NoCVA Readmissions Webinar Innovative Care Transitions Programs September 30, 2014

NoCVA Readmissions Webinar Innovative Care Transitions Programs September 30, 2014 All right. We will be starting here in a couple of minutes. So probably, if everybody could mute their lines of the a good, safe thing to do. And when you are ready to speak, just open up if you have a comment to make. That would be great. And I will be right back to open us up. Does anybody have any questions? Good morning, everyone. We want to thank you for joining us for the NoCVA Preventing Avoidable Readmissions Learning Network. My name is James Hays, and I'm a project coordinator here at the North Carolina Quality Center and I will be helping with some logistics for the call. Also with me in the room is Linda McNeil, low care manager here at the quality center. Before we get started I like to review logistics. This webinar is being recorded and will be posted to the readmissions initiative webpage shortly after the conclusion of the session. All lines are placed on listen only mode. As always, we encourage you to participate and ask that you use the chat box located on the right-hand side of your screen in the control panel. To make a comment or question. Please be sure to select chat all participants so that everybody on the webinar can see your question or comment. If you like to ask your question live, you may click on the hand icon next to your name. We will mute your line and you can ask your question at that time. Please be sure to announce worse off than hospital that you represent before speaking. So, before I turn things over to Linda, let's test the chat feature. So if you would, chat in your hospital name and the number of people that are joining you on the call today. And while those are coming in, Linda, I will turn things over to you. Thank you so much for calling into the NoCVA Preventing Avoidable Readmissions Learning Network webinar. We are really excited today for the couple of topics that we have. We are looking for innovative care transition models and our first speaker is Penny Cooper from Augusta Health, decision support manager. They are a 255 bed independent community hospital located in Fisherville, Virginia. She has a Masters in health science as a health science doctoral candidate and she is going to share with us today and innovative programs that they have come up with in terms of doing risk assessment. So, I will turn it over to you. Rate, thank you so much and thank you for the opportunity to present today and talk about the exciting things that we're doing at Augusta Health. We will get started with our presentation. Assessing the patient's risk of a 30 day readmission. Everyone on the CMS readmissions reduction program that adjusts payment for hospital based on 30 day readmissions rates, and that has to Health began an initiative about two and half years ago to develop a real-time automated tool to stratify the patient risk of a 30 day readmission at our hospital. We did find that chronicle and administrative data that was readily available in a typical community hospital system can be used to create a validated ring system that automatically assigns a probability of a 30 day readmission. Y'all forgive me, I hope that everybody can hear me okay. I'm fighting a cold, I feel much better than I sound but I'm hoping that I can be understood. So, we extracted data for two full years. 2010 was our study period, 2011 was our hospital use multiple regression analysis to look at variables associated with risk of readmission within 30 days. The

variables that we extracted from our data warehouse include the acute admissions and this is as opposed to a scheduled one, for a surgery, for example, the patient's age, male gender, marital status, but Charles and morbidity index which I'll talk about more in the next five, ER visits, within the past year, inpatient visits with them past year that does include observation patients, a payer source of a self-pay patient, lives alone, the length of stay and this is for the current admission, be ambulatory medication pill, as dictated by the patient, and the inpatient medication count. That Charlson CoMorbidity Index, we developed a method to automatically calculate the Charlson CoMorbidity Index based on the diagnoses made during the previous visit. And then, this was rolled up as a value on the variables as discussed on the previous stage. We did use that age-adjusted model as discussed by Quan et al. manuscript published in a peer-reviewed journal. We did an extensive literature search try to conducting this study. For HENs said other studies. The highest C statistics, and will talk about that on the next slide, the highest C statistic that we found was.83 and based on administrative data in addition to a manually self-reported score, our methodology uses no manual input and is fully automated. The results of our study, we had an area under the curve or AUC, also referred to as a C statistic of. 738 which was favorable in terms of comparisons to other studies in the review of literature. A little bit of background for your non-statistical types. Discrimination in this regard is the ability to distinguish between low-risk and high-risk patients for your subject study and is quantified by a measure supported or the C statistic. The C statistic is identical to the variable under the operating curve and varies between.5 and one for all models. The higher the number, the better discrimination. For example, when five would mean that there is no impact..9 is a very high correlation. But, we originally developed different groups of risk. When we submitted our nanny script for peerreviewed publication, they were insistent on a cold death files. And so when we implemented the system in-house, we kept those equal deciles for actual patient account. You will note that the last decile has a broad range of.35. I'm sorry, 3.03 to 4.81, when you get up to 3.5, the risk of readmission goes to about 57%. But again, peer-reviewed said to equal deciles, so when we implemented, that is what we maintained. The readmission risk tool. This is published and available for viewing by nursing and case management on our clinical surveillance passport. This is located within the Augusta Health portal and in addition to the percentage of readmission risk located on the far right-hand side, the display also shows the raw values that make up the scores. For example, you can see that this is an ER admission, that is the actual age of the patient, gender, number of inpatient ER visits within the past year. The financial class, inpatient medications, outpatient medications, the Charlson CoMorbidity Index, and then this area did not actually have anything to do with our testing model, but we just wanted some historical purposes on there for our clinical case managers to know that this patient doesn't fax have a history of COPD and diabetes and heart failure. So, they have special measures that they implemented these patients. Our results. The results have for the most part been positive and to show a decrease based on 2011 data as compared to 2014 data. I got two examples up here, one for

