Decreasing Medicare Readmissions. Marinka Bulic Jyothi Golkonda Diane Hunt Aziz Lalji Emad Osman

Decreasing Medicare Readmissions Marinka Bulic Jyothi Golkonda Diane Hunt Aziz Lalji Emad Osman

1 Executive Summary... 3 Introduction... 5 Background... 5 Definition of the Problem and Impact... 7 Financial Impact... 9 Impact... 11 Other Impact... 11 Goal... 12 Proposed Solutions... 13 Metrics 13 Role of Information Technology... 17 workflows and operations... 17 Improve Discharge Medications Process... 18 Optimize Transition Planning... 21 Care Coordination... 25 Patient education... 27 Integration... 28 Proposed Integrated System... 28 Privacy Issues... 31 Use Case Diagram... 32 Cost vs. Benefits Analysis... 33 Project Plan... 34 Introduction... 34 Project Governance... 35 Project Roles and Responsibilities... 37 Project Assumptions, Constraints and Dependences... 38 Assumptions... 38 Constraints / Limitations... 39 Dependencies... 40 Quality Management Plan... 40 Communications Management Plan... 41 General Guidelines... 41 Key Groups 41 Risk Management Plan... 42 High Level Functional Requirements... 43 High Level Workflow Requirements... 45 Metrics & Measurements... 46 Testing 46

2 Training Plan... 48 Deployment... 49 Schedule... 50 Conclusion... 51 References... 53 Appendices... 55 Appendix A Project Structure... 55 Appendix B Project Governance... 56 Appendix C Roles and Responsibilities... 57 Appendix D Alternate solutions for Integrated systems... 69 CCDAs and Interfaces... 69 Remote Access to all Systems... 70 One System for Entire Organization... 70 One Centralized Data Warehouse... 71 Appendix E Annotated Bibliography... 73 Figure 1: Existing system diagram... 8 Figure 2: Use case for current workflow... 8 Figure 3: Proposed integrated system... 29 Figure 4: Use case for workflow in proposed integrated system... 31 Table 1: Potential Losses... 10 Table 2: University Hospital current LVF Scores... 13 Table 3: University Hospital current ASA on Arrival Scores... 14 Table 4: University Hospital current Blood Culture Scores... 14 Table 5: Projected Return on Investment... 32 Table 6: Project Roles and Responsibilities... 36 Table 7: Project Dependencies... 38 Table 8: Project Key Groups... 40 Table 9: Risk Management Plan... 41 Table 10: Schedule... 48

3 1. Executive Summary University Hospital is concerned about Medicare-insured patients with diagnoses including acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia, as those are the diagnoses being targeted by the Hospital Readmissions Reduction Program (HRRP). Without drastic improvements in these areas, the organization is set to lose close to $1 million dollars over the next three years. University Hospital has set a goal to reduce Medicare readmissions from 21% to 10% over the next two years; The Capstone Group has developed a multi-faceted strategy to help University Hospital not only reach their goal, but also to improve care provision while doing it. Pre-proposal analysis of the current system and workflows utilized by University Hospital revealed opportunities for improvement in several areas, leading to the following recommendations: Improve hospital-wide performance on clinical quality measures, particularly as they relate to the diagnoses of AMI, CHF, and pneumonia. This will be achieved by utilizing currently-available technology to generate reports on quality measures on a monthly basis, and by focusing re-education efforts as a result of these reports. By enabling clinical leaders to focus on those providers/locations that need re-education, we can better utilize available resources to encourage improvements. Streamline workflows within the hospital at transition of care points, specifically at admission and discharge of acute care patients. This will be affected by

4 improving admission and discharge medication reconciliation processes through detailed workflow analysis, evaluating patients at acute care admission for readmission risk utilizing a BOOST score, and through the development of a Transitional Care team to standardize movement of patients from inpatient to outpatient care settings with necessary resources to ensure compliance with care plans. Develop improved interactive education modules to help patients demonstrate understanding of clinical conditions and play a more informative role in their care. This will take place primarily though development and increased utilization of the Patient Portal. Standardize current follow-up care modules within the organization, with emphasis on primary care base, and home healthcare provisions. Through the initiation of a primary care provider incentive program, which encourages primary care providers to see discharged patients within 72 hours of discharge, in addition to increased information sharing between the two care environments, this objective will be obtained. In the future, the hospital will recoup these payments through attainment of accountable care organization (ACO) quality of care incentives. Complete overhaul of currently disjointed information systems, leading to a more robust, interactive, and available electronic health record (EHR) across the organization. Primarily, we recommend developing interfaces to share basic clinical information between the different electronic medical record (EMR)

5 systems utilized throughout the organization as well as a robust clinical data warehouse to enable the tabulation of quality and other reporting information from the system as a whole. Additionally, University Hospital will be provided with a detailed project plan. The purpose of this project plan is to clearly outline the scope of the project, assumptions made with the generation of this proposal, and responsibilities necessary for both parties moving forward. This proposal will save University Hospital approximately $516,000 in Medicare readmissions penalties over the next two years. Estimated cost for implementing the various recommendations within this proposal is $470,000, which provides University Hospital with a 10% return on investment over the next two years. 2. Introduction 2.1. Background University Hospital is a 500-bed facility with an Emergency Department, Intensive Care Unit, and Cardiac Surgery Facility. In addition, University Hospital directly employs over 30 physicians in the local community encompassing a variety of specialties; however, the majority of these physicians are primary care providers. The Capstone Group has been approached by the administrative leadership at University Hospital to assist the organization in developing an outline and implementing a plan to decrease hospital readmissions. The focus of project is on not only readmissions, but also on improving the scope of care provided within the community. As a major member in a local ACO, University Hospital understands and is committed to improving care for its patients across the continuum of available services; this goal is aligned

6 with the hospital mission, which is To provide quality healthcare services to our community. University Hospital wishes to utilize the experience and expertise of The Capstone Group to help them meet their goals of improving the care provided to their patients in a timely and economical manner. This proposal will outline the means by which The Capstone group will help University Hospital meet and surpass these goals. We wish to initiate this proposal with a review of the current state of medicine as it relates to hospital readmissions in our country. In the United States, nearly 20% of all hospitalized patients ages 65 and older are readmitted to an acute care facility within 30 days of discharge (Gerhardt, 2013). Medicare attributes the costs of these readmissions to be over $17.5 billion annually, and they estimate that the gross majority of these readmissions are due to preventable causes (Gerhardt, 2013). Given these astounding figures, which pose a great threat not only to the stability of our healthcare system overall but also to the health of our at-risk elderly population, the government determined that action was necessary to reduce hospital readmissions across the country. In response, a portion of the Patient Protection and Affordable Care Act (PPACA), which was signed into law in 2010, was dedicated to solving this particular problem. Started on October 1, 2012, HRRP serves to essentially de-incentivize healthcare organizations with above-average readmission rates for their Medicare patient base (Cloonan, 2013). Initially, the new rules are applicable to the following three diagnoses: AMI, CHF, and pneumonia. Most health care professionals believe that this program will be expanded in coming years to include more diagnoses. For 2013, the initial penalty for hospitals with higher readmission rates than national average is 1% of total Medicare reimbursement; that will increase to 2% in 2014 and 3% in 2015. Expected readmission rates for the country are

