Reducing Medicaid Readmissions Webinar 1: Medicaid Readmissions 101 Amy E. Boutwell, MD MPP Co-Principal Investigator AHRQ Reducing Medicaid Readmissions Project February 25 2015
Agenda Introduction to the AHRQ Reducing Medicaid Readmission Project and the Hospital Guide to Reducing Medicaid Readmissions Why Medicaid readmissions for global revenue hospitals? Tools 1, 2, 3, 4 of the Guide Action steps
Objectives Introduce AHRQ Hospital Guide to Reducing Medicaid Readmissions, 3 action-oriented webinars & April learning session Identify 3 ways Medicaid readmission patterns differ in important ways from Medicare readmission patterns Describe why conducting your own analysis will position your team to better address readmissions under global budgets Conduct a hospital and community-based inventory of efforts and assets relating to reducing (re)admissions
Reducing Medicaid Readmissions Project
AHRQ Reducing Medicaid Readmissions Project Readmission reduction efforts to date have been largely informed by research on older adult, Medicare population Identify the similarities & differences in readmission patterns for Medicare v. Medicaid patients Explore whether the best practices to reduce readmissions apply to the Medicaid population as well Create a guide for hospitals to increase awareness of the unique issues in reducing Medicaid readmissions
AHRQ Reducing Medicaid Readmissions Project AHRQ-issued contract to John Snow, Inc (JSI); 2011-present First phase objective: Identify issues unique to Medicaid readmissions Second phase objective: Develop a guide for hospital providers to expand and adapt practices to better serve Medicaid patients Third phase objective (currently): Disseminate the Guide and test, evaluate and refine the materials for future Version 2.0 We welcome feedback on how to improve these materials anytime!
AHRQ Reducing Medicaid Readmissions Project Maryland Dissemination Maryland Global Revenue constraints focus attention to issue Maryland Hospital Association leads dissemination effort 3 webinars: February 25, March 11, March 25 In-person learning session April 1 (location TBD) 3 hospitals will participate in deep dive to work through all recommendations and tools in Guide April-September
Guide to Reducing Medicaid Readmissions and Toolkit
Introduction Table of Contents Why focus on Medicaid Readmissions? How to Use This Guide Roadmap of Tools Know Your Data Inventory Readmission Efforts Develop a Portfolio of Strategies Improve Hospital-based Processes Collaborate with Cross Setting Partners Provide Enhanced Services http://www.ahrq.gov/professionals/syst ems/hospital/medicaidreadmitguide/
Tools 1. Readmission Data Analysis 2. Readmission Interview 3. Data Analysis Synthesis 4. Hospital Inventory 5. Cross-Continuum Team Inventory 6. Conditions of Participation Checklist 7. Portfolio Design 8. Readmission Reduction Impact 9. Readmission Risk 10. Whole-Person Assessment 11. Discharge Information Checklist 12. Forming a Cross-Continuum Team 13. Community Resource Guide http://www.ahrq.gov/professionals/systems/ hospital/medicaidreadmitguide/
Why Medicaid Readmissions in a GBR world?
Medicare Focus Has Created Blinders 1. HF, AMI, PNA COPD, hip/knee replacement NOT the most frequent diagnoses leading to readmissions Disease-specific penalty obscured other meaningful ways to target efforts: High Utilizer, social complexity, behavioral health comorbidities 2. Driven a Medicare focus to the exclusion of other high risk patient groups Medicaid adults have higher readmission rates than Medicare FFS Neglect lower-volume, but high risk groups (HIV, cancer, sickle cell) 3. Driven a case-finding approach Interventions often limited to Medicare FFS with certain diagnosis Lost the focus on reliable redesign on transitional care for all patients
Readmissions are Frequent for Medicaid Adults 61M with 8 hospitalizations this year for shortness of breath returns to the hospital 10 days after discharge with shortness of breath. 45F with HIV hospitalized for pneumonia discharged to home returns to the hospital 8 days later with pneumonia. 32M with uncontrolled DM, cognitive limitations, bipolar disorder, active substance use, homeless presents with flank pain to one hospital, readmitted with chest pain to another hospital Would your hospital s readmission reduction strategy have helped these patients? If so, how? If not, why not?