diabetes and one for COPD. It is really important to note, however, based on CMS penalties as well as expenditure control for our accountable care efforts, the overall awareness for reducing readmissions has really been raised and has definitely assisted with this overall effort in the decrease of readmissions. Does anybody have any questions at this point? I have provided a link to the full manuscript as published in the applied clinical informatics if anybody is interested in reading. And, Penny, this is Laura Maynard at the Quality Center and I encourage anyone to type in questions or raise your hand if you have a question. If you're called in, we can unmute you time. I was wondering if you could mention to us what the individuals -- that you put out a very high risk. Again, clinical case managers review the list daily to identify patients at higher risk and I really can't speak to their efforts on the clinical side, but they have varying implementations including referrals to likes of the medical home which is why with the actual history for diabetes or COPD, so they can implement the specific measures. And I can get more on that information if you would like. And submit to you for this. That might be helpful, if it is readily available for you to send that to us so that we can distribute it because I think that might be useful for folks to see what you can put in place that help to prevent those readmissions want to identify those. Thank you, that would be great. This is Linda, and while we were waiting for other questions, I was wondering, I know that you said you weren't on the clinical side but could you share any information on how this was implemented across the hospital, I mean, 255 beds? Did he start with reports on one unit and roll it out? Or how does that work in the process? This was actually rolled out to all units simultaneously. Again, because it is an automated message, it runs like at 4 AM or 5 AM in the morning and gets published to the portal automatically. There is no employee intervention whatsoever in the public submits the data. So when the case manager and nursing staff arise in the morning, it is there and ready to be active. Okay, I'm making a note. Okay. This is Laura again and he mentioned this and I missed it I apologize. Which electronic medical record are you using? MediTech a proprietary system and redoing the data extraction of the MediTech data warehouse so they have a proprietary system that they transfer to our SQL data warehouse and all data extraction is done from there. Excellent, thank you.

You're welcome. Do we have other questions? I know that we have folks in both states that youth MediTech, if you want to pick Penny's brain. Well, I appreciate very much the time and effort of sharing this program with us, and how you developed it and thank you for giving us the access to the manuscript. I think that we will leave the chat open if anybody has any questions. They can most certainly chime in. And, we will move ahead with the next folks, and we got Becky. Thank you for having me, I appreciate it. Thank you very much. I hope you can stay on the line and if you have any questions help us answer. Yes, ma'am. Our next facility is Wake Med, and they are going to share information about a transition program that they have developed to help decrease readmissions out of the ED and inpatient, and we got two speakers. Rebecca Andrews, Vice President of health information and utilization management department, Becky is responsible for the clinical access. She has worked at Wake Med for more than 20 years and a variety of roles and has previously directed registration, billing and collections, corporate reimbursement, revenue management, the budget and finance planning and the corporate accounting. Becky holds a BS in business administration management from Meredith College and has an MS in community leadership from among going to murder this man, Duquesne University. Perfect. Oh, okay, great. With her is Angela Hollis, who is a nurse that is the stroke and heart failure program coordinator with Wake Med hospital and she works with the heart failure patients in both the community and the hospital. And I will go have Internet over to you all. Well good morning. We are so glad to be able to share one of our initiatives that we have partnered with to decrease hospital readmissions. Parent health cost. Health of the company that Wake Med has partnered with. Your health is a transition company. They go into patient's homes, they have both physicians and mid-levels who go into patient homes, once they're discharged, that either have the patience have trouble getting a timely follow-up with the physician, the patient does not have a physician to see, so they will see the patient as a transition name, or, they are identified either by the primary nurse, case management, physician or educator that is at high risk for readmission or noncompliance or has some kind of environmental things that may cause for readmissions. So, the Paired Health model is a for plan. The first thing as the referral.