7 calculated by the Centers for Medicare & Medicaid Services (CMS), and adjusted for patient age, gender, and co-morbid conditions. Penalties for 2013 will be levied on hospitals after it is determined that their actual readmission rates exceed the expected readmission rates for a particular time period (Joynt, 2013). 2.2. Definition of the Problem and Impact University Hospital currently has higher-than-average readmission rates for Medicare insured patients with diagnoses of AMI, CHF, and pneumonia. The Capstone Group performed a root-cause analysis to help determine the causative factors leading to this problem. Some of these factors include poor quality measure performance, inappropriate methods to track quality measure indices, inadequate workflows, inappropriate follow-up, poor patient education practices, and an insufficient Information Technology (IT) base. University Hospital is associated with a multi-site Accountable Care Organization (ACO). University Hospital has adopted Centricity EHR for the past 18 years. The physicians in the hospital use computerized physician order entry (CPOE) to electronically send prescription orders to three different pharmacies that are part of the ACO. Pharmacies respond back to the ordering physicians with the prescription fill data. Physicians also use CPOE to electronically order lab tests and procedures to three different labs within the ACO. The labs with in the ACO use different terms and different test combinations. This has been a major cause for confusion on the receiving end and a potential patient safety issue. The labs have the capability to send test results electronically to the ordering provider. The outpatient clinics in the ACO use Epic EMR to electronically send and receive data from the pharmacies and the labs. Although University Hospital can exchange data electronically with labs and pharmacies there is no electronic data

8 exchange between the Hospital and the outpatient clinics in the ACO. This has a major impact on the transition of care when a patient is discharged from the hospital. Currently there is no handoff during discharge process. The hospital has no control on the post discharge care of the patient. Figure 1 depicts the state of the current systems within the ACO. Figure 1: Existing system diagram Figure 2 captures the use case for the current workflow in the ACO. There is no transition of care between the inpatient and outpatient care systems.

9 Figure 2: Use case for current workflow Indicates areas of improved workflows; see future use case on page 31 The remainder of this proposal will touch on each of these concerns, and provide University Hospital with methods to improve them. 2.2.1. Financial Impact By careful calculation of the admissions and readmissions data for the calendar year 2012 provided by University Hospital to The Capstone Group, we have generated a potential loss projection for the next three years based on current regulations. We want to make sure that the administrative leadership at University Hospital understands that any solution enacted at this point will alleviate projected losses for 2014, but that we will not be able to recoup losses already in place to be levied for the 2013 calendar year. In 2012, University Hospital had a total of 7,500 Medicare admissions; this accounted for 5,100 novel patients. The overall 30-day readmission rate for 2012 was approximately 21%. Of these, 60% occurred within 10 days of initial hospital

10 discharge; this information is critical to any project focusing on decreasing readmissions overall. When analyzing admission diagnoses, The Capstone Group determined that 65% of the 30-day readmissions were in patients with either one or a combination of AMI, CHF, and pneumonia. When we look at comparable healthcare organizations, these figures show that University Hospital is clearly within the Medicare penalty range for 2012 data. The following table illustrates the projected financial burden that University Hospital will endure, if corrective actions are not taken in a timely manner to reduce the rate of readmission (Logue, 2013). Year 2013 2014 2015 Penalty 1% 2% 3% No. of Medicare admissions Average Medicare hospitalization rate in the service area Total Medicare payment per annum Medicare payment for readmissions Readmission payments for (AMI, CHF, and Pneumonia) Expected Medicare readmission penalty for the three diagnoses 7500 7500 7500 $13,387 $12,718 $13,119 $100,402,500 $95,382,375 $98,394,450 $21,419,200 $20,348,240 $20,990,816 $13,922,480 $13,226,356 $13,644,030 $139,225 $264,527 $409,321 Table 1: Potential Losses It is the goal of The Capstone Group to develop and implement a multi-faceted plan to help University Hospital avoid Medicare repayment penalties of over $500,000 for 2014 and 2015 that are directly related to above-average 30-day readmission rates. University Hospital is

11 already predicted to lose almost $140,000 in Medicare payments due to the new requirements in 2013. 2.2.2. Impact The Capstone Group believes that the clinical impacts presented by poor quality measure performance and inadequate transitional workflows are of much greater potential harm than the financial impacts. Currently, University Hospital is failing in its mission To provide quality healthcare services to our community. Patients being cared for within the service lines provided by University Hospital and its affiliates are not receiving the same standard of care expected at a national level. This is directly impacting not only Medicare reimbursement, but also the trust that your patients place in you as a healthcare organization. Poor quality measures are directly related to readmission rates, as well as mortality rates and decreased quality of life indicators. Without drastic changes in these measures, the future of University Hospital as a viable healthcare option in the community is at risk. 2.2.3. Other Impact At The Capstone Group, we want to make sure that our project meets your organization s mission. With that in mind, we would like for the leadership at University Hospital to understand that our approach to reducing readmissions will not only result in a generous return on investment financially, but also in terms of quality of care provided to the patients in your community. Given University Hospital s current involvement in a local ACO, this project will supply the foundation from which you can realize benefits related to ACO payment models, PCMH initiatives, Health Information Exchange (HIE) projects, and a variety of other requirements as they relate to population health.

12 3. Goal The goal of this project is to reduce readmissions in patients with the diagnoses of AMI, pneumonia, and CHF; University Hospital s stated goal is to reduce these readmission rates from the current 21% to 10% over the next two years. This proposal will outline the multi-faceted approach recommended by The Capstone Group to help University Hospital meet that goal. Our proposal will outline solutions including: Improvement of clinical quality measures and overall provision of care, with reflection of these improvements in patient satisfaction surveys, Development of standardized clinical workflows at transitions of care, with focus on discharge process, primary care follow-up, and medication compliance, Implementation of new patient education processes to better ensure that patients participate and appropriately understand their own care, Standardization of care coordination in the ambulatory settings, to allow for better utilization of home health providers, and primary care physicians after discharge, Recommendations for overhaul of the current disjointed IT solutions in the hospital and affiliated practices in order to better streamline the flow of information between care locations We believe that a multi-faceted approach, addressing the majority of the concerns revealed by the root cause analysis will help University Hospital to not only avoid further financial penalties as they are related to Medicare readmission rates, but also to drastically improve the quality of care provided within the organization.

