NoCVA Preventing Avoidable Readmissions Moving Beyond the Basics March 27, 2014
Dr. Amy Boutwell
REDUCING READMISSIONS IN 2014 Using data to drive an expanded, multifaceted strategy Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies March 27, 2014
Reducing Readmissions in 2014 Are we even targeting our work correctly? State-level data for VA & NC Developing a multifaceted strategy for work in 2014 Recommendations & Discussion
Would your targeted efforts serve these patients? 77F recently hospitalized for an infected dialysis catheter returns to the hospital 8 days following discharge with shortness of breath. 61M with 8 hospitalizations this year for shortness of breath returns to the hospital 10 days after discharge with shortness of breath. 86M with cancer hospitalized for constipation and abdominal pain returns to the hospital 1 day after discharge with abdominal pain. 45F with HIV hospitalized for pneumonia discharged to home returns to the hospital 8 days later with pneumonia.
77F recently hospitalized with sepsis returns 8 days later with shortness of breath 1 st hospitalization Tunneled catheter placed to initiate dialysis Acquired blood stream infection (sepsis) All anti-hypertensives and diuretic held Stabilized in ICU; transferred to floor; 14 day hospitalization At discharge BP stable x 24 hours off pressors Felt fine; eager to go home Readmission Progressively short of breath days 3-7 Volume overloaded Never resumed diuretics after d/c Patient demoralized to be back in hospital
61M with 8 hospitalizations this year for SOB returns to hospital 10 days post d/c with SOB 1 st hospitalization Isn t really first hospitalization is it? Intern H&P covers issues as if first presentation of HF Recognized marginal housing issues Recognized personality issues (inappropriate with staff) Refuses to work with PT At discharge Patient can not be placed in SNF due to criminal history Readmission Gained 30 lbs in 8 days oh honey, it always takes them about a week to tune me up Grabs remote, turns on TV and orders dinner
86M with metastatic cancer presents with abd pain and constipation, returns 1 day later with abd pain 1 st hospitalization Constipation x 8 days with abdominal pain Resolved in ED; ED concerned pain was due to cancer Observed, felt fine, started on bowel regimen At discharge Family eager to take him home Readmission Recurrent abdominal pain Family concerned it was due to cancer Family eager to do everything to have dad comfortable Patient clearly did not want to be there; didn t argue with family
41F with HIV hospitalized with pneumonia 1 st hospitalization: longstanding HIV Lives with mother family unaware At discharge: Discharged on anti-retroviral medications (new) Discharged on antibiotics for the pneumonia No infectious disease or primary care appointments made 2 nd hospitalization: Returned 8 days later for persistent coughing it would have helped if they made the appointment for me
Who is High Risk of Readmission? New diagnosis needs teaching, clear instructions New medications need medication review, instructions Complex medical needs continued active management Complex social isolated, active substance use, poverty Frailty/convalescence weakened, less able to manage Skilled care needs- nursing, therapy, medication management Personal care needs- caregiver, meals, respite Access to care needs- no PCP, financial, transportation Navigating low health literacy, language, cultural barriers Advocacy direct assistance in accessing resources/support Care seeking patterns- accustomed to using ED for care Chronic recurrent symptoms- need palliative care & care plan End of life goals of care decision making