They have a website that they have created that takes less than 60 seconds for our case managers to put in a referral. The next step is to stratify. All patients are referred to Paired Health for follow-up are stratified or are they to be seen the day that they are discharged from the hospital? The next day? Can they be contacted by telephone the day after and the scene in 48 hours? So, they are stratified. Part of that stratification comes from the previous number of admissions, the number of medications that they're on and any identified barriers that we have seen while they are here in the hospital. Then, there are scheduled visits based on care plans, and on routing, logistically through the County. I know that I have the privilege of helping develop some of the heart failure care plans that they use. And, will what are we seeing? Who are the people that we are seeing better coming back? And what are some of the trends that we have seen indications that bring them back to the hospitals? Or how quickly do they need to be seen when they are discharged from the hospital's? And then, the newest thing that they have is the actual visit. Paired Health has developed a software that provides health systems with a command and control capability to match patients with the right providers in the right location at the right time. Paired Health enables the continuity of care by coupling care pathways and care teams within a hospital in the continued care at home. Some of the things that I really appreciate about Paired Health is they maintain Wake Med how the hospitals care model of patient and family centered care. We are going to talk about a patient specific example in just a few minutes. I appreciate their timely follow-up. They are contacting patients either in person, by phone, sometimes the say that they are discharged, just to make sure that follow-up appointments are made, prescriptions are filled. They get the privilege of sitting in the patient's home and actually going over discharge medications with the patient. So that if they are -- if there are blood pressure medicines that have been discontinued that new medicines have started that those patients are taking all of those medicines. That they are hoping appropriately discard medicines that have been discontinued and ensuring that there are no barriers to getting prescriptions filled. The other thing that I appreciate is that with heart failure, weighing yourself everyday and keeping a log of that is very, very important. And, they can actually ensure that patients have a scale. They can read the scale. There is a lot there that they can record. Also, that their home environment is safe. You all work for the stroke operation and sometimes their ability is a challenge. And they can actually go into the home and invest and see how the patient is getting around. And this is a safe environment. It reinforces the patient education in the home. We all know that in the hospital, it is a hard time to educate people because there are changes to their lives and information being thrown at them at one time. Paired Health actually takes the same education material that we provide to them in the hospital and goes over it with them again in their homes, so they are using the same material that we are using here in the hospital. It improves the understanding of being in the home. They are able to assess the home environment. And, because they are providers, they are able to make changes and make interventions that the patient needs in real time. They also, if they make changes to medicines or whatever, they communicate that to the primary care physician. And, they give a patient in the home a copy, an electronic copy of what they have done. And, therefore that information on to the provider to let them know the changes that have been made. And 86-year-old female patient presented to with increased dyspnea, generalized weakness and lower bilateral edema for one month. She of course was in with heart failure, and actually, a new diagnosis of heart failure. Our physical therapy team recommended that she go to rehab for a while, she lives at home with her daughter, and,

the earliest available appointment with her cardiologist was it seven days. We know that we have a new diagnosis of heart failure that she needed to be seen before seven days. We wanted to honor her wishes to go home with her daughter as opposed to going to rehab for file, and so, we sent her home with a Paired Health consult. We were able to be ensured that the patient would be seen the next day, that her prescriptions would be felt, that she and her daughter knew the medicines that needed to be taken and the regimen that they need to be taking, education was reinforced and all questions answered. And, because of our relationship with Paired Health, we were able to honor this family's wishes and so we were able to maintain our care model of the inpatient and family centered, but it was a safe discharge and it was an appropriate discharge. Some of the numbers that we have seen for our Paired Health referrals, and Becky will be able to talk about this site more than I can, thank you, do you want to go? Sure. There were a number of metrics that we could have shared, but I think this particular webinar was very focused on readmissions. We pulled the rates for our inpatients, and one of the things that I want to mention, you'll see here that the readmit rates for patients is 7.6%, and the patients that get referred to Paired Health for the most part are guaranteed 30 days quarterback. There are some patient the fallout of that guaranteed category, but they get our most difficult patients, the ones that we feel fairly certain will be coming back in Anniston inpatient or to the ED. -- Comeback for readmission as an inpatient or to the ED. This is not just for medication the referrals could be for commercial patient. The majority of our referrals are Medicaid, uninsured, and then there is maybe 50% commercial. But again, there is the guarantee that the ones they are getting with the readmit it. Our overall Medicare readmit rate right now is running about 11.5%. So, this is not quite half of the overall Medicare rate that is getting darker close to half of the Medicare rates. For patients again that we are fairly certain we would see within the first 30 days. We have patients that are seen once by Paired Health, and that elect sometimes not to engage with Paired Health. We have had patients who are referred and have been able to -- not been able to engage because they have received the set up the first visit. So this topic number that I just gave you, the 7.6 is for any referrals we make to them. So even if they have it, -- even if they hadn't been able to engage the patient they typically would have had some phone conversations or other interactions with the patient. So, that would be the top readmit rates. For those that were able to actively engage, and that allow them to come back after the first visit, the readmit rates for those patients is 3.8%. So again, on a population of patients that we pretty much know would have made it a 30 day reappearance back for potential admission. They have some of the same issues that we have that they are able to overcome because they're going into the home, as some of the things that occur with home health today, the provider level service with the midlevel position folks, so there are a number of things that they can do and react to that would react much -- that would require much more coordination and health. The company in and of itself has been very good to work with. They have adapted to a number of our requests, and a number of programs that we are working with, like the ones that Angela is working with or not necessarily the initial ones that we had engaged with them, that we had engaged on an overall readmit program, but we have been able to refine and develop some specific programs to meet specific needs so, we have been very pleased with this relationship. Questions about Bosco this relationship or the numbers or processes?