13 4. Proposed Solutions 4.1. Metrics The focus on quality measures defined by CMS is a system in place to reduce patient readmissions within 30 days of being discharged. The CMS program, HRRP, will collect data on quality measures involving CHF, AMI, and pneumonia (CMS, 2013). If the data show that a hospital has a higher than expected 30-day readmission rate for these diseases, penalties will be applied against their total Medicare payments. This financial incentive has been proven to improve readmission rates in hospitals for those diseases. We have identified initial measures within University Hospital for each condition with a low score that needs to be improved. A low percentage (under 95%) of a measure score is costly in two ways: 1. Penalties in Medicare payments hurt the overall bottom line of the hospital 2. These measures are proven to reduce readmission rates with a direct correlation between higher score with lower readmission rates. CHF In the United States, there are more than 700,000 hospitalizations due to heart failure annually; University Hospital had 1,900 admissions due to heart failure last year (Good Shepard, 2013). LVF Assessment Left Ventricular Systolic Function Assessment This score shows the percentage of patients who had the left side of their heart assessed during their hospital stay at University Hospital The left side of the heart is where the main pumping

14 chamber is located. By assessing it, doctors can tell how well it is pumping and what type of treatment is needed (Memorial Health, 2013). University Hospital Quality Measure Score - LVF 2010 Total 2011 Total 2012 Total YTD 2013 Total Projected 2014 75.6% 78.4% 84.9% 87.3% 96.7% Table 2: University Hospital current LVF Scores AMI Approximately 1.1 million patients have an acute myocardial infarction in the United States annually; there were approximately 2,000 patients with a heart attack at University Hospital last year (Good Shepard, 2013). Of those patients who have an AMI, almost 2/3 do not completely recover (Good Shepard, 2013). Patients who do survive the initial stages of an AMI have an increased chance of co-morbid disease and ultimately death that is 2-9 times increased over non-ami afflicted peers (Good Shepard, 2013). ASA on Arrival Aspirin on Arrival This score shows the percentage of heart attack patients who received aspirin within 24 hours of arriving at Memorial University Medical Center. Aspirin can help break up blood clots and prevent new ones from forming. It may reduce the severity of a heart attack (Memorial Health, 2013). University Hospital Quality Measure Score ASA on Arrival

15 2010 Total 2011 Total 2012 Total YTD 2013 Total Projected 2014 66.5% 72.5% 79.5% 83.6% 95.1% Table 3: University Hospital current ASA on Arrival Scores Pneumonia The 5 th leading causes of death in the nation for patients age 65 and over are pneumonia and influenza; they are 4 th for the University Hospital patient population (Good Shepard, 2013). More than 90% of deaths due to pneumonia occur in patients aged 65 and older (Good Shepard, 2013). Blood Culture This score shows the percentage of pneumonia patients at Memorial University Medical Center who had a blood sample studied before receiving any medication. By analyzing the blood, doctors can see what type of pneumonia is present and which type of antibiotic will treat it (Memorial Health, 2013). University Hospital Quality Measure Score Blood Cultures 2010 Total 2011 Total 2012 Total YTD 2013 Total Projected 2014 73.7% 81.2% 89.4% 90.4% 98.2% Table 4: University Hospital current Blood Culture Scores In order for these CMS quality measures to be implemented with the most effectiveness, the hospital must identify its own risks by using one of the following: Influenza vaccine status

16 Patient Survey: Hospital Consumer Assessment of Healthcare Providers and Systems scores Core measures for CHF, AMI and pneumonia Readmission rates Utilization of resources Cost of care per case A review of the above results should be performed monthly in order to adjust the system and improve the performance of the hospital. Analyzing the quality measures and identifying lapses in performance can help the hospital adjust and reduce its risk for readmissions Patient Survey The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey is a survey that has been standardized and used to help hospitals determine how patients feel about the care provided to them (HCAHPS Survey, 2013). HCAPHS has provided a method to standardize a practice employed by many hospitals across the nation, as well as a means to determine performance compared to other organizations. This survey has three goals, according to the originators: to produce comparable data on based on a patient perspective of care that allow comparisons amongst peer hospitals, to publicly report results of the survey so that consumers are aware of them and there is increased transparency, and to create incentives for hospitals that provide improved quality of care (HCAHPS Survey, 2013). All data generated through the use of the HCAHPS survey is provided to the public. The following topics are addressed in the current HCAHPS patient survey, and are of particular concern to University Hospital (HCAHPS Survey, 2013):

17 Communication About Medicines Discharge Information Overall Rating of Hospital The improvement of patient satisfaction survey metrics in the above areas is addressed through recommendations in this proposal. The initiation of improved workflows as they relate to these metrics will undoubtedly lead to increased patient satisfaction. Addressing these issues through this will lead to a decrease in University Hospital s readmission rate as well as a healthier bottom line. 4.1.1. Role of Information Technology Dash boards can be used to display all the above metrics to providers and administrators alike. Dash boards provide graphical display of the key performance indicators for readmission rates and support drill down of the key performance indicators to lower levels to examine critical drivers of performance. They help track and manage readmission rates by providing at a glance display for management and department heads. The analytic reports provide details of the performance drivers that affect readmission rates. (HIMMS, 2012) 4.2. workflows and operations The arena of clinical workflows, in particular, presents an opportunity for standardization across the organization. We seek to help University Hospital optimize the processes related to post-discharge medication planning, the transition process, and care coordination. We recommend a Lean Six Sigma approach to improve the medication reconciliation processes to help standardize and streamline these workflows. Our black-belt certified Lean Six Sigma team

18 will work directly with appropriate stakeholders within the organization to map out not only the inadequate current processes, but also a desired future state that will ensure error-free medication reconciliation at all transitions of care. Our team will work with your stakeholders to analyze the entire process including clinical caregiver workflows, current EMR functionality, and caregiver to patient communication. The final stage of this project will be implementation of the future state within all patient care areas in the hospital, led by our Lean Six Sigma consultants. 4.2.1. Improve Discharge Medications Process The next step in the plan to reduce hospital readmissions at University Hospital is to improve the patient s ability to understand and adhere with medication regimens prescribed at discharge. Studies have repeatedly shown that patients who adhere to their prescribed medication regimens have lower readmission rates than those patients who are noncompliant with their medications (Stewart, 1999). At the current time, we have identified three areas of concern as they relate to the discharge medications process at University Hospital: medication reconciliation, e- prescribing, and compliance verification. Our plan to improve processes in these three areas will lead to increased medication compliance in patients after discharge, and reduced readmission rates overall. In our initial analysis, we determined that medication reconciliation is a process that is fragmented and poorly defined; in particular, we determined that last year over 75% of University Hospital s admitted patients had medication reconciliations performed incorrectly at either admission or discharge. Additionally, The Capstone Group has identified that over half of these mistakes occurred during the admission medication reconciliation process, which then led to carry-over errors in the discharge medication reconciliation process.

19 In addition to the concerns about medication reconciliation, The Capstone Group determined that University Hospital s e-prescribing rate at hospital discharge is far below the requirement for attainment of Meaningful Use. Improvement in this particular area will not only help University Hospital to recoup some of those Meaningful Use dollars, it will also help to improve patient compliance with discharge medication instructions. Upon initial investigation, it was determined that providers at University Hospital cited inconvenience as the main reason why they were not e-prescribing discharge medications consistently. We have identified an inadequate current state that requires providers to order prescriptions individually based on how they should be routed (controlled substances routed to the printer, non-controlled substances to the pharmacy); this is very inconvenient and time-consuming for your providers. The next solution we propose is that The Capstone Group work directly with Centricity s e-prescribing team in conjunction with University Hospital s appropriate stakeholders to alter the current state so that prescriptions route automatically without physician direction. This is functionality currently available in the Centricity EMR, so we do not anticipate any difficulties with this project. Once this phase of the project is complete, we will work directly with your providers to educate them about the improved process. With this project, we aim to increase provider e- prescribing at hospital discharge to more than 80% of appropriate medications, which is the current requirement to meet Meaningful Use Stage One. The final piece we recommend to improve discharge medication compliance is the development of a communication channel between outpatient pharmacies and primary care providers, with inclusion of the patient via the Patient Portal. We believe it is this phase of the discharge medications project that will have the greatest impact on readmissions overall. When