TARGETED EFFORTS The good, the bad the data
6 Very Important Messages from CMS-1 1. Readmission reduction pays or hurts to some extent Avoidance in penalties, CMMI grants/ contracts 2. We will flood the market with all best ideas on our dime Partnership for Patients, Hospital Engagement Networks (HENs) ~ $280M 1. Reducing readmissions is a cross-continuum effort QIO 10 th SOW, Integrating Care for Populations and Communities Focused on engaging numerous providers within a community SNF readmission penalties proposed for 2017
6 Very Important Messages from CMS -2 4. Attend to non-clinical issues eg integral role of community based support services 5. Reducing readmissions requires really good data QIO 10 th SOW social network analyses, readmissions from PAC providers, etc. 4. Hospitals must have updated processes in place May 2013 newly issues CMS Hospital Conditions of Participation
HOWEVER. Powerful messages from powerful agencies can create blinders
Inadvertent Blinders. 1. HF, AMI, PNA NOT the three most frequent causes of readmissions, even in Medicare FFS Many other very important targets, including high utilization & PAC 1. Driven a Medicare focus in the field Medicaid adults have as high or HIGHER readmission rates than Medicare FFS 2. Preferred first move: hire a transitional care FTE Lost a bit of the focus on the need to modernize & improve standard processes
ALL CAUSE ALL PAYER STATS
18 states, 14 million discharges 45% of all hospitalizations in US
HCUP: Readmissions by Volume
HCUP: Readmissions by Volume & Rate
HCUP: Highest Rates HCUP April 2013
STATE-LEVEL MEDICARE DATA Virginia & North Carolina, thanks to your QIOs
Medicare Readmission Stats Metric Virginia North Carolina # Medicare discharges 282,229 359,224 # Medicare patients 182,346 234,671 # Medicare readmissions 51,764 61,977 Readmission rate 18.3% 17.3% % RA to same / other hospital 76% / 24% 80% / 20% Median # days to readmission 12.8 12.9
Readmissions by Discharge Disposition Metric Virginia North Carolina % d/c to home / % RA from home 48% / 42% 52% / 47% Readmission rate from home 17% 16% % d/c to home health / % RA from home health 21% / 24% 18% / 22% Readmission rate among pts d/c to home health 22% 20% % d/c to SNF / % RA from SNF 21% / 25% 21% / 23% Readmission rate among pts d/c to SNF 22% 19%
Virginia - Top Diagnoses Leading to Readmission Discharge Diagnosis Readmission Counts Discharge Diagnosis Readmission Rates Sepsis 3806 CHF 3575 PNA 2751 COPD 2472 ARF 2273 UTI 1637 CVA 1428 Afib 1242 CAD 725 Total 19,909 % total RA 38% CHF 23.97% COPD 21.97% ARF 21.42% Sepsis 21.09% UTI 18.92% PNA 18.90% Afib 17.70% CAD 14.86% CVA 14.23% 62% all other diagnoses!
North Carolina - Top Diagnoses Leading to Readmission Discharge Diagnosis Readmission Counts Discharge Diagnosis Readmission Rates Sepsis 2953 CHF 2600 PNA 2379 COPD 1979 ARF 1902 Afib 1461 UTI 1402 AMI 1293 Resp Failure 1019 Total 19,909 % total RA 27% CHF 24.3% Resp Failure 24.3% COPD 20.9% ARF 19.2% AMI 18.9% Sepsis 18.7% PNA 17.4% UTI 16.8% Afib 16.5% 73% all other diagnoses!
Highest Impact Target Population Metric Virginia North Carolina # (%) of patients with 3 hospitalizations 23,682 (13%) 27,765 (12%) # (%) of hospitalizations used by H.U. 61,060 (22%) 108,814 (30%) # of readmissions among H.U. 36,998 42,204 % of readmissions that occur in H.U. 71% 68% Readmission rate among H.U. 40% 39%
CRUNCHING THE NUMBERS Will your current strategy get you to your goal?
