WHITE PAPER Cutting Avoidable Readmissions Starts in the Emergency Department SMARTER EMERGENCY CARE: EVERYWHERE, EVERY TIME. Our experience and innovative approach offers smarter solutions for emergency care.
Abstract On Oct. 1, 2012, the Centers for Medicare and Medicaid Services (CMS) began penalizing hospitals with excessive preventable readmissions for acute myocardial infection, heart failure and pneumonia. Beginning October 1, 2014 those penalties will include chronic obstructive pulmonary disease, coronary artery bypass graft, percutaneous transluminal coronary angioplasty and other vascular conditions. Under the Readmissions Reduction Program, two-thirds of U.S. hospitals stand to lose up to 1 percent of Medicare payments in 2013, with payment cuts growing to 3 percent for hospitals that fail to improve by 2015. 1 In 2012, it was estimated that approximately 55% of U.S. hospitals were affected by these penalties. To avoid crippling financial repercussions, hospitals must address the readmissions problem, starting with the most significant entry point to the hospital: the emergency department (ED). This white paper outlines eight actionable steps involving processes and technology that hospitals can take to improve patient care post-ed discharge and prevent avoidable readmissions. An Unavoidable Problem Approximately 2,200 hospitals will lose more than $300 million in Medicare payments in 2013 as a result of penalties from the Readmissions Reduction Program. 2 These looming financial losses threaten already tight hospital margins. Indeed, a 2012 survey of hospital CEOs cited financial challenges as the chief issue they face, and more than 72 percent of respondents specified Medicare reimbursement as the leading cause. 3 To understand where to begin addressing the avoidable readmissions problem, hospitals must first recognize where their patients are most frequently entering their facility the emergency department. Between 50 and 70 percent of admitted patients enter the hospital through the ED. 4 Patients often present to the ED because Between 50 and 70 they haven t received appropriate follow-up care in the community and/or they have no percent of admitted medical home or primary care provider to manage their outpatient care. patients enter the hospital through the According to a study appearing in the January 2013 issue of the Journal of the American ED...often because they Medical Association: An improved understanding of how the ED setting is best used in haven t received the management of acute care needs particularly for patients recently discharged from appropriate follow-up the hospital is an important component of the effort to improve care transitions Just as care in the community the Patient Protection and Affordable Care Act requires the development of programs to or have no medical home reduce readmissions, further initiatives are necessary to understand the drivers of or primary care provider post-discharge ED use and the clinical and financial efficiency associated with providing for outpatient care. such acute care in the ED. 5 In short, examining what happens to patients post-ed discharge can lead to solutions that prevent repeat visits to the ED and, ultimately, admissions to the hospital. Hospital leaders should consider the following steps when designing a plan to prevent avoidable readmissions.
1. Start with Goals Understanding the true scope of the readmissions issue is necessary to determine the appropriate allocation of resources required to solve it. Hospital leaders can begin to frame the problem by reviewing patient data from the previous three to six months. Identify patterns in readmission that could have been prevented through better care coordination. Look for common threads, such as chronic disease states (congestive heart failure, coronary artery disease, COPD, etc.) or patients who don t have a primary care provider. Calculate how frequently these patient groups are seen in the ED, and use these measures as a benchmark for setting goals. While the overall goal of a hospital s readmissions reduction initiative might be, To reduce unnecessary readmissions by 20 percent, the goal can and should be broken into smaller, more targeted objectives. These objectives will vary by hospital, and examples include: Care Transitions Intervention Reduce Readmissions 6 25% 20% ED who have no primary care physician. a primary care physician to an affiliated practice or clinic. Readmission Rate 15% 10% 30 days will be evaluated by case management upon arrival in the ED. 5% patients are seen in the ED. 0% No Follow-up Care CTI Group heart failure will be enrolled in the disease management program. Smart objectives must be measurable as they are used to evaluate the initiative s success. Be aware at the outset of where the hospital stands in relation to its objectives. If the objective is to match 90 percent of ED patients without a primary care provider to an affiliated practice or clinic, what is the hospital s current rate? In other words, what level of improvement is required? If the hospital is starting from 0 percent or an unknown percent, consider the steps it will take to implement (and measure) a new process. To maintain focus, it can be helpful to begin a readmissions reduction initiative by selecting only one or two of the most potentially impactful objectives.