Readmissions & Potentially Avoidable Utilization New world of Potentially Avoidable Utilization Avoidable admissions Avoidable readmissions Avoidable ED visits The skills required to succeed under global revenue and PAU include: Re-examining old assumptions Mastering data analysis and information exchange Meeting patient needs in new ways Embracing social and behavioral drivers of utilization Engaging clinicians in practice change Executing cross-setting care plans
Medicaid Readmissions: The Stats
Maryland: Diagnoses Leading to Readmission Discharge Diagnosis Heart Failure Septicemia & Disseminated Infections Chronic Obstructive Pulmonary Disease Bipolar Disorders Other Pneumonia Renal Failure Schizophrenia Kidney & Urinary Tract Infections Major Depressive Disorders & Other/Unspecified Psychoses Cardiac Arrhythmia & Conduction Disorders Source: MHA Analysis of HSCRC Discharge Data 2014 All Payers
US All-Payer Readmissions by Volume Elixhauser, Steiner. Readmissions to US Hospitals by Diagnosis, 2010. AHRQ HCUP Statistical brief #153. April 2013
All-Payer Diagnoses with Highest Rates Elixhauser, Steiner. Readmissions to US Hospitals by Diagnosis, 2010. AHRQ HCUP Statistical brief #153. April 2013
Elixhauser, Steiner. Readmissions to US Hospitals by Diagnosis, 2010. AHRQ HCUP Statistical brief #153. April 2013
Methods: - Used CCS groupers - Included OB Top 10 Medicaid Dx: 1. Mood disorder 2. Schizophrenia 3. Diabetes complications 4. Comp. of pregnancy 5. Alcohol-related 6. Early labor 7. CHF 8. Sepsis 9. COPD 10. Substance-use related Top 10 Medicare Dx: 1. CHF 2. Sepsis 3. Pneumonia 4. COPD 5. Arrythmia 6. UTI 7. Acute renal failure 8. AMI 9. Complication of device 10. Stroke
Key stats: 85% are over age 21 Average 6 hospitalizations/yr LOS: 6.1 v. 4.5 days Cost: $11,600 v. $9,000 Readmission rate 52% v 8% 75% HU are d/c to home Top Diagnoses of High Utilizers: Mood disorders Schizophrenia Diabetes Chemotherapy Sickle Cell Alcohol-related Sepsis CHF COPD
Maryland High Utilizers Patients 3 or more admissions/year Payer # People Total Charges % of Charges Medicare 20,592 $1.4 billion 49% Medicaid/other 13,731 $1.0 billion 35% Dual Eligible 6,278 $450 million 16% Total 40,601 $2.85 billion 100% Source: HSCRC 2012 Discharge Data
Recommendation 1: Know your own data
This is a 10-point analysis of data to facilitate a compare and contrast view of readmissions by payer to identify differences between Medicare, Medicaid, commercial, and all-payer rates.
All-Payer Readmission Analysis Medicare Medicaid Comm. Unins. Total Total discharges 218,098 33,003 89,247 46,075 386,423 % payer of total 56% 9% 23% 12% 100% Total persons d/c 134,007 20,829 69,822 35,488 252,546 % payer total 53% 8% 28% 14% 100% Hospitalizations/person 1.63 1.58 1.28 1.3 1.53 Readmissions (RA) 45,139 7,250 11,518 5,969 69,876 Readmission rate 20.7% 22% 13% 13% 18% % RA to same hospital 68% 74% 66% 73% 69% % RA to different hospital 32% 26% 34% 27% 31% Boutwell et al, unpublished analyses, 2014
All-Payer Readmission Analysis Medicare Medicaid Comm. Unins. Total ARF (1384) Sickle Cell (478) Chemo (290) Pancreatitis (187) Sepsis (1859) Sepsis (1366) Sepsis (175) CVA (276) Chemo (157) ARF (1800) PNA (1336) Chemo (175) Arthritis (260) DKA (136) PNA (1750) COPD (1211) COPD (173) Sepsis (222) CVA (125) CVA (1622) CVA (1140) DKA (156) PNA (188) COPD (109) COPD (1608) UTI (1038) PNA (145) ARF (182) ARF (97) UTI (1608) Afib (851) ARF (137) CAD (181) Sepsis (96) HF (1115) HF (822) HF (129) Pancreatitis (153) PNA (81) CAD (1092) CAD (746) Pancreatitis (127) Afib (152) ETOH w/d (76) Afib (1092) Boutwell et al, unpublished analyses, 2014
All-Payer Readmission Analysis Medicare Medicaid Comm. Unins. Total # people hospitalized >3x 20711 3765 5444 3583 29275 % of total patients d/c 15% 18% 8% 10% 12% Total hospitalizations 77686 13051 16313 10125 117175 % of all hospitalizations 36% 40% 18% 22% 30% HU d/c to home 47% 72% 67% 73% 55% HU d/c to Home Health 21% 17% 17% 9% 19% HU d/c to SNF 17% 3% 4% 1% 13% HU d/c to Hospice 3% 2% 3% 2% 3% RA rate HU 40% 44% 41% 38% 41% Boutwell et al, unpublished analyses, 2014
Recommendation 2: Ask your patients why
Adapted from the STAAR* approach, this onepage interview guide prompts clinical or This tool quality staff to elicit the patient, caregiver, and provider perspective about the causes of readmissions. *The State Action on Avoidable Rehospitalizations Initiative