Let s Run the Numbers: One Strategy Won t Get Us There Number Rate Medicare admits/year 5,000 admissions Medicare RA rate 20% # Medicare RA /year 1,000 readmissions Pilot project 200 high risk patients Pilot group RA rate 25% Expected # RA pilot 50 Expected effect of pilot 20% # RA reduced by pilot 10 # Medicare RA/year =1000 10 = 990 1% Amy Boutwell 2013
Develop Portfolio Strategy Improve standard hospital-based care for all Identify risks & mitigate Identify learner Use Teach-back Schedule early follow up Timely communication Collaborate with receivers to improve transition SNF Circle Back INTERACT Cross-continuum teams Provide enhanced services for high risk HF clinic Transitional care Self-management coaching Intensive care management Amy Boutwell 2013
1. IMPROVE STANDARD CARE FOR ALL All patients, not just high risk patients
Standardize your Processes CMS Issued New Discharge Planning Conditions of Participation May 2013 that require hospitals demonstrate the following: 1. Have a process 2. Know your data; track rates & review readmissions 3. Assess & reassess patients for post-hospital needs 4. Engage patients and caregivers 5. Teach self-care to patients & caregivers 6. Provide a written discharge plan for all inpatients 7. Communicate effectively with receiving providers 8. Know the capabilities of area providers, including support services 9. Arrange for post-acute services, including support services
2. COLLABORATE WITH RECEIVERS
CMS New COPs: Know Your Cross-Continuum Partners While hospitals cannot address these concerns in isolation, they are expected to be knowledgeable about the care capabilities of area long term care facilities and to factor this knowledge into the discharge planning evaluation. Hospitals are expected to have knowledge of the capabilities and capacities of not only of long term care facilities, but also of the various types of service providers in the area where most of the patients it serves receive post-hospital care, in order to develop a discharge plan that not only meets the patient s needs in theory, but also can be implemented. This includes knowledge of community services, as well as familiarity with available Medicaid home and community- based services (HCBS), since the State s Medicaid program plays a major role in supporting post-hospital care for many patients.
Readmissions from Different Care Settings Home Health Home SNF
Increasing Focus on SNF Readmissions, Cost, Quality 1 in 4 NH residents are hospitalized Wide variation in rates state to state (10-38%) Hospitalizations from SNF cost $14B annually Each hospitalization from SNF 33% higher cost 1 in 5 NH residents experience adverse event 60% potentially avoidable Due to inadequate care, delays Resulting hospital costs = $2.8B annually
Increasing Focus on SNF Readmissions, Cost, Quality Effect of Hospital-SNF Referral Linkages on Rehospitalization 1. Stronger hospital-snf linkages were found to reduce readmission rates 2. The greater the concentration of discharges a hospital sends to a single SNF, the lower the rate of readmission 3. Specifically lower rates of immediate bounce-backs (days 0-3) Rahman et al, December 2013
Actively Collaborate to Improve Transition Carolinas HealthCare SNF Circle Back Multi-hospital system in North Carolina Pilot in one hospital; commitment to spread system-wide if effective Problem: early readmissions from SNF Test: warm handoffs to SNF Call back to SNF 3-24 hours after transfer to answer questions Details: RCA revealed SNF-readmission patters Hospital readmission champion met with SNFs to discuss shared goals Hospital (with some leadership effort) asked SNF to participate in this communication RN calls nurse at SNF SW or care coordinator calls for follow up clarification 3-24 hours after transfer Daily workflow (with some modifications for weekends, done next business day) Follow up calls are scripted and documented in Allscripts system Pilot on paper with 1 RN and 1 SW Pilot expanded to RN call report to SNF Pilot expanded to add follow up calls Pilot expanded to build questions into Allscripts Expand to all; new standard of practice Source: Emily Skinner, Carolinas Healthcare System
Actively Collaborate to Improve Transition Carolinas HealthCare SNF Circle Back SNF Circle Back Questions 1. Did the patient arrive safely? 2. Did you find admission packet in order? 3. Were the medication orders correct? 4. Does the patient s presentation reflect the information you received? 5. Is patient and/or family satisfied with the transition from the hospital to your facility? 6. Have we provided you everything you need to provide excellent care to the patient? Insights Transitions are a PROCESS (forms are useful, but only a tool to achieve intent) Best done ITERATIVELY with COMMUNICATION Source: Emily Skinner, Carolinas Healthcare System
