Care Transitions in Michigan Nancy D. Vecchioni, RN, MSN, CPHQ 22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 www.mpro.org
22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 www.mpro.org
State Variation: Hospital Admissions Indicators Best State All States Median Worst State Michigan 50 40 30 20 10 0 Medicare beneficiaries readmitted to hospital within 30 days Long-stay nursing home residents admitted to hospital Nursing home residents readmitted to hospital within 30 days Home health patients admitted to hospital DATA: Medicare readmissions 2006 07 Medicare 5% SAF Data; Nursing home admission and readmissions 2006 Medicare enrollment records and MEDPAR file; Home health admissions 2007 Outcome and Assessment Information Set SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009
Michigan Medicare Patient 30-Day All Cause Readmission Rates (%) by County, 2010 Statewide Medicare Patient Readmission Rate= 19.9% Readmission Rates are Greatest in Southeast Michigan
Post Acute Care Readmission Rates 10/1/2010 9/30/2011 Discharges Number of 30 Day Readmissions Rates Geographic Region Setting Total (A) To Setting (B) % to Setting (B/A) Total (D) From Setting (E) % from Setting (E/D) % of discharges readmitted (D/A) % of discharges to setting readmitted (E/B) HHA 445,924 90,261 20.24% 88,368 21,319 24.13% 19.82% 23.62% State of Michigan Home 445,924 228,102 51.15% 88,368 39,229 44.39% 19.82% 17.20% Hospice 445,924 13,469 3.02% 88,368 329 0.37% 19.82% 2.44% SNF 445,924 86,072 19.30% 88,368 21,336 24.14% 19.82% 24.79% 5
Medicare Readmissions Rates by Physician Follow-Up and among Hot Spotters CY 2010 MI Statewide Population Segment Total Discharges Eligible for Readmission Readmission Within 30-days of Discharge N % N % Physician Follow-up within 30 days of discharge No 473996 39.15 134479 28.37 Yes 736605 60.85 112049 15.21 0 835896 69.05 128599 15.38 # of Admits in prior 3 months 1 247481 20.44 64696 26.14 2 83476 6.90 30467 36.50 >2 43748 3.61 22766 52.04 Total 1210601-246528 20.36 6
Report of 30-Day All-Cause Readmission Rates for: Statewide Time Period: 2010Q1-2010Q4 Payers: Medicare FFS, Medicaid FFS, BCNM, BCBSM, HAP, Priority Health, Health Plus (Managed Care Data are reported by these payers) See Data Definitions for Column Descriptions a b c d e f g h I PRODUCT Line Type of Index Discharges at RA to the Same Hospital RA to a Different Hospital RA to Any Hospital AGE GROUP Admission Risk N N % N % N % M 77,402 8,924 11.5% 2,709 3.5% 11,633 15.0% Adult S 81,427 4,345 5.3% 1,033 1.3% 5,378 6.6% O 38,994 938 2.4% 129 0.3% 1,067 2.7% M 8,822 823 9.3% 116 1.3% 939 10.6% Pediatric S 3,619 173 4.8% 26 0.7% 199 5.5% Commercial O 444 19 4.3% 2 0.5% 21 4.7% Post-neonatal M 1,685 85 5.0% 35 2.1% 120 7.1% S 415 24 5.8% 9 2.2% 33 8.0% Neonatal M 35,624 341 1.0% 207 0.6% 548 1.5% S 86 5 5.8% 0 0.0% 5 5.8% Total 248,518 15,677 6.3% 4,266 1.7% 19,943 8.0% M 87,502 11,451 13.1% 3,376 3.9% 14,827 16.9% Adult S 30,616 3,718 12.1% 1,000 3.3% 4,718 15.4% O 58,039 2,047 3.5% 458 0.8% 2,505 4.3% M 13,537 1,426 10.5% 121 0.9% 1,547 11.4% Pediatric S 4,101 423 10.3% 29 0.7% 452 11.0% Medicaid FFS O 2,772 100 3.6% 17 0.6% 117 4.2% Post-neonatal M 5,478 433 7.9% 113 2.1% 546 10.0% S 1,348 131 9.7% 32 2.4% 163 12.1% Neonatal M 50,596 641 1.3% 504 1.0% 1,145 2.3% S 3,075 57 1.9% 53 1.7% 110 3.6% Total 257,064 20,427 7.9% 5,703 2.2% 26,130 10.2% M 3,587 521 14.5% 140 3.9% 661 18.4% Adult S 1,385 146 10.5% 41 3.0% 187 