(HSAG) Today s Agenda Welcome and Introduction Readmission and Adverse Drug Event (ADE) Data High-Risk Medication (HRM) Resources Behavioral Health Education and Updates Break 7-Day Readmission Focus Nursing Home Readmission Program Meeting Summary and Evaluations 2 1
Road Map to Action Note the important takeaways from today s meeting on this Roadmap to Action. Share it with staff members and colleagues when you return to work. 3 Your Meeting Feedback Is Important! Please help us exceed the 85% target! 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 2017 2018 Evaluation Completion Rate Goal: 85% 81% 77% Aug Nov Mar June Aug 4 2
Thank You! Today s breakfast sponsored by American Orchards Senior Community Thank you to Chrissy Hall and Ricky Bautista! If you would like to sponsor the breakfast, please contact Cheryl Angotti at cangotti2@hsag.com or call 602.801.6916 5 East Valley Care Coordination Coalition () Quarterly Community 2018 Meetings Meeting Date and Time Where Registration Required Thursday 8:00-11:30 a.m. Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ 85297 Thursday June 7, 2018 8:00 11:30 a.m. Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ 85297 http://www.cvent.com/d/ktq371 Thursday August 23, 2018 8:00-11:30 a.m. Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ 85297 Save this Date Registration Coming Soon! Thursday December 6, 2018 8:00 11:30 a.m. 3133 E. Camelback Road, Suite 100 Phoenix, AZ 85016 Save this Date Registration Coming Soon! 6 3
Who Is at Our Table? 7 Special Thank You to Our Community Champions HSAG would like to specifically recognize our partners who: Attended three out of the four Community meetings in 2017, and Their organization has signed a charter showing an official commitment to the and our mission 8 4
Community Champions Certificate 9 Community Champions Bob Mancini, Consultant Community Member Carole-Lynne Richardson, Senior Health Care Advisor Centrix Health Resources Cheryl Bullock, Transitional Care Nurse Liaison OnPointe At Home Chrissy Hall, Executive Director American Orchards Senior Community Christina Andrews, Business Development Manager Maxim Healthcare Services Cyndi Black, Health System Specialist AstraZeneca Debra MacDonald, Director of Clinical Services Arizona Home Care Desiree Granillo, LMSW, SW Manager Care Coordination 10 Dignity Health 5
Community Champions (cont.) Ellen Alba, RN BSN, HCS-O, HCS-D, Quality Assurance Director Arizona Home Care Eric Ehst, Executive Director Neighbors Who Care, Inc. Joan Bowman, RN Case Manager AZ Ortho & Surgical Specialty Hospital Kerry Halcomb, Owner KC s Home Health Care LLC Lara Bowles, Executive Director Wellsprings of Gilbert Laurel Smith, Community Liaison Family Home Care Marie Fredette, Executive Director AZ Hospice and Palliative Care Organization/AZ Association for Home Care Mark Young, President 11 ComForCare/Aging in Arizona Community Champions (cont.) Mary Ellen Hinderer, Account Manager Health Current Mikell Christian, Nurse and Patient Representative Natasha Buhrman-Kleier, Director Health South Nicole Owens, Managing Partner Bx3 Management Solutions, LLC Rey Graf, Home Care Consultant Home Instead Senior Care Roxanne Dudish, Director Dignity Health Stacy Sweet, Business Development Manager Visiting Angels Val Gale, Assistant Chief Chandler Fire, Health, and Medical Department 12 6
East Valley Community Data Updates Jenna Burke, BS, CHES Quality Improvement Specialist, HSAG Community Goals How far are we from reaching our target? Target RIR 1 = 10% RIR Goal is to reach target by September 2018 (Q3 2018) 14 1. Relative Improvement Rate = RIR 7
Readmission RIR Goal (September 2018) 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% -2.0% -4.0% -6.0% -8.0% 0.00% Jan 2015 Dec 2015 launched February 2016-6.82% Apr 2015 Mar 2016-4.07% Jul 2015 Jun 2016 Target RIR -1.67% -0.18% Oct 2015 Sep 2016 Actual RIR Jan 2016- Dec 2016 Desired Direction RIR: Target: 10% RIR by Q3 2018 2.76% 4.21% 2.96% Arp 2016- Mar 2017 Jul 2016- Jun 2017 What happened? Oct 2016- Sept 2017 Target RIR 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% Actual RIR 0.00% -6.82% -4.07% -1.67% -0.18% 2.76% 4.21% 2.96% 15 Source: Medicare Fee for Service Claims Data *The formula for RIR is (Baseline-Current)/Baseline. Our Community: The Geographic Area That Comprises the CRMC MGMC 16 8