20 we evaluated compliance with discharge medications, The Capstone Group determined that fewer than 50% of discharged patients received all of the medications prescribed for them at release from the hospital. We will work directly with representatives from University Hospitals informatics team, local pharmacy representatives, and personnel from Centricity and Epic to develop electronic workflows to allow outpatient pharmacies to inform primary care physicians when medications are not filled by the patient. The first step in this process is to include the primary care physician, who was identified at the time of hospital admission, on any e- prescriptions sent at the time of discharge. This allows the local pharmacists to determine who the appropriate following provider is for any particular patient. The next step in this process is to work directly with the local pharmacies to take their current refill request process and modify it slightly to become a prescriptions unfilled notification. In projects with previous clients, we have found local pharmacies to be very willing to work with us on this communication, because it results in increased revenue for them through higher percentages of prescriptions filled. Additionally, this requires very little work for them to perform. These notifications will come into the outpatient EMR, Epic, directly through the message center, just as refill requests come to the providers or designated staff today. Once this process is in place, our team will work to educate the primary care physician base in the community about these notifications. In particular, we will focus on the employed primary care physicians with education about how to respond to these notifications and identify those patients who are noncompliant at the time of discharge. By placing that information in the hands of the primary care providers, we believe that we can improve the ability of these providers to help recently discharged patients better comply with medication instructions by facilitating dialogue that should elucidate reasons why

21 particular medications were not filled. Once they are aware of barriers facing an individual patient, the primary care provider can involve necessary resources to help patients comply with discharge orders. 4.2.2. Optimize Transition Planning Another particularly important facet of this project proposal is the transition from not only the inpatient to outpatient care setting, but also the transition from outpatient to inpatient. The Capstone group will help University Hospital to streamline the processes surrounding care in both the acute care and ambulatory settings, so that the end result will be reduced readmission rates throughout the University Hospital organization. On initial evaluation of these processes at University Hospital, we have determined that these processes are not standardized at all. Patients are currently at the mercy of an extremely varied system that may or may not utilize social workers, home healthcare resources, and primary care providers to facilitate necessary postdischarge care. The first step in this portion of the proposal is to look at what happens when a patient is admitted to University Hospital. We will start by focusing on identifying patients who are particularly at risk for readmission based on certain factors present upon admission for acute care. While there are several disease-based scoring systems available for use in the inpatient care realm, we recommend using a more global approach to stratifying patients according to risk scores; in this way we are more likely to reduce readmissions for our patient base overall and not just for those disease states identified by the measurement tools. Additionally, we simplify the admission process for the support staff, ensuring that all patients receive the same risk assessment, regardless of diagnosis at the time of admission. Although many risk-predictive

22 models have not been proven to effectively reduce readmission rates in randomized controlled studies to date, we feel that the benefits of improved targeted care and relatively low cost of such measures make the practice ultimately useful (Kansagara, 2011). In evaluating options for patient risk stratification at admission, we have determined that the BOOST Model has shown the most initial promise in reducing readmissions in the short-term. The BOOST model will allow the clinical staff to calculate a readmission risk score for all patients over the age of 65 at the time of admission, and includes alterations in care based on the following (The Society of Hospital Medicine, 2013): The presence of problem medications The presence of psychological symptoms The principal diagnosis at the time of admission The presence of polypharmacy Poor health literacy on the part of the patient The presence or absence of patient support Prior hospitalizations in the last six months Palliative care The Capstone Group will work with University Hospital s informatics team to develop a form within the inpatient Centricity system that is completed by nursing staff at the time of admission on all patients over the age of 65. This form will trigger an alert identifying a patient as high-risk for readmission if they have the presence of risk factors in 1 or more of the above categories. This alert will be visible to all care providers on the patient s banner bar within the Centricity EMR, and reminds them that appropriate care should be taken with the transition from

23 acute to outpatient wherever possible. Additionally, we recommend that this alert also trigger a task within the Centricity system that places the patient onto a list for social work and/or a transitional care team for further resources. By effectively utilizing the BOOST tool as a clinical decision support within the EMR, we have standardized a process to best stratify those patients who are high-risk for readmission at the time of presentation. Finally, The Capstone Group recommends the development of a Transitional Care Team to help smooth the movement of high-risk patients from acute inpatient care to ambulatory care provision. Traditional models show Transitional Care Teams led by a nurse practitioner in conjunction with a managing medical director, with staffing provided by a combination of nurses, home healthcare providers, and social workers. The recommended team size for University Hospital at this time is 6. This recommendation is based on initial analysis which showed that approximately 20% of the inpatient population at University Hospital is over the age of 65, and that half of those patients qualify as high-risk utilizing the BOOST scoring method; this translates to an approximate case load of 50 at any given time. The medical director should be available on a part-time basis for consultation and organizational decisions, while the remainder of the positions should be full-time. It is this team that will help patients move across the gap between acute and ambulatory care; these care providers will provide the full spectrum of care for patients as they navigate that 30 day transition. Potential services offered by this team include follow-up in home evaluation post-discharge, arrangement of home care, housekeeping, and financial support to help patients meet medical needs (prescriptions, durable medical equipment, dietary changes, Meals on Wheels, etc.), facilitation of transportation, education about diagnoses and expectations, and scheduling of appointments with follow-up

24 providers after discharge. While development of this team does require additional resources at the hospital level, we have seen that the benefits of this team far exceed the cost. The Capstone Group has seen marked success with the transitional care model across the country to date, and nationally, readmission rates have decreased anywhere from 2-10% for certain diagnoses thanks to the initiation of this type of program (Stauffer, 2012). Additionally, with the implementation of the clinical decision support-aided BOOST score, we can automatically assign patients to the Transitional Care Team based on risk. It is the task of the Transitional Care Team to act as facilitators to work directly with patients during the move from hospitalization to home; the development of this team will help patients to utilize the extensive outpatient support system offered in the community, and will help them to avoid expensive Emergency Department and Inpatient care unless it is absolutely necessary. Our final recommendation regarding the transition of care from inpatient to outpatient is the involvement of the Home Healthcare providers. While the local Home Healthcare agency is not currently affiliated with University Hospital, we believe a partnership between the two would be greatly advantageous to both entities. Home Healthcare can play a vital role in improving patients quality of life, outcomes, and unnecessary readmissions (Fleming, 2013). With the recommendation to include Home Healthcare providers on the Transitional Care Team, we allow for both entities to provide necessary services after the time of discharge. Additionally, because Home Healthcare services are reimbursable, while Transitional Care Services are not, the utilization of Home Healthcare agencies creates a symbiotic relationship for both entities as well as for the patient. Home Healthcare intervention can start within 24-48 hours after discharge with a visit by a registered nurse (RN) to the patient s house. The intervention continues for up to

