Embed Size (px)
Citation preview
MSG would like to thank Critical Signal Technologies for their generous support
of this webinar!
Nancy D. Vecchioni, RN, MSN, CPHQVice President Medicare Operations, MPRO
Co-Lead MI STA*ARIHI Improvement Advisor
Reducing Re-Hospitalizations: BackgroundRe-hospitalizations are:
• Frequent o 18% of all Medicare hospitalizations are 30 day re-hospitalizationso Average >20% for certain patient populations
• Costly o 30-day re-hospitalizations account for $15B in Medicare annual spendingo In total, hospitalizations account for one-third >$2T US healthcare spending
• Potentially avoidable o 76% of Medicare re-hospitalizations were “potentially preventable” based on 3M
definitiono 14-46% in general hospital populations in retrospective clinician reviews
• Actionable for improvemento Individual delivery systems and health services researchers have demonstrated
dramatic (30-90%) reduction of 30-day readmission rates for certain patient populations ( such as patients with HF)
40% of Medicare beneficiaries are discharged from an acute care hospital stay to a post-acute care setting; of those, roughly half enter a nursing home for skilled nursing care or rehabilitation services. HCUPnet. 2009 [cited 2009 July 21]; Available from: http://hcupnet.ahrq.gov.
Mor et al. (2010) report that on average 23.5% of SNF residents are rehospitalized within 30 days of an acute care hospital discharge amounting to a total annual cost of $4.35 billion for Medicare alone based on analysis of CMS data from 2000-2006; their study further noted a 29% increase in rehospitalizations during this time period.
Michigan has the sixth greatest SNF resident readmission rate (25.8%) in the US, At an estimated $175 million Medicare expenditure annually. Michigan also has the fifth greatest rate of prior nursing home use among rehospitalized residents.
Figure 1: Rehospitalization Rates in Total and by Prior Nursing Home Use among Medicare Beneficiaries, 2000-2006 (Mor, V., et al., The Revolving Door Of Rehospitalization From Skilled Nursing Facilities. Health Affairs, 2010. 29(1): p. 57-64)
If Re-hospitalizations are Prevalent, Costly, and Able to be Reduced, Why Haven’t They Been?
• Hospital-level barrierso Financial disincentives (volume-revenue), no financial incentives, not part of
P4P contracts, not high on priority list, limited disease-specific efforts
• Community-level barrierso Not common to engage organizations across continuum to collaborate on
improving care, frustration between inpatient and post-acute providers, unfamiliar with availability of community resources and community based organizations lack of IT connectivity, no reimbursement for coordination
• State-level barrierso Lack of population-based data, lack of understanding costs of poor quality on
systems, effect of fragmented payer market and lack of CMS participation
Patients Tell us How to Improve Care
• Inadequately prepared for the next setting• Conflicting advice for illness management• Inability to reach the right practitioner• Difficulty navigating the health care
system
Hospital Readmissions ReductionProgram (section 3025)
•Reduction in payments to hospitals with excessive readmissions
•Definition of “readmissions” includes the readmission to the same or another hospital
•Excessive readmissions will be defined by the HHS secretary
10
ReadmissionsHealthcare reform provisions
• Up to 3% cut to all DRGs for readmissions over expected• Up to 1% in FY 2013, 2% in FY 2014, not to exceed 3% in 2015 and
beyond • Initially AMI, CHF, PN
– Expands to COPD, CABG, PTCA, and other vascular in 2015• 10 year savings: $7.1 B
10
2010 2011 2012 2013 2014 2015 2016 2017
Hospital Readmissions
Penalties capped at 2%. (FY 2014)
Hospital Readmissions – HHSShares data with hospitals on 3Selected conditions: PenaltiesCapped at 1% (FY 2013)
Hospital ReadmissionsPenalties capped at 3%(FY 2015 and beyond)
Reporting Template:
11
30-Day All Cause Readmissions- Time Period: CY2008- PROVISIONAL DATA
Payers: HAP, Health Plus, Medicaid, Priority Health, Medicare, BCN, BCBSM
PRODUCT Line
See Data Definitions for Column Descriptions
a b c d e f g h I
AGE GROUP
Type of Index Admission
Discharges at Risk
RA to the Same Hospital RA to a Different Hospital RA to Any Hospital
N N % N % N %
Commercial
AdultM 81,735 8,659 10.6% 2,844 3.5% 11,505 14.1%S 84,878 4,480 5.3% 1,123 1.3% 5,603 6.6%O 41,667 997 2.4% 174 0.4% 1,171 2.8%
PediatricM 11,260 774 6.9% 194 1.7% 968 8.6%S 3,537 181 5.1% 32 0.9% 213 6.0%O 547 20 3.7% 6 1.1% 26 4.8%
Post-neonatal M 3,173 196 6.2% 58 1.8% 254 8.0%S 878 52 5.9% 24 2.7% 76 8.7%
Neonatal M 24,935 286 1.1% 149 0.6% 435 1.7%S 386 26 6.7% 10 2.6% 36 9.3%
Total 252,996 15,671 6.2% 4,614 1.8% 20,287 8.0%
Medicaid FFS (managed care data not shown for presentation
