Deborah Perian, RN MHA CPHQ Reduce Unplanned Hospital Admissions: Focus on Patient Safety
Objectives At the end of this lesson, the learner will be able to: Identify key clinical and policy issues associated with the increased focus on patient re hospitalization, particularly related to the transition from hospital to home List various predictors to assist in the identification of patients who can benefit from post acute care Recap strategies that have been utilized to promote successful, safe transitions for patients from the hospital to their homes without resulting re hospitalizations
Consensus National Attention 2007 2008 1999 Institute of Medicine (IOM) report, To Err is Human 2001 IOM report, Crossing the Quality Chasm 2007, 2008 MedPAC reports highlight avoidable rehospitalizations; recommend data reporting and payment reform May 2008 National Quality Forum (NQF) endorsed 5 outcome measures for care transitions Aug 2008 CMS launched Care Transitions contracts in 14 communities; 9 th SOW Nov 2008 National Priorities Partnership (NPP) identified care coordination as one of six national priorities; stressed need for increased communication
Consensus National Attention 2009 2010 April 2009 New England Journal of Medicine article (Jencks, Coleman, Williams) Fall 2009 CMS releases hospital specific readmission rates for AMI/Pneumonia/HF 2009 States and providers actively engaged in efforts to reduce re hospitalization and improve care coordination 2010 Enactment of the Patient Protection and Accountability Care Act (PPACA) aka Affordable Care Act 2011 10 th Scope of Work Care Integrations
Why is readmission reduction a priority? The 2009 study of the 2004 Medicare population by Dr. Jencks was published in the NEJM Findings: 19.6% were readmitted within 30 days 34% were readmitted within 90 days. 50% of those readmitted had not seen their PCP Average LOS for the rehospitalized patient was 0.6 days longer Hospital readmissions have been identified as an important outcome measure for assessing performance of the health care system New England Journal of Medicine Re hospitalizations among Patients in the Medicare Fee for Service Program, Jencks, Williams, Coleman; April 2009
Hospital Utilization In 2011, more than 7 million Medicare beneficiaries experienced 12.4 million inpatient hospitalizations This equals approximately 2.5 million re hospitalizations during 2011 (30 day Rehospitalization Rate = 20%) Older adults are hospitalized for fall-related injuries 5 times more often than they are for injuries from other causes Medicare Payment Advisory Committee (MedPAC). Report to the Congress: Medicare Payment Policy Washington, DC: March 2012 Medicare Payment Advisory Committee (MedPAC). Report to the Congress: Medicare Payment Policy Washington, DC: March 2011:Chapter 8 pp 175 180.
Rate* of Nonfatal, Medically Consulted Fall Injury Episodes, by Age Group National Health Interview Survey, United States, 2010 * Per 1,000 population. Annualized rates of injury episodes for which a health-care professional was contacted either in person or by telephone for advice or treatment. An injury episode refers to a traumatic event in which the person experienced one or more injuries from an external cause. Estimates are based on household interviews of a sample of the civilian, non-institutionalized population. 95% confidence interval. Adams PF, Martinez ME, Vickerie JL, Kirzinger WK. Summary health statistics for the U.S. population: National Health Interview Survey, 2010. Vital Health Stat 2011;10(251).
Rehospitalizations are.. Rehospitalizations are Frequent 30 day Re admission rates (2008) One in five Medicare patients (19%), One in four Medicaid patients (24%) SNF & Nursing Home patients (24%), Greater than one in ten privately insured patients (12%) Wier LM, Barrett M, Steiner C, Jiang J. All cause readmissions by payer and age, 2008. Healthcare cost and Utilization Project. AHRQ. Statistical Brief #115, June 2011.
Rehospitalizations are.. Variable (2009)
Rehospitalizations are.. Costly Medicare Spending (Billions) 10 Jencks, S., Williams, M., Coleman, E. Rehospitalizations among Patients in the Medicare Fee for Service Program. NEJM April 2009, 360(14), 1418 1428. Medicare Payment Advisory Committee (MedPAC). Report to the Congress: Medicare Payment Policy Washington, DC: March 2011:Chapter 8 pp 175 180.
Rehospitalizations are.. Potentially avoidable In 2008, one out ten hospital stays were potentially preventable 3.9% acute conditions 6.2% chronic conditions 60 % patients > 65 Actionable for improvement Greater than 30% reduction of 30 day readmission rates have been realized from research and quality improvement initiatives Care Transition Programs Coleman, Naylor, STAAR, RED, BOOST Stranges, E., Stocks, C. Potentially Preventable Hospitalizations for Acute and Chronic Conditions, 2008. Healthcare cost and Utilization Project. AHRQ. Statistical Brief #99. November 2010. National Transitions of Care Coalition. Improving Transitions of Care. September 2010
Factors leading to Hospital Readmission Bisognano M & A Boutwell. Improving Transitions to Reduce Readmissions. Frontiers of Health Service Management. 2009. 25(3): 6
What can the Hospital do to help prevent an unplanned hospitalization? Appropriate referral for home care Enhanced client / family education & coaching on self management Written discharge instructions (with health literacy) Accurate medication reconciliation Facilitate timely post acute follow up Educate patients to know who to call for an issue Improve communication to the next level of care Boutwell A. Promising Approaches to Reduce ReHospitalizations. Institute for Healthcare Improvement (IHI) 2009 National Transitions of Care Coalition. Improving Transitions of Care. September 2010
Institute for Healthcare Improvement recommends: Appropriate referral for home care Boutwell, A. Promising Approaches to Reduce Rehospitalizations. Institute for Healthcare Improvement. 2009
Who is a Potential Home Health Care Patient? Age / Gender 77 year old, female (64%) Income level over half are below $21,780 / year Health status Support Referral greater than four (4) diagnoses 90% had medication changes 61% are physically de conditioned 42% have urinary incontinence 39% have skin integrity problems (wounds) 50% have no primary care giver 35% come from inpatient facilities Caffrey C, et al. Home Health Care and Discharged Hospice Care Patients: United States, 2000 2007. CDC, National Health Statistics Reports. Number 38, April 27, 2011. Medicare Payment Advisory Committee (MedPAC). Report to the Congress: Medicare Payment Policy Washington, DC: March 2011:Chapter 8 pp 175 180.
