HEN 2.0 Readmissions Webinar October 29, 2015 11:00 AM- 12:30 PM CT
Angela Michalek, MS, PMP Program Manager, HRET 11:00-11:05 AM WELCOME AND INTRODUCTIONS 2
Agenda 11:00-11:05 AM Welcome and Introductions 11:05-11:10 AM HEN Data Update Review of the agenda and the platform. Discuss the readmissions evaluation measure specifications, including the inclusions and exclusions. 11:10-11:25 AM Didactic Education Recognize risk factors for readmissions. Summarize emerging and effective strategies to reduce readmissions. 11:25-11:40 AM Hospital Story: South Seminole Hospital Describe effective readmissions prevention strategies implemented by a community hospital in Longwood, Florida. Identify prevention challenges and discuss how those challenges were overcome. Angela Michalek, MS, PMP HRET Program Manager Julia Heitzer, MS HRET Data Analyst Pat Teske, RN, MHA Cynosure Implementation Officer Cindy Stone, RN, MSHA, NE- BC Chief Nursing Officer South Seminole Hospital Longwood, Florida Mary Jane Magill, RN, MAHA Nursing Program Manager South Seminole Hospital Longwood, Florida 11:40-11:55 AM Improvement Science Discuss how to use readmissions data to inform your Pat Teske strategy. Explain ways to stratify and further analyze readmissions data. Review practice changes that can result in improvement. 11:55 AM-12:05 PM Sharing Ideas: Huddle for Care Discover the readmissions stories and resources available through the Huddle for Care virtual Shannon Woodford, MPH HRET Program Manager community. 12:05-12:20 PM Bring it Home Review action items for the specific project team Angela Michalek roles. 12:20-12:30 PM Question & Answer All
Julia Heitzer, MS Data Analyst, HRET 11:05-11:10 PM HEN DATA UPDATE 4
Required Measure: Readmission within 30 Days (All Cause) Rate
Which Admissions Are Considered a Readmission? Readmission (Included) Not Considered a Readmission (Excluded) Inpatients returning as an acute care inpatients to the same facility (short-term acute care) within 30 days of date of discharge Planned readmissions Same-day readmits to the same hospital for the same condition (same-day readmits for a different condition are considered readmissions) Observation stays and Emergency Department (ED) visits Admissions to other facilities other than short-term acute care hospitals Additional References: The Partnership for Patients has also gathered many resources for readmissions prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-preventablereadmissions/toolpreventablereadmissions.html where the patient is admitted to a separate, non-inpatient unit that Admissions that occur at eligible short-term acute care hospitals but bills separately from the short-term acute care hospital (e.g., admitted to a rehab, psych, hospice or LTC unit within a short-term acute care hospital that bills separately)
Additional Measure Considerations While we have cited the CMS definition of a readmission, we acknowledge that: Facilities will NOT be able to risk-adjust their data the way CMS does Facilities will NOT necessarily be able to track if their patients go to a hospital other than their own Some facilities exclude OB discharges from their readmissions tracking Acceptable as long as the facility is using a consistent denominator every month Key is to track readmissions consistently through out the program
Readmissions Measurement Resources Encyclopedia of Measures (EOM) on the HEN 2.0 website http://www.hret-hen.org/audience/data-informatics-teams/eom.pdf Quality Net The CMS definition is explained in the Frequently asked questions about readmissions in Chapter 3 Readmissions Measures, section Defining readmissions beginning on page 7 http://www.qualitynet.org/dcs/contentserver?cid=1228774724512&pagename=qnetp ublic%2fpage%2fqnettier4&c=page The Partnership for Patients has gathered many resources for readmissions prevention and measurement: https://partnershipforpatients.cms.gov/p4p_resources/tsppreventablereadmissions/toolpreventablereadmissions.html Reach out to your State Hospital Association representative Email HRET Data Support hretdatasupport@aha.org
DIDACTIC EDUCATION Pat Teske, RN, MHA Implementation Officer, Cynosure Health 11:10-11:25 PM 9
Our AIM Decrease preventable complications during a transition from one care setting to another, so that hospital readmissions would be reduced by 20 percent.
Framing Your Approach Risk for Readmission Care Continuum
Risk Community ED Hospital Based Immediate Post Hospitalization Special programs such as: Complex Care Management (CCM) Disease specific programs Social programs BASIC inpatient bundle + moderate to high bundle BASIC post discharge bundle + moderate to high bundle AND stronger linkage with community programs Risk for Readmission Primary Care Physician (PCP)/care team management per patient needs with prioritized post discharge visit or outreach BASIC inpatient bundle + moderate to high bundle: Care transitions nurse Pharmacy intervention Palliative care BASIC post discharge bundle + moderate to high bundle: 7 day follow-up appointment Follow-up call(s)/visits Routine PCP/care team management per patient needs Admit BASIC inpatient bundle: Discharge planning Multidisciplinary rounds Teach back BASIC post discharge bundle: Referrals Instructions
How About You?
