Readmission Reduction and the ACO Jeffrey E. Epstein, MD Medical Director Atlantic Health System Morristown Medical Center Morristown, NJ 07960 JeffreyEpsteinMD@gmail.co m
Morristown Medical Center
Why Are Readmissions Important 4.4 Million Hospital Stays that are the Result of Potentially Preventable Re- Admissions $30 Billion per year 10% of all money spent to Hospital Care
Can we reduce Readmissions? Why haven t Readmission Reduction Programs worked in the Past? Is a Lower Readmission Rate Higher Quality Care?
New England Journal and BMJ Quality and Safety Articles
We have an Association between Global Warming and Increased Usage of Fossil Fuels BUT Is the Increased Use of Fossil Fuels CAUSING Global Warming or is it just a Coincidence? When temperature Rises, CO2 is released from the Oceans
The Thesis of this Presentation is that Higher Readmission Rates usually reflect poor Coordination of Care and poor Quality Care. We will explore how Accountable Care Organizations, Integrated Healthcare Systems and Entities that Take FULL RISK will reduce Readmissions by providing High Quality, Coordinated Care. I believe you will see a MANY FOLD reduction in Readmissions in THESE systems of care.
What makes the ACO Different?
Accountable Care Organizations (ACOs) Higher Quality Care and Lower Cost Care Coordinated Care. Fully Informed Care (Access to Medical Record Information). Reduction in Waste and Duplication of Services The right care at the right time to the right person for the right reasons. Evidence based care: Stent or No Stent into 70% Stenosis when Angina is Stable. Fee for Value (Quality/Cost) rather than Fee for Service (High Volume, High Cost) Cognitive Care, Evidence Based Decisions
An Integrated Healthcare System An Integrated Healthcare System is a managed care system that includes a hospital organization that provides acute patient care, a multispecialty medical care delivery system, the capability of contracting for any other needed services, and a payer. Primary Care Physicians Payer Hospital Multispecialty Medical Group Integrated Healthcare System Lab and Radiology Other Services
I n c e n ti v e s I n c e n t i v e Payers, Providers and Patients s
Forces are NOT Aligned in the current Fee For Service, Fragmented Healthcare Universe
When the Apple is pulled up by Financial Decisions as well as pulled down by Quality of Care issues, the Apple does not fall to the ground. When forces are aligned, the Apple goes to its lowest state of energy.
In this setting we expect the moon to fall towards the earth
Current Provider Incentives Fee for Service. High Reimbursement for Procedures. More Volume, More Money High Cost Procedures + Maximal Volumes = Maximal Revenue
Payer Incentives: High Quality/Low Cost Care; Medically Necessary Services and Procedures. Patient Incentives: High Quality Care, Safe and Effective Care. Maximal Health and Functioning. Low Premiums. Payers and Patients Incentives are actually aligned NOW!
All Previous Studies have been done in our Fee for Service, Fragmented Healthcare System. This System rewards Providers for More Procedures and More Hospital Admissions! With the ACO, suddenly we have forces that are Aligned! Everything will BEHAVE differently in this new System! All bets are off. All previous studies are NOT valid! Fee for Service to Fee for Value Fee for Service to Full Risk
Readmissions in the Context of the ACO (Full Risk Medical Care) 1. Dr. Eric Moskow and Healthcare Partners Medical Group: FULL RISK 2. Aetna s Initiatives with Dr. Krakauer, National Medical Director of Medicare Advantage: Embedded CM (Hospital and PCP Office; End of Life Care) 3. Morristown Medical Center s Initiatives: LOS Optimization combined with Readmission Reduction 1. Pre-Discharge Algorithm (Getting Patients Ready for Discharge) 2. Rapid Rounds and White Boards for Optimal Inpatient Management 3. Discharge Packets to Patients and Caregivers 4. Engaging Hospitalists, PCP Doctors, Home Health and Post Discharge Facilities Project RED, Project BOOST, Transitions in Care, Care Transitions, Aetna, Atlantic Health
Discharge Process Algorithm Day of Admission: Estimate Length of Stay and Date of Discharge Anticipate Disposition Identify Discharge Needs During Hospitalization Patient and Caregiver Education Prepare for Discharge and Prepare for Post Hospitalization Care Day of Discharge Discharge Packet Hospitalist Writes and Dictates Discharge Summary Calls Post Discharge Physician Transition to Next Level of Care
EMMI and Patient Education
EMMI Patient Education
Minimal Knowledge 1. Problem List: What are your Medical Problems? 2. Medications and How each Medication Relates to Each Problem Lasix is for my CHF Proscar is for my Prostate 3. Plan of Care for Each Problem 4. When to call the Doctor or Go to the Emergency Room
The Day of Discharge Make Appointment with PCP for 24 to 48 Hours Make sure Patient has Transportation to Appointment Medication Reconciliation Physician Writes Discharge Plan and Reviews with Patient and Caregiver Physician Dictates a Problem-Oriented Discharge Summary Hospitalist calls the Post Discharge Physician for a Verbal Handoff The Patient is Given the Discharge Packet The Patient knows Who to Call if they have any Problems or Concerns
Discharge Summary Checklist High Quality, Problem-Oriented/Dictated at the Time of Discharge Key elements of discharge summaries, according to the Society of Hospital Medicine, are as follows: Problem that led to hospitalization Key findings and test results Final diagnoses (primary and secondary) Brief hospital course (Problem-Oriented) Condition at discharge Discharge destination Medications at discharge Follow-up appointments and proposed management plan Anticipated problems and suggested interventions Pending laboratory work and tests Recommendations of subspecialty consultants Documentation of patient education Name and 24-hour phone number for hospital physician records.
Donna The Discharge Packet
Contents of Discharge Packet Leading the Way Home 3 Fold Brochure About Your Recent Hospitalization Medication List List of Physicians and their Contact Information Pharmacy Contact Information Follow-up Appointments EMMI Instructions Healthy Aging Information Discharge Instructions Notes and Questions for Doctors and Providers Names of Providers (SW, CM, Nurse, PT, OT, ST)
Post Discharge Care and Communication
Full Risk aligns incentives between Payers, Providers and Patients leading to high quality care, efficient care, safe care and high patient satisfaction.
Accountable Care Organizations (ACOs) Higher Quality Care and Lower Cost Care Coordinated Care. Fully Informed Care (Access to Medical Record Information). Reduction in Waste and Duplication of Services The right care at the right time to the right person for the right reasons. Evidence based care: Stent or No Stent into 70% Stenosis when Angina is Stable. Fee for Value (Quality/Cost) rather than Fee for Service (High Volume, High Cost) Cognitive Care, Evidence Based Decisions
An Integrated Healthcare System An Integrated Healthcare System is a managed care system that includes a hospital organization that provides acute patient care, a multispecialty medical care delivery system, the capability of contracting for any other needed services, and a payer. Primary Care Physicians Payer Hospital Multispecialty Medical Group Integrated Healthcare System Lab and Radiology Other Services
In summing up, I wish I had some kind of affirmative message to leave you with, I don't. Would you take two negative messages? Woody Allen, The Comedy Years