2. Form a Dedicated Project Team Create a multi-disciplinary team that will develop and roll out a plan based on the program s chosen objectives. It is important to include members from a variety of stakeholder groups to ensure cross-departmental and community buy-in. Team members might include representation from the ED, case management, discharge planning, social work, patient financial services and an affiliated community healthcare provider. With a team in place, select the team leader and an executive-level sponsor who can support the leader and hold him/her accountable for the program s progress. Cox Medical Center Branson, a 165-bed hospital in southwestern Missouri, experienced remarkable success with this strategy. It formed a 14-member team to work more closely with primary care physicians to manage patients chronic conditions, setting out to reduce all cause readmissions by 20 percent. The hospital began 2012 with a readmissions rate close to the state s average of 11.5 percent. By December 2012, the hospital readmissions rate was below eight percent. Preventing readmissions requires concerted efforts across the hospital and the community, said Lori Brown, RN, HCM, executive director of accountable care at Cox Medical Center Branson. Putting the right team together to achieve our readmissions goal was the first and most critical step toward our success. 3. Choose Technology to Support the Goals Create a multi-disciplinary team that will develop and roll out a plan based on the program s chosen objectives. It is important to include members from a variety of stakeholder groups to ensure cross-departmental and community buy-in. Team members might include representation from the ED, case management, discharge planning, social work, patient financial services and an affiliated community healthcare provider. With a team in place, select the team leader and an executive-level sponsor who can support the leader and hold him/her accountable for the program s progress. When evaluating a system to support your team s goal, evaluate if the system will: Automate alerts (e.g., to text or e-mail primary care providers when their patients are seen in the ED) (e.g., Set appointment with patient to see endocrinologist by end of week. ) (e.g., percent of discharged ED patients who have a follow-up appointment scheduled with a community physician this week ) The system chosen should be easy for all team members to: Access (remote users, even if all not on the same EHR) tasks to be done (care/plan/track patients, visibility into patient status, referral acceptance) target patient populations (clinical high risk, multiple ED visits) Deliver the medical record of the ED visit to the next care setting (secure, on-line access, ED record available at the time follow up care is delivered) One of the key features of the system we selected is that it matches patients without a medical home to a provider based on location, insurance coverage and other criteria, said Brown. The system then sends an accept/decline referral to the provider. This process is repeated until a provider accepts the patient.
4. Develop a Plan After forming the team and selecting the required technology tools, define the scope of the plan and keep it manageable. Meaningful results can be achieved from small but targeted efforts. Consider a phased approach that can be expanded later. Design a process that addresses the changes to be made. Map each step of the new workflow process, and define the who, what, how, when and why for each step. For example, using the goal, All patients admitted in the last 30 days will be evaluated by case management upon arrival in the ED to identify ongoing care needs, determine: 5. Take Action When the readmissions reduction team is ready to take action, begin by tackling just one of the set objectives with a small target population. Doing too many tasks or changing too many processes at once can be overwhelming, and it can also make it difficult to identify which specific action(s) achieved the most significant results. Continuously monitor the workflow of the new process, and make sure that all involved groups are abiding by it. Don t underestimate how challenging change can be; you are redesigning a process that has likely been in place for a long time. However, don t get discouraged. Stick to the plan for at least 30 days. The team will have many opinions and new ideas, and it can be tempting to modify the program too soon. It takes time for people to adjust to a new process and work out the kinks, said Brown. We avoided making changes to the process early on because we wanted to give it a real shot at success before going back to the drawing board. 6. Review Results At the end of the first 30 days, measure the hospital s progress. Compare current metrics against the ones collected prior to the start of the program. Keep in mind that readmission rates typically don t drop rapidly, but you should see some improvement with regard to your objective.