What s New Teams Inter-professional Non-clinician Technology Automation Tele-presence Education Emergency Department Embedded staff or consultation prior to admission Highest Utilizer Strategies Complex care management Community paramedics Behavioral health and substance abuse Standard Work SMART discharge instructions
Teams At WVU Hospitals in Morgantown, WV, physicians and medical residents teamed up to see their patients at the hospital s outpatient clinic, within 7 to 14 days after discharge. A psychologist, pharmacist and nurse case manager soon joined the team. Medical residents talk with patients before discharge, explaining the follow-up process and ensuring patients have a pre-scheduled appointment. The nurse case manager tracks all appointments, contacting patients until they are seen. On clinic days, the team huddles in the early afternoon and sees patients afterwards. With this team-based follow-up care, 80-85 percent of patients are seen within 14 days of discharge. One additional benefit: discharge summaries have improved now that residents use their own summaries for the follow-up. Karen Fitzpatrick, M.D., quality director, WVU Family Medicine, says buy-in from physicians was quick as we talked about the high value to patients. Team-based care after discharge provides one-stop shopping for patients, and their feedback has been positive. fitzpatrickk@wvuhealthcare.com What is the composition of your care transition team?
Augmenting with Non-Clinicians Congregational Health Network Care navigators Focus on social needs High touch Know their communities Passion for the work Are you using non-clinicians in your care transitions work? UCSF RSP New grads Public health background Coordination/navigation If so, how?
Technology Tele-presence Automation Are you using technology in your care transitions efforts? If so, how?
Emergency Department Efforts 1. Process to inform ED staff that this person had a prior admission 2. Pause to interact in-person or on the phone with a care transitions team member 3. Decision a) Admit b) Observation c) Home with follow-up What are you doing in your EDs?
Highest Utilizer Strategies Identify highest utilizers Learn what drives their utilization Meet the needs What are you doing for your highest utilizers?
Standard Work Signs What they are What to do Medications Appointments Results to track Talk to me about these three things
Cindy Stone, RN, MSHA, NE-BC Chief Nursing Officer & Mary Jane Magill, RN, MAHA Nursing Program Manager South Seminole Hospital, Florida 11:25-11:40 AM HOSPITAL STORY SHARING 21
About Us Serving Seminole County and surrounding areas 204-bed hospital Adult acute care and behavioral health services Part of Florida s most comprehensive private, not-for-profit health care networks The only hospital in Seminole County with an A safety rating from Leapfrog Health Care Model - Patient First 22
Tests & What We Learned Study literature - used evidence-based resources Engage key stakeholders Develop RN Navigator role Initiate discharge nurses Promote multidisciplinary team approach Standardize care processes Inclusion of patient engagement strategies Importance of daily multidisciplinary rounds 23
Barriers & How We Resolved Partner early with community physicians and local facilities Follow-up call within 48-72 hours to skilled nursing facility (SNF) Education for SNF s and community providers Establish a clinic Need to provide patients with home resources - scales, blood pressure (B/P) equipment Need for medication supplies 24
Measures What & How Board of Director Goals HEN Goals Press Ganey Patient Satisfaction Goals 25
Corporate Metrics: 30-day Readmissions
SSH Metrics: 30-day Readmissions
SSH Metrics: HF Readmissions
Advice For Others Care planning to serve patient needs or wishes (palliative, hospice) Crucial to identify the patient s caregiver Teach-back interventions Identify frequent flyers and expand extra resources to meet patient care needs - Discharge RNs Develop sustainable and seamless care transitions Follow-up appointments Community outreach education Follow-up phone calls/automated system 29
Wrap Up & Next Steps Telehealth - remote monitoring Strategies and technologies for patient education activities Navigator goes to ED to collaborate with ED physician to treat patient presenting to ED to avoid admission 30
Pat Teske, RN, MHA Implementation Officer, Cynosure Health 11:40-11:55 AM IMPROVEMENT SCIENCE 31
Data Analysis Example Use the most recent 12 months of data available. Using all hospital discharge data, exclude patients <18, all OB (DRG 630-679), discharges dead or transfers to another acute care hospital. Define a readmission as any return to inpatient status within 30 days of discharge from inpatient status.
What You Might Want to Learn By major payer type: Total number of discharges Total number of readmissions Rate = readmissions/discharges Discharge disposition Number home Number home with home health Number SNF
Data Questions With any coded behavioral health diagnosis Discharges Readmissions Number and/or percentage of readmissions occurring within 7 days of discharge Number of patients with 4 hospitalizations in past year Total number of discharges in >4 group Total number of 30-day readmissions among them
Top 10 Diagnosis-Related Groups (DRGs) by Payer What are they? Do they differ between payers? What percentage of readmissions do the top ten DRGs account for? Usually less than 28%
AHRQ Statistical Brief # 172 Medicaid Mood disorder Schizophrenia Diabetes complications Comp. of pregnancy Alcohol-related Early labor CHF Sepsis COPD Substance-use related Medicare CHF Sepsis Pneumonia COPD Arrythmia UTI Acute renal failure AMI Complication of device Stroke
Testing Your Plan Your plan will have several strategies such as: Improvement in standard discharge Collaboration with area SNFs Enhanced services for targeted population(s) Current state (5,000 admissions): Readmission rate is 15% = 750 readmissions Desired state: Readmission rate to 12% = 600 readmissions 150 fewer readmissions
Impacting Your Overall Rate Strategy: Improve standard discharge care for all Expected impact 10% What happens when it works Since this strategy impacts all patients, if we reduce our readmission rate by 10% from our improvements in the standard discharge process, we will reduce our readmissions from 750 to 675, preventing 75 readmissions.
