Improving Transitions from the Hospital to Community Settings IHI National Forum Learning Lab Sunday, December 9, 2012 Session L20 Presenter Disclosure Leora Horwitz, MD Assistant Professor of medicine at Yale Co chair of the Yale New Haven Hospital Readmission Reduction Committee No relationships to disclose 1
Take Home Messages At the end of this session, you will be able to: 1. Identify the core features of H2H 2. Identify good practices for reducing readmissions and improving transitions of care gathered from the H2H community 3. Identify common elements with similar improvement programs What is H2H? Hospital to Home initiative Launched 2009 National quality improvement campaign Catalyze action to improve the transition home Leverage national initiatives aimed at reducing readmissions Bring together knowledge and best practices Create a web based community 2
Leads and partners Led by American College of Cardiology and Institute for Healthcare Improvement 35 strategic partners Specialty societies Nursing organizations Hospital associations Integrated health systems Payers Patient groups Goal To reduce 30 day, all cause, risk standardized readmission rates for patients discharged with heart failure or acute myocardial infarction by 20% 3
The goal is to shift the curve 7 H2H from 2009 to 2012 Community Reach 1600+ Organizations 3000+ Participants 35 Partners 25 QIOs $70K grants in 2010 Still growing! Key Activities 30+ presentations 5+ listserv topics/month (200+ messages/quarter) 6 best practice webinars 500 people per webinar Best practices study with Yale and the Commonwealth Fund 4
H2H Registrants Follow up Core Concept Areas Patient has a follow up within a week of discharge Patient can get to appointment Post discharge medication management Patient is familiar and competent with medication Patient has access to medications Patient recognition of signs and symptoms Patient recognizes warning signs and knows who to call 5
Unique H2H Features Heart failure and AMI clinical focus Three focus areas for improvement: 1. Early follow up 2. Medication management 3. Patient recognition of signs and symptoms Community driven Nation wide Heart Failure Most Common Discharge Diagnosis Age >65 600 500 400 Males Females Discharges (Thousands) 300 200 100 0 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 Years American Heart Association. Heart Disease and Stroke Statistics 2005 Update. 6
Hospital Visits for Congestive Heart Failure Emergency Department Presentations Initial Episode 21% Repeat Visit 79% Approximately 80% of the ED visits for CHF result in hospitalizations Rates of Hospital Readmission 2% within 2 days 20% within 1 month 50% within 6 months Cardiology Roundtable 1998 Participating in the H2H Initiative Develop, Deploy and Evaluate Intervention Learn From and Share Best Practices Why participate? Patient Burden / Risk Societal Burden / Cost HealthPolicy / Incentives Form a Team Multidisciplinary Team The Goal 20% Reduction in Rehospitalization Select a Core Concept: Early Follow Up Post Discharge Medication Management Signs and Symptoms Use: Webinars Toolkits Self Assessments Participate in the Community 7
H2H s Core Parts Community Resources Challenge Projects Best Practices Study Website Listserv ACC Chapters Early Follow up Med Mgmt Patient Signs Yale study Survey data H2H s Core Parts Community Resources Challenge Projects Best Practices Study Website Listserv ACC Chapters Early Follow up Med Mgmt Patient Signs Yale study Survey data 8
Community Resources: H2H Website www.h2hquality.org Community Resources: Website Getting started Help identifying institutional readmission rates Readmission review tools Learning sessions Archived webinars, handouts Tools and strategies, organized by concept Links to other campaigns and resources 5,000+ visits/quarter 9
Community Resources: Listserv Active listserv 35 topic areas, 20 messages/week, 200+/quarter Increased volume over 2011 (150/quarter then) Web based discussion board Success stories Barriers to success Focused discussions re: core concepts Community Resources: H2H and ACC Chapters Build local H2H infrastructure to: Align state health leaders Make reducing readmissions a priority Focus on heart failure first Set local improvement goals Identify local leaders Encourage colleagues to participate 10
H2H s Core Parts Community Resources Challenge Projects Best Practices Study Website Listserv ACC Chapters Early Follow up Med Mgmt Patient Signs Yale study Survey data H2H Challenges: Core Concepts See You in 7 Challenge (5/11 9/11) Early follow up 8+ tools Mind Your Meds Challenge (10/11 4/12) Medication management 27+ tools Signs and Symptoms Challenge (5/12 12/12) Recognizing warning signs (30+ tools) 11