25 sixty days from the date of discharge and can continue for subsequent sixty day episodes until the patient completely recovers. During a patient s stay with home healthcare, additional services such as physical, occupational and speech therapy, home health aide and social worker services are also provided. These services are provided on a weekly basis or as needed. Home Healthcare agencies have an incentive to provide better care to patients. Early discharge from Home Healthcare with less than five skilled services provided to patient can result in reduction of payment to the agency. Home Healthcare agencies can also be penalized for re-hospitalizations and not meeting the required quality metrics. Home Healthcare provides the following services that can help reduce unnecessary readmissions (Logue, 2013): Providing information and education to patients about their health conditions, how to identify red flags and self-monitoring. Help create up to date medication list by doing medication reconciliation. Reminding patients and caregivers about physician follow-up. Providing plan of care for timely recovery of patients Assess and help patient in getting other community resources The combination of the Transitional Care Team and the Home Healthcare providers will help to better coordinate patient care before and after discharge. The teams together will act as a liaison between the hospital, patient, and primary care physician and will help smooth the transition of care as it occurs (Fleming, 2013). 4.2.3. Care Coordination In addition to standardizing the discharge medications process and the transition of care, the coordination of care between the acute care providers and the primary care providers is

26 another critical piece of this proposal. This coordination of care is necessary to keep patients out of the hospital. Currently, patients discharged from University Hospital have less than a 50% chance of seeing a primary care physician within 14 days of discharge. However, we know that patients who are not seen within 72 hours of discharge have a markedly increased risk of readmission (Cloonan, 2013). The primary care physician base in the community must be involved in this project, or it is doomed to fail. We believe that it is essential for University Hospital to set up an incentive program for the employed primary care physicians, to get them invested in the project. As the hospital s involvement in the ACO program evolves, those payments related to decreased readmission rates could be utilized to fund the primary care physician incentive program. A whole re-evaluation of the current payment model for these physicians is likely necessary, as many organizations are moving away from a production-based incentive program and towards a quality-based incentive program. However, for the purposes of this proposal, the recommendation at this time is to develop an incentive program for the employed primary care physicians of the hospital. This program should reward physicians who consistently get discharged patients into the office to be seen within 72 hours of discharge and who meet outpatient quality metrics set by Meaningful Use requirements. Because we know that improvements in these two areas are directly related to decreased readmission rates, this program will pay for itself in time. Additionally, given University Hospital s ACO involvement, this will help reduce per-patient expenditures and lower costs overall. A program that rewards primary care physicians for improving quality of care provided, while also reducing costs of providing that care is critical to the financial health of University Hospital moving forward. These steps in improving coordination of care, in addition to recommendations elsewhere in this proposal to

27 streamline information flow between care providers, will help facilitate improved care for patients within the organization overall. 4.3. Patient education One key element in reducing the admissions of patients and increasing their satisfaction is in them getting the proper education regarding how to take their medicine and when to make follow-up appointments. Patients who receive education on these factors are 30 percent less likely to be readmitted or visit the emergency department than patients who lack this information according to a study funded by the Agency for Healthcare Research and Quality (Jack, 2013). One program that has shown signs of success has been Project RED, the Re-Engineered Hospital Discharge Program considered to be a leading project in care coordination. This program is put into place to help nurses to help patients arrange follow-up appointments, confirm medication routines, and understand their diagnoses using a personalized instruction booklet (Jack, 2013). The next step after the nurse interaction is for a pharmacist to contact the patient up to 4 days after being discharged from the hospital in an effort to reinforce the medication place and answer any follow up questions (Krames, 2013). The preliminary results of the testing of Project Red showed that after 30 days after their hospital discharge, the 370 patients who participated in the RED program had 30% fewer subsequent emergency visits and early readmissions than the 368 patients who did not. 94% of the patients who participated left the hospital with a follow-up appointment with their primary care physician, compared to 35% for patients who did not participate. 91% of participants had their discharge information sent to their primary care physician within 24 hours of leaving the hospital (Krames, 2013).

28 We would like to emulate this program at University Hospital. We will utilize the inpatient EMR to suggest diagnosis-specific patient education at the time of discharge, and will build out a reporting tool for University Hospital to use to determine which nurses are not providing this education at hospital discharge. Additionally, we recommend utilizing the Transitional Care Team to function as the pharmacist in the Project RED scenario above, to call the patient 2-3 days post discharge to verify the patient is taking medications and following care plans as directed. Finally, patient portals help to drive patient engagement and support patients while they make health-related decisions and manage their own personal health information. Patient portals can also serve as a communication channel between the patient and the physicians (physicians who attended the patient during hospitalization and physician responsible for the follow-up care after discharge). The portal can be used to share patient specific educational resources. Patients can access clinical summaries online through the portal. Physicians can also choose to use the patient portal to post the labs results with a brief message explaining the results. We recommend optimizing the Portal currently used by University Hospital to include this functionality, and to enhance the workflows outlined above. 4.4. Integration 4.4.1. Proposed Integrated System The Capstone Group recommends the following steps to integrate the hospitals, outpatient clinics, pharmacies and labs in the ACO.

29 1. University Hospital uses Centricity EHR. The outpatient clinics use Epic EMR. There is no electronic communication between the Hospital and outpatient clinics. This is a major hurdle for transition of care between University Hospital and the primary care physician or the home healthcare providers. Capstone Group recommends using CCDAs to bridge the gap between the inpatient system and the outpatient systems and allow patient data to flow across the continuum of care. 2. University Hospital is already using CPOE to electronically send and receive data from labs, pharmacy, and radiology. But during our investigation it was observed that the labs use different terms and test combinations. This causes confusion on the receiving end (both inpatient systems and outpatient systems). Capstone group recommends using the standards recommended by CMS in all labs. Use CPT codes for procedures and LOINC codes for lab tests. Units of measure on the reported results must follow CMS recommendation. 3. Capstone group recommends creating a centralized data warehouse and feed data from all clinical systems (inpatient, outpatient, lab, pharmacy, radiology, etc.), financial systems, operational systems and human resource (HR) systems. The data warehouse could be used to generate metrics on patient care and provide possible recommendations to the providers. Data can also be used for retrospective analysis for continuous quality improvement. Figure 3 depicts the proposed integrated system. Advantages of the proposed system An integrated system provides access to complete patient record from anywhere anytime.

30 Potential data loss or incomplete patient record, due to manual consolidation of patient data is eliminated. Allows seamless data flow between the systems. Addresses patient safety issues due to lost communication Facilitates dashboard development to track readmission rates Provides the necessary infrastructure for Inpatient clinical reports, Outpatient clinical reports, Patient experience reports and Cross functional reports Track patient outcome with respect to financial impact Track patient outcome with respect to operational and staff changes

31 Figure 3: Proposed integrated system 4.4.2. Privacy Issues With the implementation of new workflows, CMS quality measures, and technology changes, the personal health information (PHI) of patients cared for by providers at University Hospital is at risk. In particular, University Hospital must be cognizant to remain compliant with the regulations included in the Health Information Portability and Accountability Act (HIPAA). With the addition of a data warehouse to the current information technology infrastructure at University Hospital, an agreement must be developed between the hospital and the Health Information Organization (HIO). While a HIO is not a covered entity, it is a business associate, under the HIPAA rules (45 C.F.R. 164.502(e), 164.504(e)) (Department of Health & Human Services, 2009). Therefore, University Hospital will need to engage legal counsel in order to draft and enforce appropriate business associate agreements with the HIO managing and storing the personal health information for the organization. This is outside of the scope of the proposal presented by The Capstone Group and must be arranged by the hospital separate to this project. Additionally, University Hospital must be cognizant of potential weaknesses in the network that may compromise personal health information. As data is sent between physicians and other care providers within the organization, it becomes more likely to be compromised. Evaluation of network security is another element not provided by The Capstone Group, but is necessary to remain HIPAA compliant. Considerations for the organization, as recommended by The Department of Health and Human Services include utilizing unique and secure ID s for all users of the network, automatic log-out protocol, encryption and decryption of data, and emergency access procedures (Department of Health & Human Services, 2009). All of these are