Knowing This We Need to Do More Strategy: Collaboration with area SNFs Expected impact 20% What happens when it works 5,000 discharges and 20% are discharged to SNFs = 1,000. Currently, our SNF readmission rate is 25% = 250. Since this strategy only impacts our SNF patients, if we reduce our readmission rate by 20% from our collaboration efforts, we would avoid 50 readmissions. Adding the avoided readmissions from both strategies results in 125 less readmissions.
We STILL Need to Do More Strategy: Specific patient population(s) approach e.g., heart failure (HF) Expected impact 20% What happens when it works 200 HF patients with current readmission rate is 25% = 50. Since this strategy only impacts our HF patients, if we reduce our readmission rate by 20% from our enhanced approach, we would avoid 10 readmissions.
Adding Up Our Impact Readmissions avoided: 75 50 + 10 = 135 fewer readmissions
If Your Plan Does Not Add Up Ask the following questions: Do the strategies we re using apply to enough patients? Are we missing proven strategies? Given our patient population, how should we modify our plan?
Risk Community ED Hospital Based Immediate Post Hospitalization Special programs such as: Complex Care Management (CCM) Disease specific programs Social programs BASIC inpatient bundle + Moderate to high bundle BASIC post discharge bundle + moderate to high bundle AND Stronger linkage with community programs Risk for Readmission Primary Care Physician (PCP)/care team management per patient needs with prioritized post discharge visit or outreach BASIC inpatient bundle + moderate to high bundle: Care transitions nurse Pharmacy intervention Palliative care BASIC post discharge bundle + moderate to high bundle: 7 day follow-up appointment Follow-up call(s)/visits Routine PCP/care team management per patient needs Admit BASIC inpatient bundle: Discharge planning Multidisciplinary Rounds Teach back BASIC post discharge bundle: Referrals Instructions
Shannon Woodford, MPH Program Manager, HRET 11:55 AM-12:05 PM HUDDLE FOR CARE 44
Vision Become the premier community that fosters real-world innovation in care transitions Mission Health care professionals will revolutionize the field of care transitions through peer exchange, learning and collaboration; thereby, engaging more effectively with patients, families and caregivers resulting in the creation of healthier communities.
Huddle for Care Goals Build a virtual community of professionals in care transitions who will generate content, network and disseminate resources Provide an open, active line of communication between innovators in the field of care transitions and Huddle for Care users to rapidly develop content that is responsive to the needs of front-line workers Strengthen connections between individuals working across the care continuum to design approaches that are coordinated, effective and patient-centered
Project ACHIEVE Project ACHIEVE: Hospitals Call Task 1- Completion of the Hospital Transitional Care Effort Adoption Survey to Action All hospitals are encouraged to participate in this task 425 hospitals have completed; goal is 600 hospitals 15 minute survey Please visit the following survey link, housed on a secure server: https://redcap.uky.edu/redcap/surveys/?s=4jlfaatyxp. Task 2- Participation in the Project ACHIEVE research study 23 letters of commitment submitted; goal is 40 Requirements include: One-day site visit with the hospital to observe the care transition process Surveys with eligible patients and their caregivers, post-acute providers, and community-based organizations Data submission list of patient discharges and Medicare claims data
How to Get Involved with Project ACHIEVE Contact the HRET team with further questions or to set-up a phone call to discuss project details further: Marie Cleary-Fishman Email- mfishman@aha.org Telephone- 312-422-2646 Shereen Shojaat Email- sshojaat@aha.org Telephone- 312-422-2627
BRING IT HOME Angela Michalek, MS, PMP Program Manager, HRET 12:05-12:20 PM 49
Physician Leader Action Items What are you going to do by next Tuesday? Drill down into your readmissions data What are you going to do in the next month? Engage a multidisciplinary team to address readmissions in a target population identified in your review of the data
Unit-Based Team Action Items What are you going to do by next Tuesday? Look at your patient satisfaction data for opportunities for improvement related to discharge What are you going to do in the next month? Engage patients and families to review and improve your discharge protocol, incorporating teach back
Hospital Leaders Action Items What are you going to do by next Tuesday? Benchmark your hospital s readmissions rate with competitors, peers, etc. What are you going to do in the next month? Establish a new partnership with a skilled nursing facility or community organization to reduce readmissions
Action Items for Patients & Families What are you going to do by next Tuesday? Ask questions and actively participate in bedside report and multidisciplinary rounding What are you going to do in the next month? Consider opportunities to partner with the health care team through a patient and family advisory council (PFAC)
Q&A 12:20-12:30 PM
Project Priorities Submit your hospital commitment letter to your state hospital association lead Complete your needs assessment Check out the HRET HEN 2.0 website: www.hret-hen.org
Thank you! More info: www.hret-hen.org Questions/Comments: hen@aha.org