Hi, this is Linda and I actually have a question. I was wondering what kind of feedback you have gotten from the patient's that have this care transitions program implemented for them. I'm sorry, Becky. Go ahead. One of the only drawback that I have seen of Paired Health is the patient's love this so much that they don't understand why these providers can. Her doctors. They can't just continue this relationship. And so, they had to make a decision early on. Are we going to be making house calls, kind of company? Or are we truly going to maintain this transition model? And so, all of the feedback that I have gotten from my patients, once I called them and touch base with them are very positive. Patients like to be visited in their home. Patients like the convenience of someone coming to them and sitting on their couch or at their dining room table. And talking about their healthcare. And my patients have really enjoyed having them. I think we have gotten a lot of positive feedback from them, family members, we follow our patient centered family model. Because they have even help people transition to home who were hospice but moved to other areas but wanted to be with the child as they were going through end-of-life things and they hope -- help open those types of programs for patients that had ended up in hospital for a day or two and were from another state or coordinated with that out-of-state provider but also allows the patient to be at home with family. Just a tremendous amount of positive feedback from family members regarding the ability to adapt to individual needs. What has the feedback been from the providers in the community? Our hospital is to admit the majority of our patients. Our amended by our hospitalist physicians. And, they have really gained respect for our hospitalist. They realize that this is a company, these are providers they can trust, these are providers that their relationship has grown. And, our hospitalist or even the same, identifying patients that would benefit from Paired Health. The community physicians really enjoy Paired Health. They have been proactive in meeting with our cardiologist and getting them involved. And this is what we are, this is what we are doing. This is the service that we are providing and making it very clear to the community provider that we are not looking to steal your patience. We are not looking to, you know, take on this patient load. But, we are truly here to help you and help the patient. And, being intentional about building those relationships. Our providers look to them and have really grown to need them and count on them to see these patients were some of our cardiologist, we just can't command for seven days, 10 days, 14 days. And, that is an unsafe discharge. And we feel like that was inappropriate and Paired Health is helping us bridge that gap. And, we will see that patient two times in a seven-day period to make sure that they are taken care of. Paired Health communicates with physicians electronically and so physicians know exactly what went on with each encounter. And, they are trusting their opinions and changes, the interventions that they are making on these patients.

Okay, we do have a question that has come in. Does Wake Med pay for the services? Or does Paired Health? Do they just billed for the services? Our arrangement is that there are visit covered overhead amounts that we take care of for patients that we refer, but then the actual professional services billed to the carrier. That the patient has their insurance with. Okay, great. And had a question in the chat. Actually, two questions. The first is, how many home business do they get on average? And the second question is about what is the cost for the service. On average they are seeing about 125 to about 140 visits per month. And in our arrangement, it is the components that would cover is less than $100 for each of those visits. And this is Laura. Just to follow up on that question, do most of the patients just get the one initial home visit or do they get some follow-up visits as well? They will follow them up for up to 30 days. And, there are some that just fit the one visit and then there are some that get visits during that whole 30 days. And if the patient needs to be seen again after 30 days before they can get in with their PCP, we always have a discussion about what we contractually are obligated to 30 days. We always have a discussion and about whether or not it is an appropriate extension of the service. And, we have only had to do that a few times, because usually they can get them into CA provider during that time. And, for patients that don't attach a provider, they also support a navigational service and help get them set up with providers as well. Excellent. And I will follow up to ask, how do you decide who gets a referral to the service? Is there a specific risk assessment? Or what process do you use to decide which patients are referred? Early on we have had a very detailed discussion about that. And they worked with us on more than one [ Indiscernible ]. So a group identified the need for the service, they will develop some of their own criteria for the things that they believe need to be referred, but early on, we felt it would be a much more program if we attached a lot of limiting factors to the service. So if a provider or case manager needed them to themselves, they were welcome to make that referral. And we would monitor those referrals to make sure that they were appropriate, but we didn't want to build and factors that would discourage the use of the service because we were encouraging to use them. You know, sometimes here, at least, when we start to limit things, and put a lot of limiting factors in, it seems to become so difficult that people don't want to use it, and it is really hard to see if this service makes a difference.

