Readmissions Moving beyond blame to fill the patient needs Jackie Conrad RN, MBA, RCC Cynosure Health jconrad@cynosurehealth.org 1
51 year old male with 3 acute care admissions and 2 ED visits in the past 180 days. When asked why he thought he was readmitted said I RAN OUT OF LASIX 2
Do you operate like this? 3
Should you continue? 4
This is NOT the answer? 5
What would be better? 6
Big DATA + Little DATA = A better approach BIG Data The entire readmissions population Dice and slice by payer, REaL, etc. Learn which groups are readmitted at a higher rate These are the groups you will TARGET with special effort Little Data What you are learning on a day-to-day basis From patients, providers, case review Help you understand where the gaps are in your current processes and program Helps you decide WHAT to prioritize from a PI perspective 7
Why use big data? Medicare readmission penalties drive many approaches But these DRGs are not the top reasons for readmissions in all populations Focusing on these DRGs only will not reduce hospital-wide readmission rates and leaves many needs unmet 8
Let s drill down BIG DATA Readmission Data Drill Down Tool A data analyst friend Several hours Process Run the data Populate the tool Answer the questions with your team What assumptions did your data confirm? What surprised you? What BIG data will tell you Readmission by payer Top discharge diagnosis Behavioral health comorbidities Days between d/c and readmit D/C disposition by payer High Utilizers 9
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What would you prioritize? DRG Bundle SEPTICEMIA OR SEVERE SEPSIS Stays with DRG Bundle Stays w/ Re-Admission within 30 days Readmission Rate 7858 1374 17.5% MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY 7052 360 5.1% SIMPLE PNEUMONIA & PLEURISY 4465 664 14.9% HEART FAILURE & SHOCK 4310 967 22.4% RENAL FAILURE 2890 588 20.3% COPD 2883 568 19.7% CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 2701 413 15.3% ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS 2462 429 17.4% KIDNEY & URINARY TRACT INFECTIONS 2404 333 13.9% PULMONARY EDEMA & RESPIRATORY FAILURE 2330 455 19.5%
Little data provide a different perspective Why ask the patients and providers? Gain their perspectives Understand reasons Identify gaps Develop a better plan for the specific patient Design a more effective program Why do case reviews (focus on quick returns)? Determine care gaps Look at plans overtime Prioritize repeated issues 12
Readmission Interview Challenge Identify 5 or more patients in the hospital that have been recently readmitted. Interview five patients/caregivers using the ASPIRE 2 tool. Analyze responses for new insight regarding why patients soon returned to the hospital. 1 2 3 4 5 ASPIRE 2 Tool: www.hret-hiin.org/resources/display/aspire-tool-2-readmission-review-tool Readmissions Case Review Analysis Tool: www.hret-hiin.org/resources/display/readmission-case-review-and-analysis
Aspire 2 Interview Tool Readmission Interview (5-10 minutes each) Why were you hospitalized earlier this month? Prompt for patient/caregiver understanding of the reason for hospitalization. When you left the hospital: How did you feel? Where did you go? Did you have any questions or concerns? If so, what were they? Were you able to get your medications? Did you need help taking care of yourself? If you needed help, did you have help? If so, who? Tell me about the time between the day you left the hospital and the day you returned: When did you start not feeling well? Did you call anyone (doctor, nurse, other)? Did you try to see, or did you see a doctor or nurse or another provider before you came? Did you try to manage symptoms yourself? Prompt for patient/caregiver self-management techniques used. In our efforts to provide the best possible care to you and others like you, can you think of anything that we or anyone could have done to help you after you left the hospital the first time so that you might not have needed to return so soon? Root Cause Analysis (2-3 min) Ask Why 5 times Identify ALL the reasons Seek to identify all the clinical, behavioral, social and logistical factors that contributed 14
Aggregate and prioritize 15
Use the data to identify unmet needs 16
Enhanced services Enhanced services generally mean $ Choose enhanced services based on need Prioritize What will benefit my readmission reduction efforts the most? 17
Enhanced Service Needs / Gaps Palliative Care / Advance Care Planning Patients Diagnosed with Sepsis Behavioral Health Services Medication Related Problems High Utilizers 18
Palliative Care & Advance Care Planning Palliative Care Resources POLST Advance Directives Conversation Project Faith based community organizations Conversation nurses Home care https://www.nhpco.org/palliative-careresources https://www.capc.org/topics/palliative-careguidelines-quality-standards/ https://guideline.gov/summaries/summary/47 629/palliative-care-for-adults http://theconversationproject.org/starter-kits/ http://polst.org/ 19
Advance Care Planning Medicare Definition: Voluntary ACP means the face-to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms. An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time. Important Concept: Team Based Care Billing / Coding Advance Care Panning = Procedure Advance Directive = Product The Procedure may or may not result in a Product Reimbursement CPT Code 99497 - $82.90 First 30 minute unit CPT Code 99498- $72.50 Each additional 30 minute unit If multiple conversations, each conversation starts with CPT 99497 20
Condition Specific Needs - Sepsis Learn from your Data What % of your readmitted patients are returning with sepsis? What was the discharge disposition for those patients? How soon did they come back?
Condition Specific Needs Behavioral Health Learn from your Data What % of your readmitted patients have a behavioral health cc s? Use ICD-10 codes: F0 F9 to capture patients with behavioral health diagnoses. What was the discharge disposition for those patients? How soon did they come back?
Filling the Gaps in BH Services High intensity primary care from and integrated team APP- Advanced Practice provider (PA or APN) MSW- Masters level social worker/therapist MA- Medical Assistant CHW- Community Health Worker, MHW Mental Health Worker Case management team with BH experience, MHWs Addiction Stabilization SBRIT Screening, brief intervention and treatment Home Based Health Community connections to behavioral and social services providers Medication Services
Impact of Medication Related Problems on Hospital Readmissions 1 out of 3 hospital readmissions are associated with medication-related problems (MRP) or complications. NEHI Issue Brief, October 2012 Improving Medication Adherence and Reducing Readmissions http://www.nacds.org/pdfs/pr/2012/nehi-readmissions.pdf Frankl SE, et al. Am J Med 1991 Jun;90(6):667-74 http://www.ncbi.nlm.nih.gov/pubmed/2042681
MRP Solutions Meds to bed Use Hospital OP pharmacy or Retail Psychiatric specialty services available Pharmacy delivers meds prior to d/c Completes paperwork, pre-authorizations 25
High Utilizers / Complex Care Management Patients with chronic conditions often have multiple issues, see an average of 11 providers, and take numerous medications. Activities designed to more effectively assist patients and their caregivers in managing medical conditions and cooccurring psychosocial factors. Improve health status and reduce the need for hospital care.
What do your High Utilizers Need? 27
JAMA article findings A study of 1000 readmitted patients to 12 academic medical centers across the US. Findings include: 26.9% were considered potentially preventable. The factors strongly associated with preventable readmission were: Emergency department decision making regarding the readmission Failure to relay important information to outpatient health care professionals Discharge of patients too soon A lack of discussions about care goals among patients with serious illnesses Inability to keep appointments after discharge Patient lack of awareness of whom to contact after discharge http://archinte.jamanetwork.com/article.aspx?articleid=2498846
ED Pause Disrupt the ordinary process of automatic readmissions Know who was recently discharged E.g. Flag Identify person & process for ED to get support to determine patient s disposition 29
Jackie Conrad RN, MBA, RCC Improvement Advisor Cynosure Health jconrad@cynosurehealth.org 30