purposes)
AdultM 64,017 5,234 8.2% 2,134 3.3% 7,368 11.5%S 18,513 1,013 5.5% 317 1.7% 1,330 7.2%O 31,200 940 3.0% 203 0.7% 1,143 3.7%
PediatricM 7,039 1,406 20.0% 104 1.5% 1,510 21.5%S 1,296 131 10.1% 13 1.0% 144 11.1%O 1,151 35 3.0% 13 1.1% 48 4.2%
Post-neonatal M 2,472 233 9.4% 86 3.5% 319 12.9%S 355 51 14.4% 11 3.1% 62 17.5%
Neonatal M 31,498 347 1.1% 403 1.3% 750 2.4%S 73 5 6.9% 5 6.9% 10 13.7%
Total 157,614 9,395 6.0% 3,289 2.1% 12,684 8.1%
Medicare (FFS)Adult M 280,012 45,250 16.2% 11,657 4.2% 56,907 20.3%
S 117,311 9,797 8.4% 2,712 2.3% 12,509 10.7%Total 398,836 55,419 13.90% 14,573 3.7% 69,992 18.0%
Total by Age Group Adult 737,544 78,696 10.7% 21,884 3.0% 100,583 13.6%Pediatric 26,378 2,591 9.8% 369 1.4% 2,960 11.2%Post-neonatal 7,365 553 7.5% 183 2.5% 736 10.0%Neonatal 58,481 702 1.2% 581 1.0% 1,283 2.2%
Grand Total 829,768 82,542 9.9% 23,017 2.8% 105,562 12.7%
Adult Medical Discharges
Pediatric Medical Discharges
Overall Rate
Michigan Medicare Patient 30-Day All Cause Readmission Rates (%) by County, 2009
Statewide Medicare Patient Readmission Rate= 18.8%
Readmission Rates are Greatest in Southeast Michigan
Medicare FFS Inpatient Data, ISAT Database
Mi Medicare FFS
F
M
>74
65-74
<65
Other
Black
White
Sex
Age
Rac
e
0 5 10 15 20 25 30
30-Day All-Cause Readmission Rate
30-Day All Cause Readmission Rate by Age, Race & Sex, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010
Mi Medicare FFS
Other
Mental Health (Secondary Dx)
COPD
PNE
AMI
CHF
Dia
gnos
is (
Dx)
0 5 10 15 20 25 30
30 Day All Cause Readmission Rate (%)
30-Day All Cause Readmission Rate by Selected Diagnoses, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010
Mi Medicare FFS
Rural
Urban
Urb
anic
ity o
f H
ospi
tal
0 5 10 15 20 25
30 Day All Cause Readmission Rate (%)
Urban vs. Rural Hospital 30-Day All Cause Readmission Rate, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010
Mi Medicare FFS
No Yes0
5
10
15
20
25
30
Physician Follow-up
30 D
ay a
ll C
ause
Rea
dm
issi
on
R
ate
(%)
30-Day All Cause Readmission Rate by Physician Follow-up Prior to Readmission or 30 days, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010
Factors Contributing to Re-hospitalizations• Health Literacy• Lack of coordinated care
– From inpatient to outpatient settings (follow-up appointments, medication management, etc.)
– Amongst clinicians in outpatient settings (primary and specialty care, home care and primary care, etc.)
• Unreliable medication management• Natural history of disease• Patient/family caregivers’ lack of understanding of care needs• Barriers to access (including the uninsured, geographical distance,
difficulty arranging post-discharge follow-up appointments, etc.)• Missed opportunities with discharge planning• Unreliable identification of need for and referral to services
18
Health Literacy
Capacity to: • Obtain, process, understand basic health
information and services • Make appropriate healthcare decisions (act on
information) • Access/navigate healthcare system
Health Literacy
• 90 million adults have trouble understanding and acting on health information
• Population of US in 2009 = 307,065,550 • 29% of the United States Population • Approximately one in three people on this call
Red Flags for Health Literacy
• Frequently missed appointments • Incomplete registration forms • Non-compliance with medication • Unable to name medications, explain purpose or dosing• Identifies pills by looking at them, not reading label • Unable to give coherent, sequential history• Ask fewer questions • Lack of follow-through on tests or referrals
Patient Safety: Medication Errors
“How would you take this medicine?”395 primary care patients in 3 states
• 46% did not understand instructions ≥ one label • 38% with adequate literacy missed at least one label
Davis TC , et al. Annals Int Med 2006 105 Health Literacy
Universal Precautions Toolkit
Rates of Correct Understanding verses Demonstration“Take Two Tablets by Mouth Twice Daily”
Handing Off
and
Receiving the Baton
Deficits in Information Handover between Acute Care and Extended Care Facilities
• 22% of transfers had no formal summary of information; • Legible summaries were available only 56% of the time; • Secondary diagnoses were missing from 30% of transfers; • Only 51% had allergies documented; • Mental status was missing in 33% of cases; • Lab, chest x-ray, and EKG results were missing 31%, 67%, and 61% of the time,
respectively; • Do-not-resuscitate (DNR) orders and advanced directives were absent from 87% of
transfers; • Dietary information was missing 19% of the time; and • Clarification of information was difficult because identification of hospital physician
was only legible 41% of the time and phone numbers only 33% of the time.