Understand the story behind the chief complaint 61M with 8 hospitalizations this year for shortness of breath returns to the hospital 10 days after discharge with shortness of breath. 45F with HIV hospitalized for pneumonia discharged to home returns to the hospital 8 days later with pneumonia. 32M with uncontrolled DM, cognitive limitations, bipolar disorder, active substance use, homeless presents with flank pain to one hospital, readmitted with chest pain to another hospital Chart reviews and administrative analyses will NOT reveal what you need to know: you must talk to your patients, their families and caregivers, providers
Root Cause of Chest Pain Admission: Shelter I need housing, not a shelter. I need someone to help make sure I take my medicines. In a shelter they don't do that and they kick you out every morning. I need a stable residence and no one is able to help with that." Acute Care Utilization over 180 days of freedom 15-Sep Prison Prison Prison Prison Prison Released 22-Sep ED DC 29-Sep 6-Oct ED ED IN IN 13-Oct IN IN DC 20-Oct ED DC 27-Oct IN ED DC ED 3-Nov IN IN IN IN IN DC/ED IN 10-Nov IN IN ED IN IN IN IN 17-Nov IN IN DC ED IN IN ED/DC 24-Nov IN ED ED ED IN 1-Dec ED IN DC ED 8-Dec IN IN IN IN IN IN IN 15-Dec IN IN DC 22-Dec 29-Dec 5-Jan ED ED IN DC ED 12-Jan ED 19-Jan ED IN IN IN IN DC ED 26-Jan DC ED ED IN 2-Feb IN IN IN IN IN IN IN 9-Feb IN IN IN IN IN IN IN 16-Feb IN IN IN DC IN IN IN 23-Feb IN IN ED (DC Brockton) IN? ED 2-Mar IN IN DC/ED IN 9-Mar DC ED DC ED IN IN IN 16-Mar IN IN
There is Never One Reason for Readmission.. KP team reviewed 523 readmissions across ~14 hospitals: 250 (47%) deemed potentially preventable Found an average of 9 factors contributed to each readmission Assessed factors related to 5 domains: 73% - care transitions planning & care coordination 80% - clinical care 49% - logistics of follow up care 41% - advanced care planning & end of life 28% - medications 250 readmissions identified 1,867 factors Feingenbaum et al Medical Care 50(7): July 2012
Interviewed 60 patients who returned to ED after d/c from ED <9days Average age 43 (19-75) Majority had a PCP, but cited ED gave more tests, quicker answers, single site and ED more likely to treat the symptoms Most reported no problem filling medications 19//60 thought they didn t get prescribed the medications they needed (pain) 24/60 expressed concerns about clinical evaluation and diagnosis Primary reason for returning: fear and uncertainty about their condition Patients need more reassurance during and after episodes of care Patients need access to advice between visits Annals of Emergency Medicine e-pub ahead of print
Recommendation 3: Interpret Findings Post, share, use for training, engagement, alignment
This template is used to create a narrative to describe the results from the quantitative data and readmission interviews.
Recommendation 4: Inventory Hospital-Based and Cross-Continuum Efforts
Use this tool to: identify readmission reduction efforts across departments Identify whether efforts are coordinated Identify whether there is duplication Identify gaps in administrative support Identify gaps in clinician engagement This tool prompts a comprehensive inventory of readmission reduction activity across departments, service lines, and units within the hospital. Identify gaps in patient engagement
This tool prompts a comprehensive inventory of community-based providers and agencies that provide services helpful in the post-discharge setting. Formal partnerships? Informal arrangements? Optimizing available resources? Is timely linkage as easy as it needs to be Unknown gaps? Time to expand beyond first phase?
Summary and Action Steps Medicaid adults have high readmission rates Top all-payer reasons for readmission include behavioral health issues Patients return to acute care seeking reassurance or for convenience Test your assumptions, examine your own data, listen to your patients Know who your high utilizing patients are Periodically conduct an inventory of readmission efforts use to align efforts, identify gaps & optimize existing community based resources
Upcoming Webinars & Meetings Upcoming Webinars: March 11: Updating Your Avoidable Utilization Strategy for 2015 March 25: High Impact Medicaid-Specific Strategies In-Person Learning Session: April 1 (Turf Valley)
Thank you! We welcome your feedback on the webinars and Guide/Tools! Amy E. Boutwell, MD MPP amy@collaborative-hcs.com 617-710-5785 Jim Maxwell, PhD jim_maxwell@jsi.com 617-482-9485