One of the things that we're starting to do is getting our emergency room physicians familiar with. Health. To help eliminate some of those like admissions. We have a very geriatric population in Cary, and if we have a patient, that is on the borderline, or should they stay or should they not, our ED physicians are getting more comfortable with sending those patients home with a Paired Health referral to follow-up the next day, to really make sure that, you know, do they need to double their diuretic for another day? Or, what is best for them to keep them, you know, out of the hospital? And I think that Raleigh, we have had an ED intern program in place for about 18 months. It is getting ready to roll out Kerry, North Carolina. So we have moved them into working with the ED physicians in the Raleigh campus, prior to the initiative that Angela is speaking about. And, they are extremely comfortable at the Raleigh campus using this service. And, they are one of their biggest advocates. And there is an additional question in the chat box asking about, you stated that you bill insurance. Is this the service reimbursed under the covert service? Paired Health 's -- has yet to made is here most of the carriers cover a visit. And, you know, there is not usually very much reimbursement added to it, because it is an inhome visit, and obviously it is going to be more expensive. But, most do not prohibit inhome visits. We have another question that popped up. Penny asks, the admission rates that you noted, are you looking at patients are reported back to Wake Med hospital only or any other hospitals? Well, Paired Health also follows the patients. So we know what our readmissions are. Now if there is potential that a patient could go somewhere else but they're talking with that patient, if they have engaged with that patient for that period of time, and also counting any readmissions to other facilities. But it would be perfect. But is the data available? It is always a work in progress, I think. I have a question, and you may have said this and I missed it and if I did, I apologize. What type of providers make home visits? [ Indiscernible ] I'm sorry. I did not catch that. Cohead, Angela. I'm sorry, they have physicians and mid-levels, nurse practitioner and physician assistants that work with them.

Okay. So it is a physician or mid-level that is seeing these patients. So it eliminates that having to call and get orders is an RN were to go and, you know, follow those programs, so they are able to actually intervene right there in the homes. Which speaks to the efficiency, I would imagine. Yeah. I'm looking at our chat and question and answers, if anybody has any other questions, chime in. Or if you have any questions for Penny, she is still on the line as well. And we will see if we have any other questions to answer. And James is giving me the know. So, I thank you all very much. We do have one that just came in. Oh, we do have one. Penny, what MediTech system do you have? MediTech 56. I'm sorry, I think I cut off last part of the comment. MediTech 56 Client Server. Okay. Okay, we were just looking to make sure that we have not missed a question. So, I want to thank all of our speakers, Penny Cooper and Becky and Paired Health for sharing your transition terminals and the work that you're doing to help improve your transitions in your community and across the state at some level. I then want to close with a couple of reminders. The 2015 Virginia patient safety pre-summit is January 28, 2015 at the Richmond Marriott downtown. And, they are going with improving the patient family experience across the continuum. And I just want to remind everybody that I believe registration is open for that. We have two featured speakers, Jason Wolf from Beryl Institute and Amy Boutwell from Collaborative Healthcare Strategies. And in North Carolina we have open registration for the 2015 North Carolina care transitions summit. We're looking at impacts and outcomes this year. It is January 30 at the Sheraton Imperial hotel and convention center in Durham. you can visit www.cact.org -- www.ncact.org for more information. We are also looking for abstracts and I believe filling, is that NCACT as well. If you have something you would like to share with the rest of the state, please feel free to submit an abstract. And, if you have any questions about the readmissions collaborative, here is our contact information. Laura, me and actually, James, we will have to update that e-mail. It is jhayes. And we will initiate everybody being on the phone and answering questions and sharing our information. You all have a good rest of the day. [ Event concluded ] Actions