All-Cause Readmission Rates by Setting Q4 2016 Q3 2017 Community Setting Discharged To 30-day Readmission Rate 30-Day Volume (Readmissions/ Discharges) Home 14.7% 1,137/7,748 Nursing Home 20.8% 420/2,023 Home Health 20.2% 444/2,195 Hospice 1.3% 7/525 Other 17.5% 207/1,185 Total 16.2% 2,215/13,676 17 Data files provided to (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. Readmission Rate by Condition Q4 2016 Q3 2017 Community Condition 30-day Readmission Rate 30-Day Volume (Readmissions/Discharges) AMI 1 17.6% 51/290 HF 2 18.5% 104/562 PNE 3 17.5% 133/762 COPD 4 22.8% 120/527 CABG 5 14.1% 12/85 THA/TKA 6 4.0% 34/843 1. Acute Myocardial Infarction=AMI 2. Heart Failure=HF 3. Pneumonia=PNE 4. Chronic Obstructive Pulmonary Disease=COPD 5. Coronary Artery Bypass Graft=CABG 6. Total Hip/Total Knee Arthroplasty=THA/TKA 18 Data files provided to (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. 9
ADE Data and HRM Resources Kari Evans, BSN, RN Quality Improvement Specialist, HSAG Readmissions Among Medicare FFS Beneficiaries on HRMs in Arizona Q4 2016 Q3 2017 30-Day All-Cause Readmission Rate 14.7% 30-Day HRM Readmission Rate 18.0% Readmissions among beneficiaries on HRMs are much more frequent than the general population, suggesting ample opportunity for improvement. Percent of 30-day readmits with an anticoagulant or diabetic agent ADE are much higher than the percent of readmits with an opioid ADE. 20 Based on CMS Medicare FFS Parts A and D claims data for 2017. 10
Readmissions for HRM Beneficiaries Q4 2016 Q3 2017 Drug Class Community Readmissions for Beneficiaries on an HRM Statewide Readmissions for Beneficiaries on an HRM All Cause Community Readmission Rate Opioids 21.3% 19.1% 16.2% Anticoagulants 17.4% 18.4% 16.2% Diabetic Agents All Three Combined 22.5% 19.5% 16.2% 19.3% 18.0% 16.2% 21 Data files provided to (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A and Par-D claims for Medicare Fee-for-Service beneficiaries. HRM Resource: Spotlight on Diabetic Hypoglycemia Data files provided to (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A and Part-D claims for Medicare Fee-for-Service beneficiaries. 22 https://www.hsag.com/arizona-med-management-tools 11
HRM Events Timeline November 2017 Introduced 6 of the 7 HRM interventions during November s all community quarterly meeting and participant interest list established February Coaching Calls Completed February combined coaching calls for Opioids, Anticoagulants, and Diabetic Agents February 15 21 11/14/17 1/9/18 2/21/18 3/15/18 January Coaching Calls Completed January 9 11 via WebEx. Reviewed interventions, tools, and developed next steps for the individual interventions. Asking participants to share findings and lessons learned for future coaching sessions March Coaching Calls Upcoming combined coaching calls: Opioids March 15 at 1 p.m. Anticoagulants March 21 at 1 p.m. Diabetic Agents March 22 at 1 p.m. https://www.hsag.com/events 23 https://www.hsag.com/arizona-med-management-tools New HRM Resource: Anticoagulant Clinics in Maricopa County 24 https://www.hsag.com/arizona-med-management-tools 12
HRM Resource Next Steps Review HRM intervention tools. Implement HRM interventions in your setting by collaborating with key stakeholders. Develop audits and action items around interventions. Analyze through internal audits and adjust interventions as needed to facilitate improvement. 25 Behavioral Health: Education and Updates Dennette Janus, MA, LPC Quality Improvement Specialist, HSAG 13
AZ All-Cause All-Age Readmission Rates From an IPF 1 discharge: Q4 2016 Q3 2017 Baseline (CY 2014) Q4 2016 Q1 2017 Q2 2017 Q3 2017 Current Rate Readmission/ Discharges 962/4642 297/1366 287/1382 279/1375 337/1409 1200 /5532 Readmission Rate 20.7% 21.7% 20.8% 20.3% 23.9% 21.7% Relative Improvement Rate (RIR) to Date from baseline period of CY 2014: -4.7% 1. Inpatient psychiatric facility (IPF) 27 Data Source: HSAG Analysis of Medicare FFS Part-A claims for Q4 2016 Q3 2017 Readmission Rates From an IPF Discharge: Return to an IPF vs. Medical Readmission: Q4 2016 Q3 2017 All-age Medicare FFS and dual-eligible beneficiaries Readmissions/ Discharges Readmission Rate All-cause 1200 /5532 21.7% Psychiatric Readmission 830/1200 69.2% Medical Readmission 370/1200 30.8% 28 Data Source: HSAG Analysis of Medicare FFS Part-A claims for Q4 2016 Q3 2017 14
Invitation Consider Readmission Reduction Interventions and Participate in Behavioral Health Educational Webinars 29 Webinar Series for 2018 2019 Relationship Alphabet Soup Inpatient Psychiatric Treatment Changing the Stigma and Images of Electro-convulsive Therapy SSI/SSDI 1 : Similar But Very Different Dementia in More Detail Caregiving: Mindfulness and Resources https://www.hsag.com/bh-webinar-series 30 1. Supplemental Security Income/Social Security Disability Insurance (SSI?SSDI) 15
