Neighborhoods, resources and capacity to improve

Transcription

1 Neighborhoods, resources and capacity to improve Jane Brock, MD, MSPH Telligen QIN QIO National Coordinating Center This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, 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. 11SOW QINNCC /01/15

2 The ACA Bundle within services Bundle across services within episodes Manage populations = reduce readmissions 2

3 What we learned early about readmissions 14 Communities 800,000 FFS Medicare beneficiaries It s a community project 3 3

4 Rehospitalizations/ % (p<.001) -2.1% (p=.08) P=.03 (difference) 4

5 QIO Communities, Quarterly Admissions and Readmissions Admissions/ = 12.1* Readmissions/ = 3.4* 5

6 6 But communities are different

7 The debate over SES and readmission risk 3-4% risk difference?quality Not accounted for in measures Safety net hospitals and penalties, OR = 2.38* Poor measures SSI Medicaid Income from survey 7 *Joynt and Jha, JAMA, Jan 2013

8 But.. 8

9 Disadvantage as a community characteristic After hospitalization: Increased vulnerability Neighborhood support Social network Safe infrastructure Environment compatible with health Many precedents 9

10 Area Deprivation Index (ADI) A validated census-based measure available at the blockgroup (neighborhood) level, first created in 2003* Factor-based index, 17 US Census-based indicators Recognized widely in research Correlated with multiple health outcomes Cardiovascular mortality Cancer mortality Cervical cancer prevalence Neighborhood disadvantage by ADI could be easily queried using patient Zip+4 codes 10 *Singh, Am J Public Health, 2003; Singh and Siahpush, Int J Epidemiol, 2006

11 11 *Kind et al, Annals, Dec 2014

12 Analysis 2000 US Census ADI for all US block-groups, geocoded to Zip+4 codes Random 5% national sample FFS Medicare ( ) DCs CHF, AMI, Pneumonia Linked via Zip+4 code listed for patient s residence Final sample = 255,744 Controlled for: Medicaid, SSI, rurality of residence Comorbidities, HCC score Characteristics of index hospital 12 *Kind et al, Annals, Dec 2014

13 30-Day Rehospitalizations and Neighborhood ADI (%) 13 *Kind et al, Annals, Dec 2014

14 14

15 Limitations: Ecological fallacy?? Or ecological reality?? Ecology = the branch of biology that deals with the relations of organisms to one another and to their physical surroundings. 15

16 So now what? Need to replicate this, 2010 entire Medicare data file Even better, Medicare and Medicaid Outcomes other than rehospitalization Need to understand differences in improvement strategies by ADI characteristics Maybe we could just start with Co.. 16

17 The 11 th SOW 17 Prominent community focus Improving the Health Status of Communities Improving cardiac health Reducing disparities in diabetes care Immunization information systems to improve prevention coordination Meaningful use of HIT/regional extension center Better Healthcare for Communities Reducing healthcare associated infections in hospitals Reducing healthcare acquired conditions in nursing homes Coordination of care Reducing adverse drug events

18 11 th SOW Coordination of Care Communities Reduce hospital readmissions 20% Reduce hospital admissions 20% Increase community tenure 10% Reduce ADEs that contribute to patient harm, ED visits, observation stays, hospitalizations 18 Convene, collaborate, organize Include pharmacists!! Provide data and analytic support on population performance Assist with intervention implementation and measuring the impact of interventions

19 19

20 20

21 Reducing Adverse Drug Events (Why Pharmacists are Crucial) National Action Plan Anti-coagulants, Opioids, Diabetes meds Chronic medication use = 60+ days/cy At risk = 3 chronic medications with at least one high risk med OR 3 chronic medications PLUS at least 30 days high risk med Definition of an ADE under construction 21