state enforcement agencies on what to look for when determining compliance to the Conditions of Participation: Discharge Planning Evaluate the effectiveness of a hospital s discharge planning process. Focus on readmissions: Could anything have been done differently in the discharge planning process to prevent them? 30 Reference for SOM: Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf CVCCC WVCCC 30 15

16 Preventing Hospital Readmissions What Is CMS Looking For? (cont.) Hospitals are now expected to: Track readmission rates at least quarterly Identify potentially preventable readmissions (sample) Choose at least one interval to track (7- or 30-day 1 ) Conduct an in-depth review of the discharge planning process for the sample Review 10% of potentially preventable readmissions or 15 cases per quarter 2 Revise/improve processes to address factors identified that contribute to preventable readmissions Other intervals are permissible 2. Whichever is larger is suggested but not required CVCCC WVCCC 31 CVCCC All-Cause Readmission Rates: 7-Day Break Down Q Q Group Setting Discharged to Days to Readmission 0 3 Days 4 7 Days 7 DAYS N % N % % Home % % 37.6% SNF % % 32.5% Central Valley State HHA % % 37.8% Hospice % % 56.3% Other % % 37.1% Total for all discharged settings Total for all discharged settings 1, % 1, % 36.6% 4, % 4, % 36.6% 32 Data files provided to (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. CVCCC WVCCC 32 16

17 WVCCC All-Cause Readmission Rates: 7-Day Break Down Q Q Group Setting Discharged to Days to Readmission 0 3 Days 4 7 Days 7 DAYS N % N % % Home % % 35.2% SNF % % 28.0% West Valley State HHA % % 34.0% Hospice % % 39.1% Other % % 38.3% Total for all discharged settings Total for all discharged settings % % 33.5% 4, % 4, % 36.6% 33 Data files provided to (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. CVCCC WVCCC 33 What Can We Do About This? 34 CVCCC WVCCC 34 17

18 7-Day Readmission Check List and Audit Tool Potential Gaps 1. Poor patient self-management skills 2. Low health literacy 3. Neglecting chronic comorbid conditions 4. Inaccurate medication history 5. Unrecognized social determinants of health 6. Lack of timely follow-up appointment after discharge 7. Lack of timely follow-up phone call 8. Failure to identify and/or secure skilled services for patients 35 CVCCC WVCCC 35 Readmission Reduction for Nursing Homes Reducing Readmission Preparation Program Starting the Journey January February Well on the Way March April Leading the Way May September Learn more at: 36 CVCCC WVCCC 36 18

19 Reducing Readmissions Preparation Program Goals: Improve staff knowledge on readmission interventions Assist nursing homes to create and strengthen their readmission prevention programs Help facilities be a preferred provider to your local hospitals Improve readmission rates by October CVCCC WVCCC 37 Nursing Home Readmission Assessment Work with your Reducing Readmissions Committee to complete the readmission assessment Focused on operational processes Pre-admission Admission/transfer from hospital Submit completed form online or scan and to Cangotti2@hsag.com 38 CVCCC WVCCC 38 19

20 HSAG Resources West Valley and Central Valley 39 CVCCC WVCCC 39 Behavioral Health: Education and Updates Dennette Janus CVCCC WVCCC 20

21 Arizona All-cause All-Age Readmission Rates: Inpatient Psychiatric Facility (IPF) Discharge Baseline (CY 2014) Q Q Q Q Q Q Current Rate Readmission/ Discharges 962/ / / / / / 5388 Readmission Rate 20.7% 19.5% 21.7% 20.7% 19.8% 20.4% Relative Improvement Rate (RIR) to date from a baseline of CY 2014: 1.4 % 41 Data Source: HSAG Analysis of Medicare FFS Part-A claims for Q Q CVCCC WVCCC 41 Readmission Rates From an IPF Discharge: Psychiatric vs. Medical Readmission Q Q All-age Medicare Fee for Service and Dual-eligible Beneficiaries Readmissions/ Discharges Readmission Rate All-cause 1101/ % Psychiatric Readmission Medical Readmission 739/ % 362/ % 42 Data Source: HSAG Analysis of Medicare FFS Part-A claims for Q Q CVCCC WVCCC 42 21

22 Invitation Consider implementation of recommended readmission reduction interventions Participate in behavioral health education webinars 43 CVCCC WVCCC 43 Webinar Series for Relationship Alphabet Soup Inpatient Psychiatric Treatment Changing the Stigma and Images of Electro-convulsive Therapy SSI/SSDI 1 : Similar But Very Different Dementia in More Detail Caregiving: Mindfulness and Resources Supplemental Security Income/Social Security Disability Insurance (SSI?SSDI) CVCCC WVCCC 44 22

23 Behavioral Health Readmission Reduction Series: Receive one Intervention per Month Top 10 Interventions Support Related 1) Post-discharge follow-up phone call to client or caregiver by someone known to the patient 2) Assess, anticipate, address readmission risk factors in discharge planning 3) Family/caregiver meeting focused on readmission reduction during admission 4) Increase individualized referrals 5) Follow-up telephone call to anyone associated with patient s aftercare plan Medication Related 6) Medications filled at discharge 7) Verify coverage for medication Teamwork-related 8) Improve communication/coordination between providers 9) Specific procedure for follow-up with clients not adherent to aftercare 10) Case conference review of every readmission 45 CVCCC WVCCC 45 Wrap-Up and Summary 23

24 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. 47 CVCCC WVCCC 47 Road Map to Action Note the important takeaways from today s meeting on this Roadmap to Action. Share it with staff members and colleagues when you return to work. 48 CVCCC WVCCC 48 24

25 Questions? 49 CVCCC WVCCC 49 Thank You all for Your Participation Today! 50 CVCCC WVCCC 50 25

26 Thank you! Ettie Lande CVCCC WVCCC This material was prepared by, the Medicare Quality Improvement Organization for California, 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