32 considerations for University Hospital as they work to improve their information system to reduce readmissions. 4.5. Use Case Diagram Figure 4 depicts the use case diagram with Capstone Group s proposed solution. Use cases in yellow represents modification to the existing use case (using additional tools to improve care and changes to the care delivery and discharge process). Use cases in green represent a new use case added as a result of the proposed solution to improve patient care across the continuum of care and reduce readmissions. Figure 4: Use case for workflow in proposed integrated system

33 5. Cost vs. Benefits Analysis The benefit of implementing the proposed solutions will not only reduce the overall Medicare readmission rate from 21% to 10%, but will also help University Hospital save $516,618 or 64% in readmission penalties. Year 2013 2014 2015 Total for 3- Penalty 1% 2% 3% years No. of Medicare admissions Average Medicare hospitalization rate in the service area Total Medicare payment per annum Medicare payment for readmissions Readmission payments for (AMI, Heart Failure and Pneumonia) Penalties after implementation of proposed solutions Penalties before implementation of proposed solutions Savings in penalties due to implementation of proposed solutions 7500 7500 7500 $13,387 $12,718 $13,119 $100,402,500 $95,382,375 $98,394,450 $294,179,325 $21,419,200 $9,538,238 $9,839,445 $40,796,883 $13,922,480 $3,433,766 $2,951,834 $20,308,079 $139,225 $68,675 $88,555 $296,455 $139,225 $264,527 $409,321 $813,073 $0 $195,852 $320,766 $516,618

34 Estimated cost of proposed solutions Return on investments ($188,000) ($211,500) ($70,500) ($470,000) ($188,000) ($15,648) $250,266 $46,618 Table 5: Projected Return on Investment Before the implementation of the proposed solutions 65% of the readmissions were patients with either one or a combination of AMI, CHF, and pneumonia. After implementation of the proposed solutions the readmissions of patients with the three diagnoses will be 33%. The estimated costs of implementing the proposed solutions will be $470,000. Majority of the estimated costs will be utilized for upgrading and integrating the infrastructure, training, consultancy and other expenses. In the next two years, the proposed solutions will help University Hospital gain 10% Return on Investment (ROI). 6. Project Plan 6.1. Introduction The implementation approach proposed for the solution will take on a multi-phased approach over the course of a (12) month timeline beginning in January 2014. Core groups of work that will be concentrated on are as follows 1) Project Management, 2) Infrastructure, 3) Application Solution, 4) Testing, 5) Training, 6) Operations and Communications. The work will be broken out in the following project phases or milestones: Planning

35 Design Build Testing Deploy and Close Capstone consulting project plan aims to clearly manage goals, strong communications, realistic schedules, a cost schedule quality equilibrium supported by detailed plans. The Project Plan and associated work breakdown structure will become the working documents of the project and updated throughout the life of the project. Project success factors: Agreement among the project team, customer, and management on the goals of the project. A plan that shows an overall path and clear responsibilities, which is also used to measure progress during the project. Constant, effective communication between everyone involved in the project. A controlled scope. Management support. 6.2. Project Governance

36 Project governance is illustrated in (2) ways for the Medicare Readmission Reduction (MRR) project. Both diagrams are submitted as addendums (A & B). Overall Project Governance The overall project governance reflects the organizational governance structure w/ respect to the MRR. As illustrated in addendum A, the project itself will run up through the Chief Operations Officer at University Health. Other key decisionmakers and business/clinical unit representation will be a part of the MRR Oversight committee. These key members will represent: Information Technology Physician stake holders Nursing Stakeholders Revenue Cycle / Finance Patient Care Services Additionally, the responsibilities of the project leaders vary from direction on the tactical/ operational approach of the project, as well as execution, and overall organizational strategy. As the MRR project is not just focused on technology, and financial goals, there is also clinical representation both at execution and steering committee. ITS Project Team Governance An additional governance chart (addendum B) has been supplemented to highlight the governance structure with respect to the actual project execution. As you review you will notice the different teams that will comprise the overall project team and their roles with:

37 Design / Build / Testing Training Development Training Delivery Implementation / Operations Please note that the steering committee will work in coordination with the patient care service team, and the overall EMR leadership team with ultimate reporting up to the MRR oversight committee as highlighted in the overall project governance chart. 6.3. Project Roles and Responsibilities Below are the project team members that will be involved with project execution and a brief review of their responsibility. A full review of roles by responsibilities has been submitted as addendum C. Role Responsibilities Adoption Mgr. MRR Analysts MRR Educators MRR Oversight Participate and/or lead design sessions to ensure that system design and workflows support clinical care & departmental processes Development of business process solutions and requirements with support from application support Conduct training sessions following predefined standards Resolve and/or Escalate to project concerns/issues to Executive Sponsor as needed team to design enterprise-focused learning objectives, course outlines, assessments, storyboards, instructor manuals, and participant materials

38 Role Responsibilities Adoption Mgr. Dept. Business Owner Education Liaison Executive Sponsor MRR Design Project Director Project Manager Resource Manager Participate and/or lead design sessions to ensure that system design and workflows support clinical care & departmental processes Oversee identification, review, modification and creation of clinical policies and procedures and discharge instructions. Develop and maintain training plan and training work breakdown structure Provide overall strategic leadership to the project Business solutions & requirements: gathering and documentation Resolve issues escalated from Project Manager, Accountant, and Architect Provide project tracking for each affected system and process within the project scope Work with the Project Manager to staff the project appropriately so timelines and targets can be achieved Table 6: Project Roles and Responsibilities 6.4. Project Assumptions, Constraints and Dependences 6.4.1. Assumptions Accurate and Timely Documentation One key design feature of the MRR project will be its ability to mine discreet patient data that is deemed critical to identifying the high risk patient population. To be effective, the data in the patient record will need to be wholly, accurate and timely. Decision Support - Another key feature of the MRR project will be its ability to provide clinicians with evidence based patient care instructions. For the project to be effective the

39 care instructions developed as part of the MRR initiative will need to be reviewed and executed accordingly. Scope- While the MRR project will focus on (3) core measures, the project understands there are other core measures that can adversely affect organizational readmission statistics. This project assumes no more than a moderate (+/-3%) deviation in the core measures outside of the scope of this project in order to drive down the whole organizational readmission population. Integration In order to observe the benefits of fully integrated patient data across the whole care team and both University Health EMR s (Centricity/Epic) this project assumes significant investment in integration and interoperability efforts between both systems and standardization of data standards 6.4.2. Constraints / Limitations <Data Standards> In the current state the University Health existing architecture hosts (2) separate EMR s. This is identified as a limitation to this project with regards to the lack of standardization of data across both EMR s. o To counter this constraint we propose significant work be invested in identifying organizational data standards with respect to patient data being documented by provider and exchanged from system to system <Data Sources> Again, with the existing architecture and use of (2) separate EMR s, clinicians application workflow, data mining/reporting will be constrained.

