Glendale Healthier Community Care Coordination Collaborative Health Services Advisory Group (HSAG) March 06, 2018
Today s Agenda and Packet Materials Welcome and Introductions Community Readmissions and High-Risk Medications (HRMs) HRMs Best Practices Networking Break CMS 1 Readmission Updates and Resources Meeting Summary and Evaluations 2 1. Centers for Medicare & Medicaid Services (CMS)
Things I Will Share
Your Meeting Feedback Is Important! Please help us exceed the 85% target! 2018 Evaluation Completion Rate 1 0.95 0.9 0.85 0.8 0.75 0.7 0.65 0.6 0.55 0.5 Mar. 2018 Apr. 2018 May. 2018 Jun. 2018 Jul. 2018 Goal Aug. 2018 Sep. 2018 4
We Hear You! Evaluation Debrief Comments How to Improve More opportunity for discussion Provide more tools to bring back to staff Learn more about best practices Spend more time discussing Behavioral Health Invite speakers from different organizations 5
Thank You! Today s breakfast sponsored by Adventist Health Glendale Thank you to Cristy Alagao-Quon! If you would like to sponsor the next breakfast, please contact Aileen Torres at atorresmumby@hsag.com or call 818.265.4672 6
Community Introductions Who Is at Your Table? 7
Community Collaboration 8
Medicare Fee-for-Service (FFS) Activity Data Pyramid 854 7-day readmits 34.1% of all readmissions 2,504 readmissions within 30 days 19% 12,963 were discharged from hospital admissions 26% 48,780 reside in the Glendale Community 9 Data files provided to Health Services Advisory Group (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.
Glendale All-Cause Readmission Rates By Setting Q4 2016 Q3 2017 Community Setting Discharged To 30-day Readmission Rate 30-Day Volume (Readmissions/ Discharges) Home 17.5% 935/5,340 Glendale Skilled Nursing Facility (SNF) Home Health Agency (HHA) 23.4% 678/2,895 19.0% 606/3,182 Hospice 4.4% 12/275 Other 21.5% 273/1,271 Total 19.3% 2,504/12,963 10 Data files provided to Health Services Advisory Group (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 (FFS) beneficiaries.
Glendale Readmission Rate by Condition Q4 2016 Q3 2017 Community Condition 30-day Readmission Rate 30-Day Volume (Readmissions/Discharges) AMI 1 19.9% 59/297 HF 2 27.6% 240/868 Glendale PNE 3 21.9% 204/932 COPD 4 26.2% 131/500 CABG 5 15.6% 10/64 THA/TKA 6 5.3% 22/412 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 11 Data files provided to Health Services Advisory Group (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.
Glendale Community Goals How far are we from reaching our target? Target RIR 1 = 6% RIR Goal is to reach target by September 2018 (Q3 2018) 12 1. Relative Improvement Rate=RIR
Glendale Readmission RIR 1 April 2015 September 2017 7.5% 5.5% 6.0% 6.0% 3.5% 1.5% Desired Direction: Goal: 6% RIR by Sept 30, 2018-0.5% -2.5% -2.40% -4.5% -5.03% -6.5% -8.5% -7.35% -6.95% -8.91% -7.01% -7.59% -10.5% Apr 2015 Mar 2016 Jul 2015 Jun 2016 Oct 2015 Sep 2016 Jan 2016 Dec 2016 Apr 2016 Mar 2017 Jul 2016- Jun 2017 Oct 2016- Sep 2017 Goal 6.0% 6.0% 6.0% 6.0% 6.0% 6.0% 6.0% Actual -2.40% -5.03% -7.35% -6.95% -8.91% -7.01% -7.59% 13 Source: Medicare FFS Claims Data for beneficiaries residing within the Zip codes of this community. 1. The RIR is calculated based on the readmission rates per 1,000 beneficiaries and this formula: (Baseline-Current)/Baseline.
Where Should We Focus Readmission Efforts? 51.2% of readmissions in Glendale came from patients discharged to SNF and HHA In Glendale, patients discharged to SNFs have the highest readmission rate with second largest volume of readmissions Out of 6 conditions penalized by CMS, heart failure has the largest volume of readmissions and the highest readmission rate 1:3 patients in Glendale readmit to a different hospital 17.5% of readmissions came from patients discharged to home 14 Data files provided to Health Services Advisory Group (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.
30-Day Readmissions Among Medicare FFS Beneficiaries on HRMs in California: Q4 2016 Q3 2017 30-Day All-Cause Readmission Rate 17.9% 30-Day HRM Readmission Rate 20.7% 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 diabetes agent ADE are much higher than the percent of readmits with an opioid ADE. 15 Data files provided to Health Services Advisory Group (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.
Glendale 30-Day Readmissions on HRMs Of the 2,504 30-day readmissions in Glendale, 1,377 (55%) were on one or more HRMs. 16 Source: HSAG Analysis of Medicare FFS Part-D Claims Data for Q3 2016 Q2 2017
Glendale Readmissions for HRM Beneficiaries Q4 2016 Q3 2017 Drug Class Community Readmissions for Beneficiaries on a HRM All Cause Community Readmissions Rate Statewide Readmissions for Beneficiaries on a HRM Anticoagulants 24.2% 19.3% 21.2% Diabetic Agents 22.7% 19.3% 21.9% Opioids 24.8% 19.3% 21.2% All Three Combined 23.6% 19.3% 20.7% 17 Data files provided to Health Services Advisory Group (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.