Use the reports from the technology tools you have selected to reduce manual data collection needs. Many systems allow users to set up custom, automatic reports. Quantify the results with a visual chart and a quick summary, and communicate the findings to other stakeholder groups. The 30-day mark also presents a good opportunity to gather the project team to discuss lessons learned and suggestions for improvement. 7. Revise Plan as Needed Taking into consideration the results, objectives, suggestions and team discussion, make revisions to the plan where it makes sense. Consider how any changes might impact the objectives, employees involved or even the ED patients. It s crucial to obtain input from the entire project team and other stakeholders prior to making changes. Once it is determined what changes (if any) need to be made, document and communicate the new process, then make the changes. Continuously monitor and track the progress toward your objective. The display of trending charts where staff can see progress that has been made can be a helpful motivator. 8. Expand the Program Once the hospital has experienced success with one objective, it becomes easier to expand the program and target the next objective. Identify the next patient group to manage, and work through the aforementioned steps again to plan, implement, review and revise. At this stage, it can be helpful to invite some new team members who will offer a fresh perspective. However, it s suggested that some of the program s previous team members remain to serve as the project leaders. Once the new program is implemented, ensure that progress is continuously monitored and that the team is communicating regularly to evaluate the program s success. The Time to Change is Now The financial ramifications of avoidable readmissions are undeniably expensive for hospitals, and they will only get more costly in the years ahead. But the disservice to patients experiencing readmission is equally significant. Targeting patients starting at the hospital s front door the ED allows the hospital to prevent these unnecessary repeat visits wherever possible. As outlined above, a multi-pronged strategy that blends technology and processes is required to solve such a complex problem. See how T-System can help: T-System Care Continuity An automated, web-based ED patient management tool that: o Actively manages workflow with separate work queues for care team members who are key to effective patient transition, including medical home, case manager, discharge planning and specialists.
o Automatically identifies patients at high risk for readmission using customizable filters that allow identification for repeat visits, specific conditions and PCP status. o Instantly notifies the care team of high-risk patients via text and/or e-mail. o Connects the hospital care team to providers, incorporates existing patient/provider relationships, includes patient referral functionality and provides customizable provider alerts for changes in patient status. o Includes closed-loop care coordination with communication log and management functionality, care team notes and secure messaging. o Provides measurement and goal-tracking with pre-built reports and advanced analytics for usage, patient status, managed/target populations, key providers and business development opportunities. ED Performance Consulting Focus on patients while T-System focuses on your ED. With decades of experience, T-System professionals support more than 1,900 hospitals nationwide hospitals ranging in age, size, location, staffing and resources. T-System offers a range of services to address your facility s needs, including: workflow optimization, clinical quality optimization, risk analysis, continuing education and more. 1 http://www.amednews.com/article/20120827/government/308279952/6/ 2 http://www.amednews.com/article/20120827/government/308279952/6/ 3 http://www.ache.org/pubs/research/ceoissues.cfm 4 http://www.hcmarketplace.com/prod-8560-ehlm/the-hospital-executives-guide-to-emergency-department-management.html 5 http://media.jamanetwork.com/news-item/emergency-department-use-within-30-days-of-hospital-discharge-common/ 6 Archives of Internal Medicine, The Care Transitions Intervention: translating from efficacy to effectiveness, Voss et al, July 27, 2011.
About T-System T-System, Inc. advances the practice of emergency medicine with solutions proven to solve clinical, financial, operational and regulatory challenges for hospitals and urgent care clinics. Approximately 40 percent of the nation s emergency departments leverage T-System solutions to provide an unmatched patient experience. Through gold-standard documentation, revenue cycle management, and performance-enhancing solutions, T-System optimizes care delivery from the front door through discharge and beyond. Today, more than 1,900 facilities rely on T-System solutions. For more information, visit www.tsystem.com. Follow @TSystem on Twitter, or become a T-System fan on Facebook. SMARTER EMERGENCY CARE: EVERYWHERE, EVERY TIME. 4020 McEwen Drive :: Dallas, Texas 75244 :: 800.667.2482 :: www.tsystem.com