Admissions, Readmissions & Transitions Core Functions & Recommended Actions

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1 How to use this resource An important single component of COMPASS for accomplishing the goals promised to CMS is the reduction of avoidable hospital admissions and readmissions as well as emergency room visits. The promised cost reductions are entirely predicated on those decreases, since improving quality and experience may have little or no cost impact in the first year or two. Therefore, this is an important focus for care managers, clinic sites and the systematic case review teams. The following are core functions, recommended actions and resources for primary care COMPASS practices to prevent unnecessary emergency department visits and hospital admissions (including readmissions). Some functions will also need to include systematic hand-offs between care settings and/or providers. Building relationships and agreements between primary care and hospitals around re-admissions and care coordination is a critical pre-implementation step. Medical organizations including primary care, hospitals and emergency departments need to map their processes, services and gaps to establish highly coordinated care to ensure COMPASS goals. This includes finding out what each other is already doing to reduce avoidable readmissions and having a systematic process for primary care to know about new hospitalizations and ED visits and to promptly obtain key information about those events. 1. Care Transition Communication Build strong relationships with local hospitals, developing processes to communicate about admissions, discharges and ED visits. Use EHR s where possible, to communication about care in all settings. Create systematic processes and agreements with relevant hospitals and EDs to assure prompt information when COMPASS patients are seen in ED or hospitalized Create systematic processes and agreements to obtain key discharge information from hospitals and EDs within 24 hours of discharge as well as processes to have these lists reviewed daily. Building My Medical Neighborhood tool Example Transitions of Care Policy 2. Risk Identification Proactive risk assessment using a combination of past utilization patterns and prediction models Patient clinical and utilization history Review hospitalization and high-utilizer data through COMPASS metrics Initiate panel management to improve risk stratification Involve caregivers in recognizing and reporting risks and concerns 3/11/13 1

2 There are no current readmission risk prediction models that have been shown to function well outside of research setting, many showing a prediction success that is only slightly better than chance. (Kansagara, 2011). This COMPASS Consortium workgroup recommends care managers collect and track, at a minimum, the following two risk predictors for all COMPASS patients: All medical and mental health diagnoses Hospitalizations and ED visits This recommendation is based on work done at Regions Hospital in Minnesota, where 38,0000 admissions were tracked. They found the highest risk predictors of 30 day readmission were: More than 9 diagnosis codes, and more than 1 hospitalization in the past year. Care managers are strongly encouraged to calculate and document a patient s risk score using the Regions Hospital risk predictor tool, or other locally used tool. Calculation of Risk Score Predictor point 2 points 4 6 points point points points Diagnosis Code Count <7 7 to >14 Past Year Hospitalizations >2 Past Year ED Visits 0-1 >1 Discharge to a Skilled Nursing Facility No Yes Primary Dx of Heart Failure or COPD No Yes Surgery During Stay Yes No Risk score & probability of 30-day readmission (%) 0 = = = = = = = = = = = = = = = = = 41.6 There are other risk calculators that may be in use in local settings, which may be used as an alternative. COMPASS intervention sites should continue sharing and refining their learnings in this area so that we can collectively improve our capabilities. Billings, et al. Development of a Predictive Model to Identify Inpatients at Risk of Readmission Within 30 days of Discharge. BMJ Open. 2012,00:e Kansagara, et al. Risk Prediction Models for Hospital Readmission: A Systematic Review. JAMA, Oct 19, Vol 306, No 5 Krumholz, H. et al. Post-Hospital Syndrome - An Acquired, Transient Condition of Generalized Risk. NEJM Jan 10, ;2 Society of Hospital Medicine, Risk Assessment 8P Screening Tool. Project BOOST (Better Outcomes for Older Adults Through Safe Transitions. 3/11/13 2