Predictors for Referral to Post Acute Care Indicator Major walking restrictions More likely to refer: 6.5 x Who had no or intermittent help available Self rated health as fair poor Self rated health as good Remained in the hospital longer Multiple of co morbidities Higher depression scores 3.0 x 4.0 x 3.1 x 1.2 x 1.2 x 1.1 x Bowles KH, Holmes JA, Ratcliffe SA, et al. Factors Identified by Experts to Support Decision Making for Post Acute Referral. Nurs Res. 2009 ; 58(2): 115 122
Predictors for Referral to Post Acute Care Indicator Major walking restrictions Who had no or intermittent help available Self rated health as fair poor Self rated health as good Remained in the hospital longer Multiple of co morbidities Higher depression scores More likely to refer: 6.5 x 3.0 x 4.0 x 3.1 x 1.2 x 1.2 x 1.1 x **Multiple medications / med changes Bowles KH, Holmes JA, Ratcliffe SA, et al. Factors Identified by Experts to Support Decision Making for Post Acute Referral. Nurs Res. 2009 ; 58(2): 115 122
Medication Management/Reconciliation Medication adverse events 30% of patients one medication discrepancy D/C from the hospital One in five patients D/C to home experience an adverse event within 3 weeks of discharge 60% medication related and could have been avoided Medication errors harm an estimated 1.5 million people per year at a cost of $3.5 billion annually 18
Reduce Hospitalizations: A National Study to Reduce Avoidable Hospitalizations through Home Care
Delta Study Top 5 Strategies to Reduce Unplanned Hospitalizations 1. Fall Prevention 94.9% 2. Agency Awareness, Culture & Support 92.5% 3. Front Loading 89.0% 4. Medication Management 78.8% 5. 24 Hour Availability/Response System 78.5% Delta Health Technologies, LLC, Fazzi Associates, Inc. The Delta Study to Reduce Hospitalizations: A National Study to Reduce Avoidable Hospitalizations through Home Care.. January 2012
Findings Practices used by most successful and least successful agencies were nearly identical in frequency of use of the strategy They use the same strategies the same percentage of the time What distinguished successful agencies from unsuccessful agencies was not the strategy but, rather, how the strategy was implemented How not What Delta Health Technologies, LLC, Fazzi Associates, Inc. The Delta Study to Reduce Hospitalizations: A National Study to Reduce Avoidable Hospitalizations through Home Care.. January 2012
What can a Home Health Agency do to keep clients safe? Step 1 Step 2 Step 3 Step 4 Step 5 Assess & Identify who is at Risk Plan and implement appropriate interventions Develop patient Self Management skills Medication Reconciliation and Management Communicate and Coordinate
Risk Assessments Hospitalization Risk Assessment Fall Risk Assessment Emotional Risk (Depression) Assessment Pressure Ulcer Risk Assessment Diabetic Foot Assessment
Hospitalization Risk Assessment
OCS Predictive Risk Assessment Based on OASIS SOC responses Reported in 5 levels High, Moderate, Low Risk Drivers Important to discuss at SOC case conference with clinician Focus on drivers of risk
OASIS C Fall Assessment CMS Requirement: A multi factor falls risk assessment must include at least one standardized tool that has been validated as effective in identifying falls risk in community dwelling elders, and which includes a standard response scale. TUG Timed Up and Go Functional Reach
Self Management Skills Zone Tool for Fall Risk
Home Safety PlanTM
Degrees of Integration IOM (Institute of Medicine). 2012. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: The National Academies Press.
Self Management is a Partnership
Client Activation 32 Hibbard, J. Development of the Patient Activation Measure. Health Services Research 39:4, Part I, August 2004
Activation can be developed
Patient Activation Center for Studying Health System Change (HSC) Health Tracking Household Survey 2007
Key program components Timely admission (24 hour Start of Care) Identification of ACH risk at start of care Interdisciplinary focus SN, PT, OT, ST, RD, MSW, HHA Individualized plan of care Client/Caregiver Education Frequent contact Home visit and/or phone call daily for first 7 14 days after start of care Specialized support tools
Holistic Approach American Physical Therapy Association, 2012
Eliminate medication discrepancies Improve communication among healthcare providers Improve timeliness of medical follow up Improve patient education Decrease deficiencies in health literacy 37
Thank you Deborah Perian, RN MHA CPHQ Regulatory & Quality Affairs BAYADA Home Health Care dperian@bayada.com 38