13.5% O 5,127 143 2.8% 39 0.8% 182 3.5% M 945 36 3.8% 16 1.7% 52 5.5% Pediatric S 313 10 3.2% 3 1.0% 13 4.2% Medicaid Managed Care O 269 9 3.3% 1 0.4% 10 3.7% Post-neonatal M 400 12 3.0% 5 1.3% 17 4.3% S 34 2 5.9% 1 2.9% 3 8.8% Neonatal M 3,383 51 1.5% 24 0.7% 75 2.2% S 3 0 0.0% 0 0.0% 0 0.0% Total 15,446 930 6.0% 270 1.7% 1,200 7.8% M 19,025 2,935 15.4% 914 4.8% 3,849 20.2% Medicare Managed Care (reported by Adult S 10,738 895 8.3% 258 2.4% 1,153 10.7% payers) O 6 0 0.0% 0 0.0% 0 0.0% Total 29,769 3,830 12.9% 1,172 3.9% 5,002 16.8% Medicare (FFS) Adult M 344,416 56,845 16.5% 15,023 4.4% 71,868 20.9% S 138,493 11,228 8.1% 3,158 2.3% 14,386 10.4% U 2,742 758 27.6% 364 13.3% 1,122 40.9% Total 485,651 68,831 14.17% 18,545 3.8% 87,376 18.0% Total by Age Group Adult 899,499 104,894 11.7% 28,642 3.2% 133,536 14.8% Pediatric 34,822 3,019 8.7% 331 1.0% 3,350 9.6% Post-neonatal 9,360 687 7.3% 195 2.1% 882 9.4% Neonatal 92,767 1,095 1.2% 788 0.8% 1,883 2.0% Grand Total 1,036,448 109,695 10.6% 29,956 2.9% 139,651 13.5%
Integrate Care for Populations & Communities - Objectives and Outcomes Improve the quality of care for Medicare beneficiaries who transition among care settings through a comprehensive community effort Coordinate community-wide adoption of improved practices Facilitate Community Coalition Charters Yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries 8
Integrate Care for Populations & Communities Project Goals Reduce 30-Day Hospital Readmissions by 20% Communities participating in formal Care Transitions (CT) Program (e.g. ACA 3026 Community CT demo, AAA CT grants) Eligible entities CBOs, high-readmission hospitals Community-level coalition building, data analysis, action plan development Recruit at least four communities Northern Southeast Michigan Western Southeast Michigan Calhoun County Ingham County Detroit High-level of CBO involvement especially AAAs 9
Integrate Care for Populations & Communities Project Goals Communities not accepted in a formal CT Program Continue to provide technical assistance 7% reduction in readmissions Part of statewide CT learning network MI STA*AR 2% reduction in readmissions 10
Integrate Care for Populations & Communities Provide Technical Assistance Community Coalition Formation Materials to use as models for community coalition formation Consultative support for convening a community coalition Technical support to create an initial strategic plan for organization, intervention, monitoring, and decisionmaking that articulates how the community proposes to achieve the aims 11
Integrate Care for Populations & Communities Provide Technical Assistance Recruit and educate provider groups and communities to participate in formal Care Transitions Initiatives Data analysis and reports Community and individual hospital Root cause analysis readmission drivers Evidence-based intervention selection & implementation process Provide intervention measurement strategies 12
