M7: Reducing Avoidable Rehospitalizations Overview of the Problem and Promising Approaches Eric A. Coleman, MD, MPH Director, Care Transitions Program This presenter has nothing to disclose. Session Objectives Participants will be able to: Make the case for creating a more patient-centered transition from the hospital to post-acute care Enumerate the challenges to executing high quality care transitions Identify promising approaches to reduce avoidable rehospitalizations Describe key elements of the CMS Communitybased Care Transitions Program (Section 3026) 1
Charting Our Course Describe the nature of the challenge for reducing readmissions and the accompanying expanding national focus on this topic Identify evidence-based models of care designed to reduce readmissions and meet patients care needs Provide the goals and approaches employed within IHI s STAAR Initiative Determinants of Preventable Readmissions Identification of determinants does not point to a single intervention for how to reduce their occurrence a multifaceted approach is needed There is a need to address the tremendous complexity of variables contributing to preventable readmissions Further importance of identifying modifiable risk factors Preventable hospital readmissions nevertheless remain a leading topic in healthcare policy reform 2
Why So Much Fuss Over Readmissions? Frequent 17.6% of all Medicare hospitalizations are 30d rehospitalizations Costly $12B in Medicare spending; est. $25B across all payers annually Actionable for improvement Significant potential may be avoidable Performance highly variable Medicare 30-day rehospitalization rate varies 13-24% across states MedPAC Report to Congress, Promoting Greater Efficiency in Medicare. June 2007 Mark Taylor, The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008 Commonwealth Fund State Scorecard on Health System Performance. June 2009 1. One in five Medicare Beneficiaries are readmitted in 30 days 2. National cost of over USD $17 Billion 3. Half of patients readmitted had no physician contact 4. 70% of surgical readmits were for chronic medical conditions 3
Medicare Rehospitalizations 2007 Medicare data analysis finds: 20% beneficiaries are re-hospitalized at 30 days 35% are re-hospitalized at 90 days 67% are re-hospitalized or deceased at 1 year Among patients re-hospitalized at 30 days, half had no bill for MD service between discharge and re-hospitalization Among surgical patients re-hospitalized at 30 days: 70% were re-hospitalized with a medical DRG S. F. Jencks, M. V. Williams, and E. A. Coleman, Rehospitalizations Among Patients in the Medicare Fee-for-Service Program, New England Journal of Medicine, Apr. 2, 2009 360(14):1418 28. Rehospitalization from SNF ~25% of Medicare beneficiaries discharged from the hospital to a SNF are readmitted to the hospital within 30 days Annual cost of $4.3 Billion in 2006 Vincent Mor, Orna Intrator, Zhanlian Feng, and David C. Grabowski Health Affairs, 29, no. 1 (2010): 57-64 4
Transition-Related Disparities Amy Kind studied stroke bounce-backs 20% Medicare Beneficiaries experience poor quality transitions African Americans more likely to experience multiple poor quality transitions A J Kind Journal American Geriatrics Society March 2007. When are patients being readmitted? Initial readmissions spike within 48 hours of discharge 66% of readmissions occur within 15 days 5
Commonwealth Fund State Scorecard on Health System Performance, 2009 Ohio: Overall Rank: 27 Avoidable Hospital Use & Cost: 34 30-day Readmissions: 40 (rate of 19.8%) If Ohio improved to the level of the top performing state, $162,254,116 would be saved from reducing Medicare readmissions. 6
Sticks : Affordable Care Act Section 3025 Up to 3% cut to all DRGs for readmissions over expected Up to 1% in FY 2013, 2% in FY 2014, not to exceed 3% in 2015 and beyond Initially AMI, CHF, Pneumonia Expands to COPD, CABG, PTCA, and other vascular conditions in 2015 10 year savings: $7.1 B Hospital Readmissions HHS shares data with hospitals on 3 selected conditions; Penalties capped at 1%. (FY2013) Hospital Readmissions Penalties capped at 2%. (FY2014) Hospital Readmissions Penalties capped at 3%. (FY2015 and beyond) 13 2010 2011 2012 2013 2014 2015 2016 2016 2017 The proposed prospective payment system begins October 1, 2012 (FY 2013) Carrots : Opportunities and Incentives within the Affordable Care Act Section Name Description Amount Timeframe 3026 Community Based Care Transitions Program Must provide at least 1 transitional care intervention to high risk Medicare beneficiaries $500 million 2011-2015 3021 Center for Medicare and Medicaid Innovation Identify, evaluate, and disseminate innovative care delivery and payment models $10 billion 2011-2019 7
