REDUCING READMISSIONS through TRANSITIONS IN CARE

REDUCING READMISSIONS through TRANSITIONS IN CARE Christina R. Whitehouse, PhD, CRNP, CDE Postdoctoral Research Fellow NewCourtland Center for Transitions and Health University of Pennsylvania School of Nursing Associate Fellow of the Leonard Davis Institute of Health Economics Pennsylvania Coalition of Nurse Practitioners November 4, 2017 15th Annual Conference Erie, PA Define and discuss the complexity of care transitions. OBJECTIVES Identify gaps in care and barriers to safe transitions in care. Discuss models of transition in care. Discuss transitional care management (TCM) codes and requirements for reimbursement. Case Study An 83-year-old male patient with multiple problems was admitted with CHF exacerbation. During his inpatient stay he received IV furosemide, and in five days, he appears euvolemic and ready for discharge. He receives his printed discharge and verbal instructions from the nurse along with written prescriptions. He has a routine exam scheduled with you in 2.5 weeks. Although his discharge instructions indicate to see a provider within a week he decides to wait since he already has a scheduled appointment. 1

Within eight days, his spouse contacts your office to notify you that the patient is readmitted to the hospital with another CHF exacerbation. She states both she and the patient were confused about his medications and the patient did not take his diuretic. TRANSITIONAL CARE is a What is Transitional Care? Range of time limited services and environments that are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple health care team members and across settings such as hospitals to homes. Adapted from, J Am Geriatr Soc, 2003, 51(4): 556-557. Why are we talking about this? 35 million hospital discharges annually in the United States In 2014, hospitals provided 9.5 million Medicare discharges Hospital admission can be the first of many care transitions for older patients ~46% of hospitalized pts >65yrs are discharged to home under self-care 20% are discharged to skilled nursing care Nearly 50% of those transferred from hospital to SNF/rehab have 4+ additional care transitions in the next 12 months Source: http://www.cdc.gov/nchs/fastats/hospital.htm; MedPAC: A data book: Healthcare Spending and the Medicare Program, June 2016. 2

Affordable Care Act (ACA) established in 2012. Hospital Readmission Reduction Program (HRRP) Under this program, hospitals are financially penalized if they have higher than expected risk-standardized 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia. Expanded in 2015 to include patients with acute exacerbation of chronic obstructive pulmonary disease and patients admitted for elective total hip arthroplasty and total knee arthroplasty. Medicare fee-for-service, all-cause, 30-day readmission rates Source: Office of Information Products and Data Analytics, CMS 3

Potential Problems during Transitions High rates of patient/safety medical errors Serious unmet patient/family needs Poor patient care experiences Tremendous cost and human burden Potential Problems during Transitions Co-morbidity associated with many adverse effects Poor QOL Polypharmacy Increased ADRs Use increased resources Increased mortality Caregiver burden Multiple conditions/therapies Functional deficits Poor Outcomes: Patient Factors Emotional problems Poor general health behaviors Poor subjective health rating Lack of support Cognitive impairment Language, literacy and culture 4

Multiple providers Inconsistent medical management Poor Outcomes: System Factors Poor/incomplete communication between providers and across settings Limited access to services (reimbursement) Narrow perceived accountability Inadequate patient and caregiver education Lack of systems to bridge transitions Keys to successful Transitions Coordination and Communication Evidence based practices to facilitate safe transitions of care Comprehensive, multidisciplinary, discharge planning Ideally starting from day #1 of admission; appropriate referral to PAC Timely and complete handoffs to outpatient providers Ensuring that discharge summaries are complete and accurate Communication of diagnostic procedure/test results Notification of medication changes Communication regarding pending tests/procedures after discharge Accurate and complete medication reconciliation Patient and caregiver education prior to discharge Discharge instructions must be easy to read and understand Techniques like the Teach Back method can be helpful Close follow up appointments with outpatient providers Ideally coordinated prior to hospital discharge SOURCE: Care Transitions: Best Practices and Evidence-based Programs. Center for Healthcare Research and Transformation (2014) 5

Evidence Based Models for Transitions in Care Care Transitions Intervention (CTI) Transitions Care Model (TCM) Project BOOST (Better Outcomes for Older Adults through Safe Transitions) Project RED (Re-Engineered Discharge) Uses nurse, social worker or community worker as a transitions coach The Care Transitions Intervention (CTI) Four elements of CTI: Medication self-management Patient-centered health record Primary Care Provider/ Specialist Follow-up Knowledge of Red flags Intervention patients had: Lower re-hospitalization at 30 and 90 days Lower costs at 180 days Coleman et al Arch Intern Med. 2006 Sep 25;166(17):1822-8. Developed in 1981 as a response to shortened hospital lengths of stay Transitional Care Model Pressure to provide effective health care services at lowest cost Initially tested with early discharge of low birth weight infants Recently the model has been applied to improve outcomes and reduce cost of care for hospitalized elders SOURCE: http://www.nursing.upenn.edu/ncth/transitional care model/ 6

Case Study 72y.o. African American female Weight :104.3 kg ( 229.46lbs)/ BMI: 40.75 PMH: T2DM Hyperlipidemia HTN Hypothyroidism Medications: Amlodipine 5mg PO daily Crestor 10mg PO daily Levemir 40 units SQ 2xdaily Metformin 1000mg PO 2x daily Novolog Flexpen 30units 3xdaily Ramipril 10mg PO 2x daily Synthroid 0.125mg PO daily Xalatan 0.005% 1 gtt each eye daily Transitional Care Model Naylor et al (1999), JAMA, 281(7), 613-620; Naylor et al (2004), JAGS, 52(5), 675-684; Naylor et al (1994), Ann Intern Med, 120, 999-1006. Naylor et al (2014).J Comp Eff Res,3(3), 245-247. Hospital to Home Findings* BETTER CARE Enhanced access, Reduced errors, Enhanced care experience Decreased symptoms, Improved function, Enhanced quality of life BETTER HEALTH * Based on 3 NIH funded RCTs: Ann Intern Med, 1994,120:999-1006; JAMA, 1999, 281:613-620; J Am Geriatr Soc, 2004, 52:675-684 7