Glendale Community ADE Report by Drug Class Q4 2014 Q2 2017 HRM Category Number of Adverse Drug Events (ADEs) Top Drug Class Percentage of Total ADEs Anticoagulants 805 Warfarin 50.3% Diabetic Agents 858 Insulin 54.1% Opioids 75 Oxycodone 29.3% 18 Data files provided to Health Services Advisory Group (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.
HRM Interventions
HRM Resources 20
HRM Resource: Spotlight on Diabetic Hypoglycemia 1 https://www.hsag.com/care-coord-ca-tools 21 1. Data files provided to Health Services Advisory Group (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.
People Remember 10% of what they read 20% of what they hear 30% of what they see 50% of what they hear and see 70% of what they say or write 90% of what they do 22 Sources: Dale, Edgar. Cone of Experience. 1946. Treichler, DG. Film and Audio-Visual Communications. 1967. Glaser, R. (1983, June). Education and Thinking: The Role of Knowledge. Technical Report No. PDS-6. Pittsburgh, PA: University of Pittsburgh, Learning and Development Center. Thalheimer, Will. Will at Work Learning. May 1, 2016.http://www.willatworklearning.com/2006/05/people_remember.html
HRM Resource: Spotlight on Insulin Management 1 23 1. Daniel S. Budnitz, MD, MPH, Maribeth C. Lovegrove, MPH, Nadine Shehab, PharmD, MPH, and Chesley L. Richards, MD, MPH. Emergency Hospitalizations for Adverse Drug Events in Older American. http://www.nejm.org/doi/full/10.1056/nejmsa1103053
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 24
Network/Break: 15 Minutes http://www.online-stopwatch.com/eggtimer-countdown/full-screen 25
CMS Readmission Updates and Resources
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? 27 Reference for SOM: https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf
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% of potentially preventable readmissions or 15 cases per quarter 2 Revise/improve processes to address factors identified that contribute to preventable readmissions. 28 1. Other intervals are permissible 2. Whichever is larger is suggested but not required
Handout 29
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 17.5% 34.8% SNF 23.4% 30.7% Glendale HHA 19.0% 35.1% Hospice 4.4% 33.4% Other 21.5% 37.7% Total 19.3% 34.1% 30 Data files provided to Health Services Advisory Group (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 Setting Discharged to Days to Readmission 0 3 Days 4 7 Days 7 DAYS N % N % % Home 175 18.7% 151 16.1% 34.8% Glendale Community State SNF 98 14.5% 110 16.2% 30.7% HHA 97 16.0% 116 19.1% 35.1% Hospice 2 16.7% 2 16.7% 33.4% Other 51 18.7% 52 19.0% 37.7% Total for all discharged settings Total for all discharged settings 423 16.9% 431 17.2% 34.1% 23,619 17.8% 25,145 19.0% 36.8% 31 Data files provided to Health Services Advisory Group (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 do You Think 7-Day Readmissions Are Occurring? 32
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 33
#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 contraindicated medications (e.g. aspirin and Coumadin), etc. 34
#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 35
#3 Lack of Timely Follow-up Calls and Appointments After Discharge Common Challenges: 1. Process and accountability for scheduling followup 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 36
#4 Lack of Standardized Discharge Processes Common Challenges: 1. Hospital staff members lack knowledge about SNFs capabilities, especially emergency department and front-line staff 2. Patients/families have unrealistic expectations about staff and resources at nursing homes and want to go back to the hospital 3. Inconsistent information sent from hospital such as mismatched transfer forms, discharge summaries, missing or inconsistent medications list, instructions for care, and patient histories 4. Lack of standardized procedures to conduct successful handoff, such as use of SBAR, 1 nurse-to-nurse phone call, doc-todoc phone call 37 1. Situation, background, assessment, recommendation (SBAR)
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. 38
Strategy Tree 39
Key Lesson A key lesson learned is that a portfolio of mutually reinforcing interventions is needed to achieve project impact, and success depends more on robust implementation than on choice of any one intervention. New York Office of Mental Health https://www.omh.ny.gov/omhweb/special-projects/dsrip/docs/rbhr.pdf
Meeting Summary Connecting all the moving pieces 41
Your Meeting Feedback Is Important! Please help us exceed the 85% target! 2018 Evaluation Completion Rate 1 0.95 0.9 0.85 0.8 0.75 0.7 0.65 0.6 0.55 0.5 Mar. 2018 Apr. 2018 May. 2018 Jun. 2018 Jul. 2018 Goal Aug. 2018 Sep. 2018 42
Thank you! Oscar Lopez 818.696.7015 olopez@hsag.com Jenna Burke 602.801.6652 Jburke@hsag.com
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, 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 CA-11SOW-C.3-03012018-06