Challenges to Improving Quality 8
Challenges Occur at Multiple Levels Patient Practitioner Health care institution Information technology Payment Performance measurement Patient Level Institutions fosters dependency and complacency This changes abruptly on transfer when expected to assume major role in self-care 9
Practitioner Level Rare for one clinician to orchestrate care across multiple settings Many practitioners have never practiced in settings to which they transfer patients 10
Health Care Institution Level Barriers Hospital SNF Home Care Information Technology Health Information Technology infrequently extends from hospital or clinic into post-acute care settings and long-term care settings 11
Payment Perceived as providing little financial incentive for collaboration across settings Most prevailing payment approaches do not exact financial penalties for poorly executed transfers Performance Measurement 12
Performance Measurement Lack of quality measures for transitional care is a significant barrier to quality improvement Few measures incorporate the consumer perspective Meeting Patients At Their Level 13
Chronic Care Model Community Resources and Policies Health System Health Care Organization Self- Management Support Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Trouble with the Southwest Corner of the Chronic Care Model Clinicians letting go of control of the agenda has proven challenging Making mistakes is part of the learning process Need to redefine professional gratification 14
Health Literacy and the Teach Back Approach The clinician explains information to the patient or family caregiver Then asks the individual to explain what was shared The request must be inviting -- avoid shame and embarrassment If a gap in understanding is identified, additional explanation is offered, followed by a second request for Teach Back More cycles as needed Health Literacy and the Teach Back Approach Teach Back is very effective in closing gaps in understanding between health care providers and the patient and family caregivers. Teach Back is efficient and usually can be part of work flow Closing the loop after teaching, the patient is asked to demonstrate how he or she will do what was taught. 15
Executive Cognitive Functioning Executive cognitive functions involve relatively complex activities: (planning, problem solving, working memory, anticipating consequences of a course of action, and the capacity to monitor the effectiveness of one s own behavior) Executive cognitive functions decline some with age, beginning in the mid-50 s Screening for Cognitive Impairment Clock drawing test Mini-Cog MMSE 16
Activation Is Developmental Judith Hibbard, PhD University of Oregon (c) Judith Hibbard, PhD University of Oregon Promising Approaches to Reduce Rehospitalizations Improved transitions out of the hospital for all patients Project RED BOOST IHI s Transforming Care at the Bedside and STAAR Initiative Hospital to Home H2H (ACC/IHI) Supplemental transitional care after discharge from the hospital Care Transitions Intervention (Coleman) Transitional Care Intervention (Naylor) Reliable, evidence-based care in all care settings Enhanced ongoing management for high risk patients Evercare Model VNSNY Home Care Model Heart failure clinics Intensive care management from primary care or health plan 17
Improved Transitions after an Acute-care Hospitalization for all Patients Hospitals Ambulatory Care Clinics Home Skilled Nursing Facilities Home Care & Community Resources Improved Transitions from SNFs to Home Hospitals Ambulatory Care Clinics Home Skilled Nursing Facilities Home Care & Community Services 18
Reliable, Evidence-based Care in all Care Settings Hospitals Ambulatory Care Clinics Home Skilled Nursing Facilities Home Care & Community Resources Enhanced Transitional Care or Intensive Care Management for High-risk Patients Hospitals Ambulatory Care Clinics Home Skilled Nursing Facilities Home Care & Community Resources 19
