This presenter has nothing to disclose L19: Improving Transitions from the Hospital to Post Acute Care Settings Gail A. Nielsen December 8, 2013 25th Annual National Forum on Quality Improvement in Health Care Orlando, Florida 1
We can t solve problems by using the same kind of thinking we used when we created them. Albert Einstein Changing Paradigms Traditional Focus Immediate clinical needs Patients are the recipients of care and the focus of the care team GPS location team (teams in each clinical setting) Transformational Focus Comprehensiveneeds of the whole person Patient and family members are essential and active members of the care team Cross Continuum Team with a focus on the patient s experience over time 2
Changing Paradigms Traditional Focus Length of stay in the hospital and timely discharges of patients Handoffs Clinician teaching Transformational Focus Initiating a post-acute care plan to meet the comprehensive needs of patients Senders & receivers co-design handover communications What are the patient and family caregivers learning? STAAR Initiative: Two-Levels Concurrent Strategies 1.Provide technical assistance to front-line teams of providers working to improve the transition out of the hospital and into the next care setting 2.Create and support state-based, multistakeholder initiatives to concurrently examine and address the systemic barriers to improving care transitions, care coordination over time 3
Process Changes to Improve Transitions from Hospital (or SNF) to Home Skilled Nursing Care Centers Hospital Primary & Specialty Care Home (Patient & Family Caregivers) Home Health Care Supplemental Care for High-Risk Patients Transition to Community Care Settings and Better Models of Care The Transitional Care Model (TCM) Transition from Hospital to Home or other Care Setting Patient and Family Engagement Cross-Continuum Team Collaboration Health Information Exchange and Shared Care Plans 4
4 Guides on Transitions Senders: From Hospital to SNF or Home Receivers: Office Practice Home Care Skilled Nursing Care Facilities Key Changes to Achieve an Ideal Transition from Hospital (or SNF) to Home: HOW CAN WE. 1. Gain a deeper understanding of the comprehensive postdischarge needs of the patient through an ongoing dialogue with the patient, family caregivers and community providers? 2. Gain a deeper understanding of patient and family caregiver understanding and comprehension of the clinical condition and self-care needs after discharge? 3. Develop a post-acute care plan based on the assessed needs and capabilities of the patient and family caregivers? 4. Effectively communicate post-acute care plans to patients and community-based providers of care? 5
What have we learned to date in the STAAR Initiative? What are we learning about Reducing Avoidable Readmissions? Local learning about the failures and problems that exist is core to success Knowledge of patients home-going needs emerges throughout hospitalization Family and community caregivers are important sources of information about patients home-going needs Though Teach Back we learn what patients may be able to remember and do 6
Diagnostics 360 review Chart reviews Interviews with patients and families Interviews with community providers Observations Assessment Discharge processes for senders and receivers Patient teaching and learning Patient and family experiences of transitions Data analyses Outcome measures Process measures Diagnostic Case Reviews Reveal opportunities for learning from a small sampling of patients experiences Engage the hearts and minds of clinicians and catalyzes action toward problem-solving Formal chart reviews and interviews Cross-continuum team hears first-hand about the transitional care problems through the patients eyes 7