40 o To counter this constraint, the project proposes significant investment and time into the development of future state workflows and development ofclear policies and procedures for use of both EMR s. 6.4.3. Dependencies Below is a list of project dependencies for the MRR project. Meaningful Use Stage 2 project will impact the future state integration architecture and standards for University Health. Additionally, the ICD-10 implementation will have significant impact on billing / reimbursement as well as documentation standards in the future state. Description Status Owner Escalation Date Due Date Meaningful use stage 2 Open MU PM 1/1/2014 6/30/2014 ICD -10 Open ICD 10 PM 1/1/2014 10/1/2014 Table 7: Project Dependencies 6.5. Quality Management Plan The MRR project will utilize the following tools to monitor and control the progress, project objectives, quality, and risk with regards to the project. Capstone consulting believes monitoring and controlling affects all other phases of the project life cycle. Risks / Issues Will be documented in a Microsoft SharePoint site designed uniquely for the project. Risks and issues documented will be communicated to the project manager as well as the lead for the particular phase of the project (i.e. design/training, implementation) for tracking and escalation purposes.

41 Time Tracking Will be documented and managed utilizing Microsoft Project Server. Time tracking will be assessed by phase and project activity by the team member responsible for the work. Time tracking will assist the project leadership with future phase cost and resource planning. Project Progress Will be documented by the Project Manager in Microsoft Project will be integrated to project server. 6.6. Communications Management Plan 6.6.1. General Guidelines Capstone consulting has developed thefollowing guidelines for all project communications -- Communicate with all affected parties. Every message should be audience-specific. Set appropriate expectations. Provide regular, unbiased reporting of project progress. Communicate with other people before they need to know the information. Provide time to assimilate the information. 6.6.2. Key Groups Below is a list of the key groups of people with whom the project manager and/or project team will communicate with during the project.

42 Groups Members Project Sponsor(s) Chief Operation Officer (University Health) Project Team MRR Analysts MRR Educators Department Business Owners (Department Managers) Educator Liaison MRR Design Project Director Project Manager Department Stakeholders ClinApps Project Management Office (PMO) Resource Managers Ambulatory Medical Directors Acute Care Medical Directors ICU Managers ED Managers Ambulatory Clinic Managers Cardiology Managers / Directors Director of Pharmacy Director of Lab Operations Director of Radiology Home Health Managers Project director / Project Manager Resource Managers Table 8: Project Key Groups 6.7. Risk Management Plan The following risks have been identified by Capstone consulting and are evaluated based on Likelihood Impact Severity

43 Risk Likelihood Severity Impact Mitigation Project Resources With so many regulatory projects in 2014 such as ICD-10 and Meaningful Use there is a risk of recruiting and retaining project resources Highly Likely HIGH HIGH impact to timeline Contracting staff Adoption Additional Decision support functionality if improperly designed and trained can impact adoption and impede clinical workflow Likely High Significant impact to project goals Training Assessment Post-Go Live Monitoring and assessment of log files Qualitiative postproduction surveys by users ICD-10 The ICD-10 project poses significant risk to reimbursement as well as documentation standards for providers. High High Significant Add ICD-10 validation checkpoint as part of requirement acceptance Table 9: Risk Management Plan 6.8. High Level Functional Requirements General Integration Integrates with existing Centricity and EPIC EMR architecture Development of additional system to system integrations with adherence to CCDA standards Full integration ability with all ancillary systems

44 o o o o o Lab Radiology Pharmacy Home Health Primary Care providers portals Decision Support Alert Functionality - must identify patient data with respect to the following 3 measures and alert based on reference range violation developed as part of application design efforts (see core measures above in section 4.1) Congestive Heart Failure Acute Myocardial Infarction Pneumonia Decision Support Functionality Based on identification of high risk alerts and patient identification, system will provide detailed plan of care instructions to providers with respect to: Discharge Summary Follow-Up visits Communication to entire patient care team Patient Triage Coordinated provider hand-off Tailored medication reconciliation STAT routing for all lab

45 Documentation of Vitals Tailored assessment instructions Tailored communication and follow up messaging thru Patient Portal Printing Patient Discharge Summary out of both EMR s in addition to patient portal Add new printing devices (as needed) Workflow Complies with ICD-10 documentation requirements Complies with MU requirements Reports Ability to assess increase / decrease of readmission within core measure population Hardware Servers 6.9. High Level Workflow Requirements Based on development of policies and procedures new workflow requirements will need ability to tailor the following to high risk protocols created as part of the MRR project - Discharge Summary Follow-Up visits Communication to entire patient care team Patient Triage Coordinated provider hand-off Tailored medication reconciliation

46 STAT routing for all lab Documentation of Vitals Tailored assessment instructions Future Orders 6.10. Metrics & Measurements Measurements of readmission volume will be completed every (3) months. The following teams and responsibilities have been highlighted for providing the metrics and measuring of them Operations Will provide figures on the number of readmissions broken out by 1) chief complaint 2) primary diagnosis. Operations will also provide figures and input on qualitative surveys completed by patients as well as users of the system for continuous process improvement IT Will provide data figures on the amount of alerts triggered, appropriateness and adoption of decision support steps provided RevenueCycle Will provide figures on the amount of reimbursement and subsequent additional cost of readmission 6.11. Testing Capstone consulting will also complete a detailed testing assessment as part of the project implementation plan. A multi-phased testing approach will be utilized. The objectives of testing for the University Health Readmission Reduction projectare to: Document that the system reliably and repeatedly performs as designed. Ensure regulatory documentation standards are met. Verify business and system requirements are satisfied.

47 Capture discrepancies (problems) to eliminate defects. Establish testing documentation that can be reused for system maintenance. Provide information to assess go-live readiness. Practice a dress rehearsal build and testing Key testing milestones and purpose will include Unit Testing Unit testing will focus on application components (i.e. a unit of functionality) as they are built. For a specific list of units that will be tested, please refer to high level requirements section (above). Unit testing verifies basic application components work as designed during the build process. Application / Functional Testing Application Testing confirms that the component functions of the product/application perform to meet the business and technical design requirements. Focus is on software defects. This testing will confirm correct configuration of the infrastructure as well. The application testing will focus on the full system requirements and how they flow together, beginning with the alert and on to the decision support guidance and full system integration and communication to the full patient care team. Regression / Performance Performance Testing validates the ability of the application to function under maximum volumes and peak transaction loads.