Medicare All-Cause Re-Hospitalization Within 30 Days of Discharge from a Michigan Hospital, 1C Service Area, 1/1/08 12/31/10 Population Segment Race Age Sex Physician Follow-up within 30 days of discharge Diagnosis Length of Index Admission # of Admits in prior 3 months Time^ MI Statewide Total Discharges Eligible for Readmission Readmission Within 30- days of Discharge Total Discharges Eligible for Readmission Zip Code Region Readmission Within 30- days of Discharge N % N % N % N % White 973825 80.44 185887 19.09 122898 86.49 26971 21.95 Black 211471 17.47 55307 26.15 16091 11.32 4323 26.87 Other 25305 2.09 5334 21.08 3105 2.19 652 21.00 <65 251428 20.77 62042 24.68 27734 19.52 7276 26.23 65-74 346850 28.65 65060 18.76 37629 26.48 7692 20.44 >75 612323 50.58 119426 19.50 76731 54.00 16978 22.13 M 525546 43.41 111026 21.13 58758 41.35 13548 23.06 F 685055 56.59 135502 19.78 83336 58.65 18398 22.08 No 473996 39.15 134479 28.37 51679 36.37 16152 31.25 Yes 736605 60.85 112049 15.21 90415 63.63 15794 17.47 CHF 74087 6.12 21127 28.52 9148 6.44 2750 30.06 AMI 29380 2.43 6777 23.07 3690 2.60 940 25.47 PNE 45443 3.75 9107 20.04 5712 4.02 1366 23.91 COPD 45930 3.79 11020 23.99 6979 4.91 1796 25.73 OTHER 1015761 83.91 198497 19.54 116565 82.03 25094 21.53 < 4 days 590955 48.82 93770 15.87 64634 45.49 11247 17.40 4-8 days 466280 38.52 104898 22.50 57435 40.42 13918 24.23 > 8 days 153366 12.67 47860 31.21 20025 14.09 6781 33.86 0 835896 69.05 128599 15.38 93758 65.98 15852 16.91 1 247481 20.44 64696 26.14 31070 21.87 8730 28.10 2 83476 6.90 30467 36.50 11284 7.94 4296 38.07 >2 43748 3.61 22766 52.04 5982 4.21 3068 51.29 Qtr. 1 104197 8.61 21544 20.68 12256 8.63 2796 22.81 Qtr. 2 103526 8.55 21003 20.29 11737 8.26 2648 22.56 Qtr. 3 97899 8.09 20129 20.56 11405 8.03 2551 22.37 Qtr. 4 93212 7.70 18740 20.10 11049 7.78 2434 22.03 Qtr. 5 96541 7.97 20469 21.20 11449 8.06 2646 23.11 Qtr. 6 98675 8.15 20598 20.87 11707 8.24 2618 22.36 Qtr. 7 97002 8.01 20183 20.81 11578 8.15 2692 23.25 Qtr. 8 95715 7.91 19523 20.40 11383 8.01 2569 22.57 Qtr. 9 105575 8.72 21297 20.17 12499 8.80 2813 22.51 Qtr. 10 108512 8.96 21933 20.21 12763 8.98 2867 22.46 13 Qtr. 11 105760 8.74 21285 20.13 12084 8.50 2680 22.18
Integrate Care for Populations & Communities Provide Technical Assistance Ongoing QIO assistance if not accepted into a formal Care Transitions Program in the following areas: Monthly or Quarterly Readmission Metrics Intervention measurement strategies 14
Current CCTP Participants 15
Integrate Care for Populations & Communities Statewide CT Learning and Action Network Bring together groups of quality-minded providers, consumers, physicians and stakeholders to focus on improving care delivery and outcomes Shared goal to improve quality of care as patient transition between setting types Rapid, wide-scale improvement Action-based May 1 st kick-off with 350+ attendees MISTA*AR platform for LAN Future webinars and conference calls Affinity groups 16
Integrate Care for Populations & Communities Progress Recruitment Have formally recruited five communities Three have applied for and two successfully received 3026 funding; one awaiting review One submitting application in May 2012 Actively assisting three additional communities 17
Statewide Summit May 1, 2012 How to Guides expanded to all healthcare settings Transformation of MI STA*AR steering committee to Care Transitions Coalition Development of Care Transition Initiatives Crosswalk Development of affinity groups Expansion of ReWaRD report to post acute care settings 18
Frequent User System Engagement CSH (cross continuum, community) Advanced Care Planning Lisa Ashley (Cross Continuum) ReWaRD Harolyn Baker, MPRO Care Link & Coordination MPRO (Cross Continuum) Payor/ Payment Policy Robert Yellan Facilitator Medication Management MPRO (Cross Continuum) Hospital to Physician Coordination MHA
Individually, we are one drop. Together, we are an ocean." A TSUNAMI Ryunosuke Satoro & Nancy Vecchioni