Re-Engineered Discharge (RED) Discharge Advocate; assigned role to ensure all components are complete The intervention significantly reduced the combined endpoints of ED use and hospitalization within 30 days by 30% (incidence risk ratio 0.695, p=0.009) Intervention required approximately 1 hour for implementation Jack BW, Veerappa KC, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Intern Med.. 2009;150:178-187. Re-Engineered Discharge (RED) Eleven mutually reinforcing components: 1. Medication reconciliation 2. Reconcile discharge plan with National Guidelines 3. Follow-up appointments 4. Outstanding tests 5. Post-discharge services 6. Written discharge plan 7. What to do if problem arises 8. Patient education 9. Assess patient understanding 10.D/C summary to PCP 11. Telephone Reinforcement 20
BOOST Toolkit: Primary Components Tool for Identification of High-Risk Patients Patient and Family/Caregiver Preparation - Primary cause for hospitalization and other diagnoses - Test results and interpretation, pending tests - Treatment plan during and after hospitalization - Follow up plans including appointment - Principal care provider identification -- who to call? - Warning signs and how to respond - Medication reconciliation Discharge Summary Communication BOOST Recommendations for Patients at Increased Risk for Readmission Direct communication with provider before discharge Telephone contact within 72 hours post-discharge to assess condition, discharge plan comprehension and adherence, and to reinforce follow-up Follow-up appointment with provider within 7 days Direct contact information for hospital personnel familiar with patient s course provided to patient/caregiver to raise questions/concerns if unable to reach principal care provider prior to first follow-up 21
H2H is a national quality improvement initiative to reduce unnecessary readmissions for cardiovascular patients Goal is to reduce all-cause readmission rates among patients discharged with heart failure or acute myocardial infarction by 20% by Dec 2012 Virtual Learning Community and H2H website Over 1000 hospitals enrolled, 34 national strategic partners, 24 QIO partners 3 Question Framework Medications + Appointment + Symptom Management = Transition 1. Medication Management Post-Discharge: Is the patient familiar and competent with his or her medications and is there access to them? 2. Early Follow-Up: Does the patient have a follow up appointment scheduled within a week of discharge and is he or she able to get there? 3. Symptom Management: Does the patient fully comprehend the signs and symptoms that require medical attention and whom to contact if they occur? 22
Key Elements of The Care Transitions Intervention Adaptable to wide variety of care settings One home visit, three phone calls over 30 days Transition Coach is the vehicle to build skills, confidence and provide tools to support self-care Model behavior for how to handle common problems Practice or role-play next encounter or visit Elicit patient s health related goal Create a gold standard medication list Four Pillars Medication self-management Follow-up with PCP/Specialist Knowledge of red flags or warning signs/symptoms and how to respond Patient-centered record 23
Personal Health Record Remember to take this Record with you to all of your doctor visits Hospital Visit Introduce the Program and explain how it will feel different Introduce the Personal Health Record Schedule home visit (with family caregiver) 24
Home Visit Patient identifies a 30-day health related goal Transition Coach models the behavior for how to resolve discrepancies, respond to red flags, and obtain a timely follow up appointment Patient and Transition Coach practice or role play next encounter(s) Patient identifies 2-3 questions for next encounter Three Phone Calls Follow-up on active coaching issues Review the Four Pillars Estimate progress made in activation Ensure that patients needs are being met 25
Key Findings of The Care Transitions Intervention Significant reduction in 30-day hospital readmits) Significant reduction in 90-day and 180-day readmits (sustained effect of coaching) Net cost savings of $300,000 for 350 pts/12 mo Adopted by over 500 leading health care organizations in 38 states nationwide Please visit www.caretransitions.org The Transitional Care Model (TCM) Naylor, M.D. et al. 2004. J Am Geriatr Soc 52:675 84 26