TCM s Impact on All Cause Rehospitalization Rates 70% 60% 50% 40% TCM Group Control Group Hospital Nurse Intervention 56% 48% 61% 45% 48% 38% 30% 20% 10% 10% 23% 28% 0% at 6 weeks* 1994 at 26 weeks** 1999 at 52 weeks*** 2004 at 26 weeks 2014 High-Risk Multiple High-Risk Multiple High-Risk Heart Failure High-Risk Patients with Chronic Conditions Chronic Conditions Cognitive Impairment 3 NIH funded RCTs: *Ann Intern Med, 1994,120:999-1006; ** JAMA, 1999, 281:613-620; *** J Am Geriatr Soc, 2004, 52:675-684; One comparative effectiveness study: Naylor et al. JCER 2014 Why is seeing a provider SO important during care transitions? Only 44% of patients are seen by any physician 14 days after discharge 49% saw PCP within 30 days of discharge Discharge summaries available at 1 st follow-up visit: 12-34% Patients who saw PCP had a 3% readmission rate, those that didn t had a 21% readmission rate SOURCE: Fam Pract Manag 2013; 20(3): 6; JAMA 2007; 297: 831 41. Billing for Transitional Care Management CPT Code 99495 Covers communication with pt or caregiver within 2 business days of hospital discharge Moderate complexity F2F visit within 14 days of discharge CPT Code 99496 Covers communication with pt or caregiver within 2 business days of hospital discharge High complexity F2F visit within 7 days of discharge Source: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/transitional-care- Management-Services-Fact-Sheet-ICN908628.pdf 8

Who Qualifies? Service Settings Requirements Patients Discharged From: Hospital Stay Inpatient acute care or psychiatric hospital Outpatient observation service Outpatient partial hospitalization Skilled Nursing Facility Skilled nursing facility Rehabilitation hospital Long-term acute care hospital Community Partial Hospitalization Mental health Substance abuse During the 30 days beginning on the date of discharge, you must furnish these 3 components: TCM Components 1. An interactive contact 2. Certain non-face-to-face services 3. A face-to-face visit An Interactive Contact Methods Communication with patient and/or caregiver Within 2 business days of discharge Forms of communication Direct contact Telephone call Electronic communication OR documentation of 2 unsuccessful attempts Content Assess medication regimen understanding Initiate medication reconciliation Educate on care plan and potential complications Assess need for home and community-based resources Coordinate follow-up visits 9

Certain Non-Faceto-Face Services Services Furnished by Providers: Obtain or review any discharge information Review need for follow-up on pending tests/treatments Provide education to patient, family and/or caregiver Establish or re-establish referrals and arrange for community resources & assist with scheduling Services Furnished by Clinical Staff under Direction of Providers: Identify & communicate with agencies & community health services Provide education to patient, family and/or caregiver Assess and support treatment regimen adherence and medication management Assist the beneficiary and/or family in accessing needed care and services Face-to-Face Visit Within 7 days for 99496 (high complexity) 14 days for 99495 (moderate complexity) Calendar days (not business days) Elements for Each Level of Medical Decision Making Type of Decision Making Number of Possible Diagnoses and/or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Significant Complications, Morbidity, and/or Mortality Straightforward Minimal Minimal or None Minimal Low Complexity Limited Limited Low Moderate Complexity Multiple Moderate Moderate High Complexity Extensive Extensive High 10

Which of these patients are eligible for (billable) TCM services? A. A 60 yo patient discharged from a substance abuse partial hospitalization B. A 65 yo patient discharged from an inpatient rehabilitation hospital after a hip replacement surgery C. A 72 yo patient seen in the emergency department for hypoglycemia discharged to home with self-care D. A 88 yo patient discharged to home from a skilled nursing facility after a 20 day hospital stay following cardiac surgery More about TCM billing Not limited to primary care providers Telephone call / F-2-F: MD, DO, NP, PA, CNS or CNM Practicing within the scope of their authority according to laws in their state and the Medicare statutory benefit Payable only once in the 30 days following a discharge By a single provider who assumes responsibility for patient post discharge TCM service Bill using the date of the face-to-face visit Documentation Required for TCM Billing Date the patient was discharged Date of the interactive contact Date of the face-to-face visit Complexity of medical decision making Moderate? High? Place of service (where was face-to-face?) Resource: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/downloads/faq-tcms.pdf 11

Additional Resources CTI: https://caretransitions.org/ Transitional Care Model: https://www.nursing.upenn.edu/ncth/transitionalcare-model/ Project Boost: http://www.hospitalmedicine.org/web/quality Innovation/Mentored_Imple mentation/project_boost/project_boost.aspx Project RED: https://www.bu.edu/fammed/projectred/ Transitional Care Management: https://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNProducts/downloads/Transitional-Care- Management-Services-Fact-Sheet-ICN908628.pdf https://www.cms.gov/medicare/medicare-fee-for-service- Payment/PhysicianFeeSched/Downloads/FAQ-TCMS.pdf Thank you! christina.whitehouse@uphs.upenn.edu @CRWhitehouseNP 12