48 Also serves to validate the technical environment supporting the application under normal and stressed conditions. Stress Testing attempts to find system defects exposed by overloading its resources in a short span of time. An example of this method of testing is for multiple users to open a flow sheet at the exact same time. Volume Testing determines the system s general ability to handle heavy volumes of data. This is exemplified when many users are using a variety of applications simultaneously. Focus is on response time and system performance. Integration Testing Integration Testing validates the ability of the application of the MRR system, to communicate and exchange data between BOTH EMR s in the normal or proposed course of a clinical encounter. It also verifies that processes between all ancillary systems to behave as expected, whether a new anticipated process change or continuance of an existing one. Additionally, integration testing will assess the systems ability to successfully operate thru use cases, similar to one illustrated as part of this project proposal. 6.12. Training Plan Training Plan - A detailed evaluation for training will be incorporated into the projects implementation plan. The training strategy will have two core focuses: Curriculum Development Education

49 The curriculum development aspect will begin by assessing the content that will be delivered,, all resources for content. The key exercise in curriculum development will be the stakeholder analysis as the project will look to identify what individuals will be impacted most by the projects solution, the level of impact. Additionally, an assessment into their existing experience in both EMR s as well as any prerequisite knowledge needed and preferred method of training. Content will ultimately be driven by both the workflow and application requirements designed by the subject matter experts from the departments and the clinical analysts designing the system. The education aspect will focus on the execution of training, the coordination, logistics and methods for delivering the content. Recommended options for training are as follows: Classroom Online Self Study Job Aids Blended solution of classroom and online 6.13. Deployment Capstone consulting recommends a big bang approach of implementing ALL functionality at once, commonly known as a big bang approach. The deployment will have one centralized command center that will be staffed by the project team and any additional resources. The

50 deployment coverage will focus on at the elbow support for the end-users as well as a team responsible for triage of service requests, troubleshooting, testing and education needed. 6.14. Schedule Pre-Planning Major Milestones Target Completion Date Project Approval 12/1/2013 Planning Project kick-off meeting 1/6/2014 Initial Work Breakdown Structure (WBS) approval 1/13/2014 Technical Environment Planning 1/20/2014 Project Charter Sign-off 1/27/2014 Project Plan Sign-off 1/27/2014 MRR QA Checkpoint #1 - Planning 1/31/2014 Design Design workshops complete 4/25/2014 Initial design review complete 5/2/2014 MRR QA Checkpoint #2 Design 5/9/2014 Build Test cases identified/scripts written 7/25/2014 Build Complete 8/1/2014 MRR QA Checkpoint #3 Build 8/8/2014 Testing First round of integrated testing complete 8/29/2014 Second round of integrated testing complete 9/26/2014 MRR QA Checkpoint #4 Testing 10/3/2014

51 Production Readiness Hardware installed and printing configuration complete Curriculum development & training preparation complete 11/3/2014 10/3/2014 Training for first site complete 11//28/2014 Go-live prep activities for first facility complete 11//28/2014 Go No Go Decision for site #1 approved 10/3/2014 Go Live Site 1 Implementation 12/3/2014 Project Close Post Implementation Review 3/31/2015 Project Close-out Report complete 5/1/2015 Table 10: Schedule 7. Conclusion We have found that the current system has limitations, hindering the quality of care delivered and hurting the hospital financially. The project proposal is intended to bring new technology and processes that will reduce University Hospital s 30-day readmission rate, but also improve the bottom line. Upfront the cost may seem daunting, but the return on the investment is set to be at 10%. Going forward, the benefits come not only from meeting CMS measures, but also from the trust developed with the community. As hospital operations become more transparent, readmission data will be a large variable that the community uses to decide what

52 hospital to receive treatment. Having an improved system in place allows for better quality of care provided to patients allowing for closer ties between the community and hospital. Our proposal not only provides a plan to improve the current state of the hospitals readmissions, but also becomes a solid foundation for future improvements. As the healthcare system transitions to a more modernized and integrated one, University Hospital will be ready for the future of healthcare.

8. References Centers for Medicare & Medicaid Services. (2013). Quality Measures. Retrieved November 26, 2013 from: http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/ QualityMeasures/Downloads/Hospitals-and-CAH-2014-Proposed-EHR-Incentive-Program- CQM.pdf Cloonan, P., Wood, J., & Riley, J. B. (2013, July/August). Reducing 30-Day Readmissions [Journal]. The Journal of Nursing Administration, 43(7/8), 382-387. http://dx.doi.org/10.1097/ NNA.0b013e31829d6082. Retrieved on November 04, 2013 Department of Health and Human Services. (2009). Security 101 for Covered Entities. Retrieved December 4, 2013 from: http://www.hhs.gov/ocr/privacy/hipaa/administrative/ securityrule/security101.pdf Fleming, M., Haney, T. (2013). Improving patient outcomes with better care transitions: The role for home health. Cleveland Clinic Journal of Medicine, 80(e-Suppl 1), e-s2. Retrieved on October 9, 2013 from http://www.ccjm.org/content/80/e-suppl_1/e-s2.full Gerhardt, G., Yemane, A., Hickman, P., Oelschlaeger, A., Rollins, E., Brennan, N. (2013). Medicare Readmission Rates Showed Meaningful Decline in 2012. Medicare and Medicaid Research Review, 3(2), E1-E12. Good Shepard Medical Center. (2013). Quality: What are Core Measures? Retrieved December 7, 2013 from: http://www.gsmc.org/quality/. HIMMS (2012). Reducing Readmissions -Top Ways Information Technology Can Help Retrieved October 13, 2013 from: http://www.himss.org/files/himssorg/content/files/controlreadmissionstechnology.pdf Jack, B., Passche-Orlow, M., Mitchell, S., Forsythe, S., Martin, J. (2013). Re-Engineered Discharge (RED) Toolkit. Agency for Healthcare Research and Quality. Retrieved October 14, 2013 from: http://www.ahrq.gov/professionals/systems/hospital/toolkit/redtool1.html# Joynt, K., Jha, A. (2013). A Path Forward on Medicare Readmissions. New England Journal of Medicine, 368(13), 1175-1177. Retrieved on October 24, 2013 from: http://www.nejm.org/doi/ full/10.1056/nejmp1300122 Kansagara, D., Englander, H., Salanitro, A., Kagen, D., Theobald, C., Freeman, M. (2011). Risk Prediction Models for Hospital Readmission, A Systematic Review. Journal of the American Medical Association; 306(15): 1688-1698. 53

Krames Patient Education. (2013). Reducing Hospital Admissions With Enhanced Patient Education. Retrieved October 14, 2013 from: http://www.bu.edu/fammed/projectred/ publications/news/krames_dec_final.pdf Logue, M., Drago, J. (2013). Evaluation of a modified community based care transitions model to reduce costs and improve outcomes [Magazine]. BMC Geriatrics, 13(94), 1-11. http:// dx.doi.org/10.1186/1471-2318-13-94. Retrieved on October 24, 2013 Memorial Health. (2013). Quality Data. Patient Satisfaction. Retrieved November 26, 2013, from https://www.memorialhealth.com/quality-data.aspx The Society of Hospital Medicine (2013). Risk Assessment Tool: The 8 P s. Retrieved November 3, 2013 from: http://www.hospitalmedicine.org/resourceroomredesign/ RR_CareTransitions/html_CC/06Boost/03_Assessment.cfm Stewart,S., Marley, J., Horowitz, J. (1999). Effects of a Multidisciplinary, Home-based Intervention on Planned Readmissions and Survival Among Patients with Chronic Congestive Heart Failure: A Randomized Controlled Study. Lancet; 354(9184): 1077-1083. Stauffer, B., Fullerton, C., Fleming, N., Ogola, G., Herrin, J., Martin, S. (2011). Effectiveness and Cost of a Transitional Care Program for Heart Failure. Journal of the American Medical Association Internal Medicine; 171(14): 1238-1243. The HCAHPS Survery. (2013). The HCAHPS Survey: Frequently Asked Questions. Retrieved December 8, 2013 from: http://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/HospitalQualityInits/downloads/HospitalHCAHPSFactSheet201007.pdf 54

9. Appendices 9.1. Appendix A Project Structure 55