Improving Transitions of Care Mark V. Williams, MD, FACP, FHM Professor & Chief, Division of Hospital Medicine Northwestern University Feinberg School of Medicine Principal Investigator, Project BOOST Health Affairs 9/08 The growth of hospitalist programs contributes to a loss of physicians participation on hospital medical staffs, which increases the burden of coordination and blurs accountability for the quality of postdischarge care. 1
June 2007 MedPAC Report Medicare pays for ALL admissions regardless Initial stay or readmission for same condition 17.6% of admissions result in re-admissions within 30 days (6% in 7 days) = $15 billion in spending Future CMS proposes to require that all general acute hospitals conduct a CARE assessment on every Medicare beneficiary being discharged. Continuity Assessment Record and Evaluation Public Disclosure of readmission rates Lower case payments for readmissions MedPAC March 2010 Report > 10 million FFS Medicare admissions in 2008 to 3,500 participating hospitals $139 billion in payments Outpatient grew while inpatient stable Access and quality improved Readmission rates unchanged or worsened across most states from 2003 to 2007 2
1 in 5 Medicare patients rehospitalized in 30 days Half never saw outpatient doc 70% of surgical readmissions chronic medical conditions Costs $17.4 billion Rates of Rehospitalization within 30 Days after Hospital Discharge Jencks S, Williams MV, Coleman EA. et al. N Engl J Med 2009;360:1418-1428 3
Health Affairs 2010; 29:57-64 ER Visits post-discharge 2% (2.3 million ER visits) from patients discharged from hospital within 7 days 10% of these ER visits for complications related to recent hospitalization Uninsured 3 times more likely to visit ER Future quality measure of discharge? Burt CW, McCaig LF, Simon AE. Emergency department visits by persons recently discharged from U.S. hospitals. National Health Statistics Reports July 24, 2008; Number 6. 4
Preventable Admissions Hospital inpatient care is the most expensive type of health care > 4 million Preventable Admissions Cost nearly $31 Billion Heart Failure and Pneumonia Half of the $ problem COPD 16% Diabetes 13% Elderly 2/3 of these hospitalizations - 1 in 5 Medicare admissions Hospital Readmissions and Mortality www.hospitalcompare.hhs.gov 5
5/26/10 Quality ver$us Quantity As Congress debates health care, some policy experts say no meaningful improvement can be made without changing the payment system so medical centers have more financial incentive to help people stay out of the hospital. Reform It s here! H.R. 3590, the Patient Protection and Affordable Care Act H.R. 4872 the Health Care and Education Reconciliation Act Multiple aspects will impact hospitals and hospitalists Paying for quality instead of quantity Demonstration projects 6
Reducing Readmissions Financial penalties on hospitals for excess readmissions vs. expected HF, AMI, Pneumonia FY2013 $7.1 billion in savings over 10 years Not supported by SHM Community Based Care Transitions Program Starts Jan. 1, 2011 A Few Other Big Things Value Based Purchasing program FY2013; budget neutral Bundling Accountable Care Organizations Center for Innovation at CMS The Patient-Centered Outcomes Research Institute National Strategy to Improve Quality of Care 7
Hospital Discharge - currently Random events connected to highly variable actions with only a remote possibility of meeting implied expectations. Roger Resar, MD Agent of Tremendous Change and Global Innovation Seeker Luther Midelfort Mayo Health System Senior Fellow, IHI Dangers of Discharge 19% of patients had a post discharge AE - 1/3 preventable and 1/3 ameliorable Ann Intern Med 2003; Vol. 138 23% of patients had a post discharge AE - 28% preventable and 22% ameliorable CMAJ 2004;170(3) 8
Dangers of Discharge Ann Intern Med 2005;143(2):121-8 1095 of 2644 (41%) inpatients discharged with test result pending - 191 (9.4%) potentially required action - Survey of MDs involved: almost 2/3 unaware of results - Of these: 37% actionable and 13% urgent Dangers of Discharge Arch Intern Med. 2007;167:1305-1311 ¼ of discharged patients require additional outpatient work-ups > 1/3 not completed Increased time to post-discharge f/u associated with lack of work-up completion Availability of discharge summary increased likelihood of work-up being done 9
Hospitalist to PCP Info transfer and communication deficits at hospital discharge are common Direct communication 3-20% Discharge summary availability at 1 st postdischarge appt 12-34%; 51-77% at 4 weeks Discharge summaries often lack info Dx test results (33-63%), hospital course (7-22%), discharge meds (2-40%), pending test results (65%) Follow-up plans (2-43%), Counseling (90-92%) Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW JAMA 2007;297:831-41. SHM Initiatives Discharge Checklist Halasyamani L et al. Transition of care for hospitalized elderly patients --development of a discharge checklist for hospitalists. J of Hosp Med 2006:354. Resource Room Safe STEPs Project BOOST Better Outcomes for Older adults through Safe Transitions John A. Hartford Foundation $1.4 million 10