Actively Collaborate to Improve Transition Mass General 3-day waiver experience Warm follow-up Process with SNFs: Warm handoff from ED to SNF clinician-clinician; joint decision Support staff were available to facilitate Telephonic card flipping between MGH team & SNF Key lessons: Took a while to develop collaborative rapport v. in-charge No substitute for verbal communication and problem solving
Know Your Partners Capabilities
Know Your Partners Service Improvements
3. PROVIDE ENHANCED SERVICES Best transition out and reception in won t suffice for some patients
High Risk Care Teams Funded by hospital or ACO or plan/payer North Carolina example for nation: CCNC Often multi-disciplinary Navigator Behavioral health Social Work Pharmacist Address full complement of medical, social, logistical needs Affordable medications; waiving office visit copayments Transportation Stable housing Navigating the healthcare system, asking questions, making appointments Identify using combination of clinical and non-clinical criteria History of high utilization, no PCP, numerous prescribers, numerous meds, behavioral health comorbidities, homeless.not just chronic disease
Let s Run the Numbers: Three-part strategy Medicare admits/year Number 5,000 admissions Rate Medicare RA rate 20% # Medicare RA /year 1,000 readmissions 1. Improve standard care 5,000 admissions (20% RA rate) Expected effect 10% Expected # RA reduction 2. Collaborate with receivers 100 RA avoided 1650 admissions (1/3 total) (30% RA rate) Expected effect 20% Expected # RA reduction 3. Enhanced Service for Pilot 99 RA avoided 200 admissions (25% RA rate) Expected effect 20% Expected # RA reduction 10 RA avoided Total (*illustrative) 209 RA avoided* 209/1000 = 20% overall* Amy Boutwell 2013
RECOMMENDATIONS Updating your readmission reduction strategy in 2014
Recommendations 1. Know your data for ALL readmissions Don t forget sepsis, behavioral health, renal failure, cancer, frailty Recognize all these risks are the whole of general medicine 2. Move beyond Medicare or disease specific criteria 3. Recognize Medicaid as independent risk of readmission 4. Know what your current strategy is expected to achieve 5. Implement a multifaceted strategy: improve standard care, cross-setting collaboration and enhanced services
THANK YOU Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies Lexington, Massachusetts
Reducing Avoidable Readmissions Collaborative June 2014 June 2015 IHI STAAR model and tools 3 in-person learning sessions Monthly content and networking webinars Small group coaching and sharing calls Guided improvement activity
Mission To improve transitions in care and reduce avoidable hospital readmissions.
Goals Reduce readmission rates by 20% (from 2010 baseline). Increase the number of patients in the pilot unit or population who undergo assessment for risk of readmission to 95%. Increase number of patients in the pilot unit or population who are assessed to be at high risk of readmission who are scheduled for a follow-up physician visit within 7 days of discharge from hospital to 95%. Increase the number of patients in the pilot unit or population who are assessed to be at high risk of readmission who receive a follow-up visit or telephone call to 95%. Test and implement process improvements in four key areas: enhanced assessment of post-hospital needs, effective teaching/enhanced learning, ensuring post-hospital care follow-up and providing real-time handover communications. 10% improvement or national 25 th percentile in scores on four HCAHPS dimensions
Methods Pilot Unit Multidisciplinary tiered project team Assessment of 5 recent readmissions Observations Process maps Risk assessment Follow up appointments and follow up calls or visits
Methods Test improvement in 4 key areas: Enhanced assessment of patient post-hospital needs Effective teaching and enhanced patient learning Ensuring post-hospital care follow-up Providing real-time handover communications Implement and spread improvements Community engagement readiness assessment Community cross continuum team
For all NoCVA hospitals: Quarterly webinars Resources on website Targeted 1:1 coaching NC ACT Care Transitions Summit January 30, 2015
Contact For more information, contact: Laura Maynard, Director of Collaborative Learning, lmaynard@ncha.org 919-677-4121 Erica Preston-Roedder, Director of Quality Measurement, eroedder@ncha.org 919-677-4125 Dean Higgins, Project Manager, dhiggins@ncha.org