What are we learning about Reducing Avoidable Readmissions? Cross-continuum partnerships design transformational changes together Senders and receivers agree upon and co-design the needed local changes Vital few critical elements of patient information can be available at the time of discharge to community providers Written handover communication for high risk patients is insufficient; direct verbal communication allows for inquiry and clarification What have we learned about Reducing Avoidable Readmissions? Appropriate and timely follow-up care is dependent on availability and payment for services There are no universally agreed-upon risk assessment tools We need a much deeper understanding of how best to meet the needs of high-risk patients Use practical methods to identify modifiable risks 8
What Are We Learning about Reducing Avoidable Readmissions? Strategies to promote patient and family caregiver engagement are critical Appropriate and timely follow-up care is dependent on availability and payment for services Achieving Desired Results Results 9
Analysis of Results-to-Date Reducing readmissions is dependent on highly functional cross-continuum teams and a focus on the patient s journey over time Improving transitions in care requires co-design of transitional care processes among senders and receivers Providing intensive care management services for targeted high risk patients is critical Reliable implementation of changes in pilot units or pilot populations require 18 to 24 months An Early Look at a Four-State Initiative to Reduce Avoidable Readmissions. Boutwell, A,, Bihrle Johnson, M, Rutherford, P, et. al. Health Affairs, July 7,2011 10
Ohio Hospital Association Work Results in Hospital Readmission Reductions AUGUST 2, 2012 OHA s Quality Institute worked to decrease hospital readmissions through the Ohio State Action on Avoidable Rehospitalizations (STAAR) Initiative. Eighteen hospitals participated, and results showed an eight percent greater reduction in STAAR hospitals readmissions than other Ohio hospitals. The Columbus Dispatch reported that hospital readmissions in Ohio dropped six percent in 18 months and accredited the STAAR program as a factor in the decrease. 11
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Heart Failure Readmissions (for Any Cause) within 30 Days 45% 40% 35% Percent 30% 25% 20% 15% 10% 5% 0% 2006 Q2 2006 Q3 2006 Q4 2007 Q1 2007 Q2 2007 Q3 2007 Q4 2008 Q1 2008 Q2 2008 Q3 2008 Q4 2009 Q1 2009 Q2 2009 Q3 2009 Q4 2010 Q1 2010 Q2 2010 Q3 2010 Q4 2011 Q1 2011 Q2 %HF to Any Reason Median prepared at the request of the Center for Medicare and Medicaid Innovation (CMMI) http://www.mitre.org/work/health/news/bundled_payments/st_lukes_case_study.pdf 13
30 Day All-Cause Readmissions 40% 35% 30 Day Readmissions for HF Pilot Nursing Units: Any Dx of HF 2009 Average = 24% 2010 Average = 18 % 2011 Average = 13% % of Patients Readmitted within 30 days 30% 25% 20% 15% 10% 5% Goal Line: 16% (30% reduction) 0% Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Time Period Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 90-Day All Cause Readmissions % of Patients Readmitted within 90 days 50% 45% 40% 35% 30% 25% 20% Jan-Mar 09 Feb-Apr 09 Mar-May 09 Apr-Jun 09 May-Jul 09 90 Day Readmissions for Heart Failure Patients Goal Line: 31% (30% reduction) Jun-Aug 09 Jul-Sep 09 Aug-Oct 09 Sep-Nov 09 Oct-Dec 09 Average for 2009 = 40.2% Average for 2010= 31% Average for 2011 = 26% 30% Reduction from 2006 (45.2%) to 2010 www.commonwealthfund.org/publications/case-studies/2012/nov/university-of-california- San-Francisco.aspx?omnicid=20 Nov-Jan 10 Dec-Feb 10 Jan-Mar 10 Feb-Apr 10 Mar-May 10 Apr-Jun 10 May-Jul 10 Time Period Jun-Aug 10 Jul-Sep 10 Aug-Oct 10 Sep-Nov 10 Oct-Dec 10 Nov-Jan 11 Dec-Feb 11 Jan-Mar 11 Feb-Apr 11 Mar-May 11 April - June 11 May - July 11 June - Aug 11 14
UCSF Heart Failure Program http://www.commonwealthfund.org/publications/case- Studies/2012/Nov/University-of-California-San-Francisco.aspx It s About Systems of Care The quality of patients experience is the north star for systems of care. Donald Berwick, MD 15
Donald Goldmann, MD (dgoldmann@ihi.org) Pat Rutherford, RN, MS (prutherford@ihi.org) Co-Principal Investigators, STAAR Initiative Institute for Healthcare Improvement Azeem Mallick, MBA (amallick@ihi.org) Project Manger, STAAR and Care Transitions Programs http://www.ihi.org/ihi/programs/strategicinitiatives/stateactiononav oidablerehospitalizationsstaar.htm 16