H2H Challenge Components H2H Challenges 6 month projects 1 topic focus Success metrics 1 tool kit 3 webinars Community call to action to help build tools and strategies Webinar #1 H2H Challenge Webinars introduce the evidence introduce the success metrics Webinar #2 strategies and solutions from the field ( tool kit ) Webinar #3 lessons learned community members present 12
H2H Challenge #1: Early Follow up After Discharge See You in 7 Goal All patients have a follow up appointment or cardiac rehab referral scheduled within seven days of discharge SY7 Success Measures The hospital discharge process is successful if: 1. HF and MI patients are identified prior to discharge and risk of readmission is determined. 2. Follow up visit or cardiac rehab referral within 7 days is scheduled and documented. 3. Patient is provided with documentation of the scheduled appointment (e.g., appointment card). 4. Possible barriers to keeping the appointment are identified, addressed, and documented. 13
SY7 Success Measures The follow up or cardiac rehab referral is successful if: 5.HF patient arrives at appointment or AMI patient is referred to cardiac rehab. 6.Discharge summary (including summary of hospitalization, updated medication list) is available to follow up clinician. 7.Patient brings his/her medications or a medication list to clinic visit. 8.Reason for referral available to cardiac rehab center SY7 Self-Assessment Scorecard 14
Success Measure H2H Challenge Toolkit 4. Possible barriers to keeping the appointment are identified in advance, addressed, and documented in the medical record. Tool 29 H2H Challenge #2: Post Discharge Medication Management Mind Your Meds Goal Clinicians and patients discharged with a diagnosis of HF/MI will work together to ensure optimal medication management. 15
Mind Your Meds Success The clinician is successful if: 1. HF and MI patients are prescribed appropriate medications, dose, type, and frequency. 2. Medication reconciliation is performed accurately AND is documented. 3. Possible external barriers to obtaining prescribed medications are identified in advance, addressed, and documented. 4. Possible barriers to patients remembering/ understanding medication regimen are identified, addressed, and documented. 31 Mind Your Meds Success The clinician is successful if (continued): 5. Patient/Caregiver is provided with documented clear instructions and prescriptions. 6. Patient/Caregiver can demonstrate they understand the importance of taking and adhering to their medications, especially medications that are discontinued or changed. 7. Patient/Caregiver can demonstrate they understand possible side effects and symptoms of medications, and know who to call. 32 16
Mind Your Meds Success The patient is successful if: 1. Patient/Caregiver remembers to take all medications as prescribed. 2. Patient/Caregiver demonstrates understanding of medication importance and side effects. 3. Patient/Caregiver brings his/her medications or a medication list to every clinic visit. 4. Patient/Caregiver can discuss any challenges, problems, issues, side effects, or questions about medications with clinician. 33 Tool Success Metric and Tool Success Metrics 3 & 4 Possible external barriers to obtaining prescribed medications and barriers to patients remembering/understanding the need to take medications are identified in advance, addressed, and documented in the medical record. 34 17
H2H Challenge #3: Signs and Symptoms Goal To ensure patients can recognize early warning signs of clinical deterioration and have a plan to address them H2H s Core Parts Community Resources Challenge Projects Best Practices Study Website Listserv ACC Chapters Early Follow up Med Mgmt Patient Signs Yale study Survey data 18
H2H Best Practices Study Funded by Commonwealth Fund Conducted by Yale researchers Survey 594 H2H participants Response rate 91% Descriptive summary of findings Performance against readmission data 1 year follow up evaluation Prevalence of 10 Key Practices *Of the 594 hospitals surveyed, 537 completed the survey. Less than 3% had all 10 practices in place On average, 4.8 practices in place Bradley, E.H. et al, J Am Coll Cardiol, 2012 19
H2H Initiative Alignment H2H aligns with other core interventions ACC/IHI H2H See You in 7: Early Follow-up within 7 days Mind Your Meds: Medication Management Patient Signs and Symptoms IHI STAAR Ensure timely posthospital care follow-up Assessment of post-hospital needs Effective teaching enhanced learning SHM BOOST TARGET Risk specific interventions Teach-Back training AHRQ RED Make appointment for follow-up Confirm medication plan with patient Review the steps if problems arise Take Home Messages 1. Start by identifying HF patients before discharge 2. Understand all of the touch points throughout the hospitalization 3. Build bridges with outpatient and community care settings 4. Try simple, focused solutions first 5. Share your experience with others 20
Thank You hospital2home@acc.org www.h2hquality.org 21