3 Patient identification and enrollment powerpoint Proactive identification & transitions of care powerpoint 3. Preventive Actions & Education Build a good foundation through the care manager/patient relationship Educate patient/family about the importance of contacting the care manager promptly and first if there are concerns that might lead them to consider ED visit or hospitalization; establish access and after hours process if health concerns arise Use Motivational Interviewing and Teach Back for risk reduction, health education and self-management coaching to proactively prevent unnecessary hospitalizations and ED use. At initial contact, the care manager should review the patient s history of hospitalizations and ED visits and partner with the patient and family to discuss effective access and optimal use of the health care system. The care manager role serves as the patient s key translator and navigator for management of their condition (especially at times of crisis), along with the broader primary care team. The care manager educates the patient about red flags, symptom triaging and high-risk situations for that patient s specific clinical conditions and the resources available within primary care and the community so these are optimized before patient decides to go to ED or hospital. The care manager provides self-management health coaching for clinical conditions and uses Teach Back to do medication reconciliation, and utilization on a consistent and routine basis. While the highest health care costs are most likely to occur with poorly managed medical conditions, patients may also utilize ED or hospital services for somatic symptoms such as abdominal pain, migraine, etc. Preventive actions and education should support patients mental health as well. Agency for Healthcare Research & Quality, Health Literacy Universal Precautions Toolkit: American Medical Association, February There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. Improving Chronic Illness Care: Minnesota Health Literacy Partnership: 3/11/13 3

4 Care manager role and population management powerpoint Diabetes protocols & guidelines Depression protocols & guidelines Hyperlipidemia protocols & guidelines Hypertension protocols & guidelines Substance Use protocols & guidelines Case studies & demo videos Medical emergencies pdf Health literacy and teach back powerpoint, worksheets and exercises Motivational interviewing intro/basic, intermediate/advanced powerpoints and exercises Diapression powerpoint Increasing patient self-awareness of medical emergencies powerpoint 4. Follow-up Process - Call the patient within 24 hours of a discharge and consider weekly calls for 30 days (Graham, 2012) - Assure primary care visit within one week of most hospital or ED discharges - Proactively coordinate care transitions so patients and caregivers know what to do and assure that it occurs - Establish process for primary care access, messaging and back-up - Develop efficiencies through stratifying risks/complexities so patient needs can be served by different levels of care (i.e. panel management, care management, care coordination, etc) - Internal review, dissemination and discussion of COMPASS QI metrics The process for post-hospitalization follow-ups will vary depending on practice relationships with hospitals, but is still a critical function. The practice needs to have a well-defined process for transitions of care and follow-up that takes into account access, messaging, involvement of caregivers and backup/contingency planning. COMPASS care managers are in an optimal role for staying informed of patient hospitalizations and ED visits because they will need to have systematic follow up processes in place already. Engage with the patient, family and caregivers. Patients often need additional support after hospitalization. Consider that there may be transient cognitive impairment from medications, so using Teach Back and other techniques are highly important. Formal screening tests for cognitive impairment may be useful. Medication management strategies to verify with the patient their current medication regime, if possible by using medication discharge lists and ambulatory lists are know to be valuable. Consult with Pharmacist (MTM) if available for complex regimens. Follow up appointments are recommended in most cases. These visits might focus on identifying the factors that lead to the hospitalization/ed visit and what alternatives might be considered if these occur again, clear plan for seeking emergency and non-emergency after hours care, follow up on tests done that may not have been resulted prior to discharge, answering questions about medication and other treatment changes. 3/11/13 4

5 Coleman EA, California HealthCare Foundation The Post-Hospital Follow-up Visit: A Physician Checklist to Reduce Readmissions Hesselink, G., et al. Ann Intern Med 2012;157: Improving Patient Handovers From Hospital to Primary Care: A Systematic Review Institute for Healthcare Improvement, How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations National Transitions of Care Coalition: Creating Medication Safety. Pathways for Patient Safety, Health Research & Educational Trust, Institute for Safe Medication Practices, and Medical Group Management Association: Patient education and adherence strategies powerpoint and videos Maintenance planning powerpoint and handouts 3/11/13 5