THANKS!!! The John A. Hartford Foundation Project BOOST Team Tina Budnitz, MPH Eric Coleman, MD, MPH Jeff Greenwald, MD Eric Howell, MD Lakshmi Halasyamani, MD Mark V. Williams, MD Janet Nagamine, MD Dan Dressler, MD, MS Kathleen Kerr Greg Maynard, MD Arpana Vidyarthi, MD 11
Advisory Board Chair: Eric Coleman, MD, MPH with organizational representatives from: Social work Case management Clinical pharmacy Geriatric medicine Geriatric nursing Health IT Blue Cross/Blue Shield United Health Health systems NQF AHRQ TJC CMS National Consumer s League Other content experts www.hospitalmedicine.org/boost 12
BOOST Toolkit: Primary Components Tools for: Identification of High-Risk Patients Raising the bar on all discharges Being sensitive to patient specific needs Peparing patients and family/caregivers Coupled with recognition of the importance of: Discharge summary communication Timely follow-up BOOST Toolkit: Primary and Secondary Components Developing teams and facilitating teamwork Focusing initiative and developing an aim statement Assessing knowledge base and gaps Understanding current State Sales program (C-Suite and Staff) Evaluation Plan (local) 13
BOOST Tool: The 7Ps 7P Risk Scale Prior hospitalization Problem medications Psychological (depression) Principal diagnosis Polypharmacy Poor health literacy Patient support Each associated with risk specific interventions Universal Patient Discharge Checklist GAP assessment Medications reconciliation Medication use and side effects reviewed* Confirm understanding of prognosis, self-care, and symptoms requiring immediate medical attention* Best Practice guidelines assessment Discharge plan completed, taught, and provided to patient/caregiver Discharge communication provided to posthospitalization care provider Documented receipt of discharge information from principal care providers *Using TeachBack with patient/caregiver 14
The General Assessment of Preparedness: The GAP Caregivers and social support circle for patient Functional status evaluation completed Cognitive status assessed Abuse/neglect Substance abuse Advanced care planning addressed and documented On Admission Functional status Cognitive status Access to meds Responsible party for ensuring med adherence prepared Home preparation for patient s arrival Financial resources for care needs Transportation home Access (e.g. keys) to home Nearing Discharge Understanding of dx, treatment, prognosis, followup and postdischarge warning S/S (using Teach Back) Transportation to initial follow-up At Discharge Checklist Michael Scriven Western Michigan U The humble checklist and the process of validating an evaluative checklist is a task calling for considerable sophistication. 15
DPET Discharge Patient Education Tool DIAGNOSIS I had to stay in the hospital because: The medical word for this condition is: I also have these medical conditions: TESTS While I was in the hospital I had these tests: which showed: TREATMENT While I was in the hospital I was treated with: The purpose of this treatment was: 16
NEW CONCEPT: Health information, advice, instructions, or change in management Teach Back Assess patient comprehension / Ask patient to demonstrate Explain new concept / Demonstrate new skill Patient recalls and comprehends / Demonstrates skill mastery Clarify and tailor explanation Adherence / Error reduction Re-assess recall and comprehension / Ask patient to demonstrate Modified from Schillinger, D. et al. Arch Intern Med 2003;163:83-90 Mentored Implementation Secret Sauce for Project BOOST Target hospitalists at sites QI effector arm Mentor conference calls with hospital teams Email follow-up Mentor experienced hospitalist with QI expertise 17
So what happens to readmission rates? 12/08 6/09 12/09 12/10 Cohort 1 (n=6) kickoff Cohort 2 (n=24) kickoff Implementation Survey Hierarchical time series analysis of readmission rates (one year prior to kick-off through one year post kick-off) 12/10 Prelim Results Across all sites overall readmission rates decreased from 13% to 11%. BOOST Intervention Units 6 months post go live Readmission rates rose in non-boost units by 2% Marked increased patient satisfaction at some sites. 18
Qualitative Analysis Facilitators to BOOST Implementation Enhances care for patients Site Mentor Delivered value beyond BOOST I love your toolkit Barriers Discharge process worse than realized Competing demands Lack of resources or administrative support Beyond BOOST Some patients need more attention and support beyond the foundation provided by Project BOOST Frail elderly patients with multiple medical problems, multiple medications and potentially multiple social issues 19
COPD Issues Depression Pulmonary Rehab / Respiratory Therapist Social Worker Case manager / Home health Pulmonologist role Caregivers and patient Palliative Care BOOST@hospitalmedicine.org 20