Behavioral Health Readmission Reduction Series: Receive One Intervention per Month Top 10 Interventions Support Related 1) Post-discharge follow-up phone call to client or caregiver by someone known to the patient 2) Assess, anticipate, address readmission risk factors in discharge planning 3) Family/caregiver meeting focused on readmission reduction during admission 4) Increase individualized referrals 5) Follow-up telephone call to anyone associated with patient s aftercare plan Medication Related 6) Medications filled at discharge 7) Verify coverage for medication Teamwork-related 8) Improve communication/coordination between providers 9) Specific procedure for follow-up with clients not adherent to aftercare 10) Case conference review of every readmission 31 https://www.hsag.com/bh-resources Network/Break: 15 Minutes 00:15:00 http://www.online-stopwatch.com/eggtimer-countdown/full-screen 32 16
7-Day Readmission Focus Jenna Burke Preventing Hospital Readmissions What Is CMS Looking For? December 2017, CMS revised the State Operating Manual (SOM) Guidance to state enforcement agencies on what to look for when determining compliance to the Conditions of Participation: Discharge planning Evaluate the effectiveness of a hospital s discharge planning process. Focus on readmissions: Could anything have been done differently in the discharge planning process to prevent them? 34 Reference for SOM: https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf 17
Preventing Hospital Readmissions What is CMS Looking For? (cont.) Hospitals are now expected to: Track readmission rates at least quarterly Identify potentially preventable readmissions (sample) Choose at least one interval to track (7- or 30-day 1 ) Conduct an in-depth review of the discharge planning process for the sample Review 10 percent of potentially preventable readmissions or 15 cases per quarter 2 Revise/improve processes to address factors identified that contribute to preventable readmissions. 35 1. Other intervals are permissible 2. Whichever is larger is suggested but not required Handout 36 18
All-Cause, 7-Day Readmission Rate by Setting Q4 2016 Q3 2017 Community Setting Discharged To 30-day Readmission Rate 7-Day Readmission Rate Home 14.7% 37.7% Nursing Home 20.8% 32.6% Home Health 20.2% 41.9% Hospice 1.3% 42.9% Other 17.5% 31.9% Total 16.2% 37.1% 37 Data files provided to (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. All-Cause, 7-Day Break Down Q4 2016 Q3 2017 Group State Setting Discharged to Days to Readmission 0 3 Days 4 7 Days 7 DAYS N % N % % Home 215 18.9% 214 18.8% 37.7% SNF 64 15.2% 73 17.4% 32.6% HHA 85 19.1% 101 22.7% 41.9% Hospice 2 28.6% 1 14.3% 42.9% Other 30 14.5% 36 17.4% 31.9% Total for all discharged settings Total for all discharged settings 396 17.9% 425 19.2% 37.1% 4,144 18.0% 4,261 18.5% 36.6% 38 Data files provided to (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. 19
7-Day Readmissions by Condition Q4 2016 Q3 2017 Group Setting Discharged to Days to Readmission 0 3 Days 4 7 Days 7 DAYS N % N % % AMI 10 19.6% 13 25.5% 45.1% HF 19 18.3% 20 19.2% 37.5% PNE 22 16.5% 30 22.6% 39.1% COPD 23 19.2% 14 11.7% 30.8% CABG 2 16.7% 3 25.0% 41.7% THA/TKA 8 23.5% 8 23.5% 47.1% Total for all 6 penalized conditions 84 19.0% 88 21.3% 40.2% 39 Data files provided to (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries. Why Are 7-day Readmissions Happening? Potential Gaps 1. Poor patient self-management skills 2. Low health literacy 3. Neglecting chronic comorbid conditions 4. Inaccurate medication history/medication reconciliation 5. Unrecognized social determinants of health 6. Higher patient acuity management in the post-acute setting 7. Lack of timely follow-up calls and appointments after discharge 8. Lack of standardized discharge processes 40 20
#1 Inaccurate Medication History/ Medication Reconciliation Common Challenges: 1. Inaccurate medication histories and lack of comprehensive medication reconciliation 2. Medication adherence issues: financial, transportation, side effects, etc. 3. Low health literacy leading to misunderstanding of the medication instructions 4. Lack of medication knowledge leading to patients taking contraindicating medications (e.g. aspirin and Coumadin), etc. 41 #2 Higher Patient Acuity Management In the Post-Acute Setting Common Challenges: 1. Staffing model often does not provide enough manpower to manage complex patients (RN, MD, respiratory) 2. Staff perhaps lacking knowledge to recognize early signs of deterioration for patients who are likely to be readmitted 3. Missing or incomplete documentation in the post-acute referral process that accurately conveys the severity of the patient s illness or condition 42 21