The Transitional Care Model (TCM) Nurse Practitioners provide inpatient assessment NPs review medications and goals Design and coordinate care with patients and providers Attend first post discharge MD office visit Direct home care for 1-3 months Conduct home intervals Results: Decreased the total number of rehospitalizations at 6 months by 36% (37% v. 20% p<0.001) Decreased average total cost of care by 39% Naylor, M.D. et al. 2004. J Am Geriatr Soc 52:675 84. JAMA 2004; 291:1358-67 Meta-analysis; 18 RCTs from 8 countries Interventions generally began in hospital with post-discharge support Follow-up ranged from single home visit to extensive visiting and phone support Results: 25% reduction in readmissions; 13% reduction (p=.06) in allcause mortality; Net savings $359-536 per month of intervention 27
communication tools clinical care paths advanced care planning tools Evercare Model Nurse Practitioners and Care Managers develop and manage personalized care plans coordinate multiple services help facilitate better communication between physicians, institutions, patients and their families help ensure effective integration of treatments Four levels of care, with each level involving different priorities and focus of care provided by the NP or CM Results: Reduced hospitalizations by 45% with no change in mortality Reduced emergency room visits by 50% Kane, R. L., G. Keckhafer, et al. (2003). The effect of Evercare on hospital use. Journal of the American Geriatric Society 51(10):1427-34. 28
Partnership for Patients: Two Primary Goals Keep hospital patients from getting injured or sicker. To decrease hospital preventable conditions by 40 percent Help patients heal without complication. To decrease preventable complications during transitions and subsequent hospital readmissions by 20 percent 29
Walkers: just starting to think about care transitions & reducing readmissions New Opportunities Joggers: currently involved in efforts to improve care transitions & reduce readmissions Attribution to Jane Brock, MD Marathoners: have a permanent structure in place to improve care transitions & reduce readmissions (ACOs) ACA Section 3026 30
Disclaimer The information presented in this session represents the speakers opinions and best estimates of what the Community Care Transitions Program (Section 3026) entails. (and more may be known by Forum) Applicants should carefully review all materials published by CMS for guidance. Community-Based Care Transitions Program (Section 3026) HHS Secretary funds eligible entities to furnish evidence based care transitions services to high-risk Medicare beneficiaries Entities include: hospitals with high readmit rates in partnership with community-based organizations Started April 2011; Up to $500M of eligible funding 31
Eligible Applicants Acute care hospitals with high readmission rates in partnership with a community based organization (CBO) CBOs that provide care transition services in partnership with acute care hospital(s) or other non-hospital partners There must be a partnership between the acute care hospital(s) and the CBO Priority Given to Partnerships that: Participate in a program administered by the Administration on Aging to provide concurrent care transitions interventions with multiple hospitals and practitioners; or Provide services to medically underserved populations, small communities, and rural areas 32
Care Transitions Approaches: Initiate care transition services no later than 24 hours prior to discharge Provide timely, culturally, and linguistically competent post-discharge education Ensure timely and productive interactions between patients and providers Perform medication review/management Promote patient centered self-management CBOs Will Be Paid an All-inclusive Rate Per Eligible Discharge Cost of services provided at the patient level Costs of implementing system changes at hospital level Develop a blended rate based on the interventions proposed, the anticipated volume for each, and the duration of the intervention(s) Choose interventions carefully limited by anticipated savings Budget template on the CCTP website 33
Application Guidance Complete a root cause analysis Specify how to address the root causes Characterize your past experience Describe interface with any accountable care organizations and medical homes Describe how to align their care transitions programs with other initiatives What Makes for a Strong Partnership? Not simply exchanging pleasantries on letterhead Tie into respective mission statements Point to prior collaboration and accomplishments Present the CBO and Hospital as equal partners Highlight the overlap in populations served 34
CMS Community Based Care Transitions Program http://www.cms.gov/demoprojectsevalrpts /MD/itemdetail.asp?itemID=CMS1239313 (or go to Google and enter CMS CCTP) 35