#3 Lack of Timely Follow-up Calls and Appointments After Discharge Common Challenges: 1. Process and accountability for scheduling follow-up visit prior to discharge 2. Lack of an ongoing primary care relationship 3. Confusion between hospitalist, primary care physician, and/or specialist regarding patient s current course of treatment 4. Patients do not feel well enough to leave home for appointments or have limited transportation options 43 #4 Lack of Standardized Discharge Processes Common Challenges: 1. Hospital staff members lack knowledge about skilled nursing facilities capabilities, especially emergency department and front-line staff 2. Patients and their families have unrealistic expectations about the staff members and resources at nursing homes and want to go back to the hospital 3. Inconsistent information sent from hospital such as mismatched transfer forms and discharge summaries and missing or inconsistent medications list, instructions for care, and patient histories 4. Lack of standardized procedures in conducting successful handoff such as use of SBAR, 1 nurse-to-nurse phone call, doc-to-doc phone call 44 1. Situation, background, assessment, recommendation (SBAR) 22
Table Top Activity Review your tables assigned gap topic: 1. Inaccurate medication history/medication reconciliation 2. Higher Patient Acuity Management in the Post-Acute Setting 3. Lack of timely follow-up calls and appointments after discharge 4. Lack of standardized discharge processes Select one of the common challenges listed for your assigned gap topic. Develop solutions for that challenge. Be specific and identify 4 5 tactics to implement that solution. Example on next page. Identify spokes person to report out tactics to the group. 45 Template 46 23
Additional HSAG Tools to Assist Your Readmission Efforts 7-day Readmission Checklist and Audit tool Organizational Gap Assessment template and webinar Teach-back training and materials Medication History Tool Kit HRM resources Behavioral health interventions and webinars 47 Nursing Home Readmission Reduction Preparation Program Barb Averyt Executive Director, HSAG 24
Readmission Reduction for Nursing Homes Reducing Readmission Preparation Program Starting the Journey January February Well on the Way March April Leading the Way May September Learn more at: www.hsag.com/az-rrpp 49 Reducing Readmissions Preparation Program Goals: Improve staff knowledge on readmission interventions Assist nursing homes to create and strengthen their readmission prevention programs Help facilities be a preferred provider to your local hospitals Improve readmission rates by October 2018 50 25
Nursing Home Readmission Assessment Work with your Reducing Readmissions Committee to complete the readmission assessment Focused on operational processes Pre-admission Admission/transfer from hospital Get started at: www.hsag.com/az-rrpp Submit completed form online or scan and email to Cangotti2@hsag.com 51 2018 Webinar Series INTERVENTION STRATEGIES Welcome: Understanding Changes in Readmission Measures Principles from Evidence-based Care Coordination Programs Running a Readmission Review Committee Listening to Your Residents: Teach Back and Motivational Interviewing CLINICAL SKILLS Sepsis Heart Failure, Anticoagulants, Medication Reconciliation Diabetes and Hypoglycemia Chronic Obstructive Pulmonary Disease (COPD) Sharing Success Stories 52 26
Next Steps: Let the Journey Begin! Sign Up! Submit commitment agreement to participate Submit Reducing Readmissions Committee Roster Submit Nursing Home Readmission Pre-Assessment Submit QAPI Self- Assessment Survey www.hsag.com/az-rrpp Work with your Reducing Readmissions Committee to: Request and review available CMS readmissions data to establish your baseline readmission rates. Begin QAPI project to implement a readmission intervention 53 Meeting Summary and Evaluations Jenna Burke 27
Meeting Summary Connecting all the moving pieces 55 Your Meeting Feedback Is Important! Please help us exceed the 85% target! 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 2017 2018 Evaluation Completion Rate Goal: 85% 81% 77% Aug Nov Mar June Aug 56 28
Questions? 57 Thank You! Jenna Burke 602.801.6652 jburke@hsag.com 29
This material was prepared by, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-11SOW-C.3-02272018-01 30