•National Hospital Discharge Annual Survey 2001; Health US 2003. Available at: http://www.cdc.gov/nchs/about/major/hdasd/listpubs.htm.
Nearly Half of U.S. Adults Report Failures to Coordinate Care
Percent U.S. adults reported in past two years:
No one contacted you about test results, or you had to call
repeatedly to get results
Test results/medical records were not available at the time of appointment
Your primary care doctor did not receive a report back from a specialist
Any of the above
25
21
19
15
13
47
0 20 40 60
Doctors failed to provide important medical information to other doctors
or nurses you think should have it
Your specialist did not receive basic medical information from your
primary care doctor
Source: S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S. Health System Organization: A Call for New Directions (New York: The Commonwealth Fund, Aug. 2008).
Mr. Smith. It looks like you have severe congestive heart failure. Your cardiac enzymes
were negative, but your ejection fraction was only 30%. You’ll need to take
some diuretics, an ACE-I, a beta blocker, and aspirin.
hmmmm……. heart failure?... ……
(what?)…. 30%......aspirin….
Yes doctor.
Unreliable Medication Management
Medication Use in the Elderly• 20% community dwelling elderly (>65) take 10 or more medications• Adherence drops with increasing the number of doses per day
– Average adherence falling from 80% (once daily) to 50% (4 times a day)• Studies documented an average of 1 unnecessary drug per patient• Adverse events occur with number of medications
– 5 to 35% per year– Responsible for 10% of readmissions
• Communication gaps resulted in 37% of remediable adverse drug events
• Hospitalized elderly-44% were discharged with at least 1 unnecessary medication
Barriers to Medication Adherence and Targeted Solutions
• Forgetting to take• Patient believes drug is not needed, ineffective
or too many• Difficulty taking (opening bottles, swallowing)• Cost
• 81% of patients requiring assistance with basic functional needs failed to have a home-care referral
• 64% said no one at the hospital talked to them about managing their care at home
• Flawed Process– Discontinuity between inpatient and outpatient providers– Inadequate Communication– Lack of medication reconciliation– Inadequate patient education
Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based BestPractices. Marblehead, MA: HCPro, Inc.; 2006.
Current Discharge Process
Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital
MI STA*AR Overview• An Institute for Healthcare Improvement (IHI) initiative to
reduce avoidable 30-day rehospitalizations – Commonwealth Fund grant
• May 2009 – May 2013• MPRO and MHA co-leading statewide initiative
– Improvement Advisors to assist teams• Three states selected as partners in this initiative
(Massachusetts, Michigan, Washington)
Goals
• Increase patient and family satisfaction with transitions in care and with coordination of care
• Reduce each state’s all-cause 30-day rehospitalization rates by 30 percent
Steering Committee Members• Tina Abbate Marzolf CEO, Area Agency on Aging 1-B• Caroline Blaum, MD, MS Gerontologist, University of Michigan• Amy Boutwell, MD, MPP Institute for Healthcare Improvement• Peggy Brey Deputy Director, Office of Services for the Aging, MDCH• Laura Champagne Executive Director, Citizens for Better Care • Ed Gamache President, Michigan MICAH • David Herbel President & CEO, Aging Services of MI • Jeanette Klemczak, RN, MSN Chief Nurse Executive, MDCH • David LaLumia President & CEO, HCAM • Cecelia Montoye, RN, MSN, CPHQ Michigan Chapter , American College of Cardiology• Susan Moran Bureau Director, Medicaid Program Operations and QA • Richard Murdock Executive Director, MAHP • Julie Novak Executive Director, MSMS • Larry Abramson, DO Michigan Osteopathic Association• Appointment Pending Michigan Hospice & Palliative Care • Tom Simmer, MD Senior VP & CMO, BCBSM • Nancy Vecchioni, RN, MSN, CPHQ VP Medicare Operations, MPRO • Sam R. Watson, MSA, MT (ASCP) Senior VP Patient Safety and Quality, MHA• Appointment Pending Policy Advisor, Office of Governor• Robert Yellan, JD, MPH President and Chief Executive Officer, MPRO• Harvey Zuckerberg Executive Director, MHHA
Strategies to Reduce Rehospitalization AC LTAC EC HH PO
Perform an Enhanced Assessment of Post-transition Needs √ √ √ √ √
Provide Effective Teaching and Facilitate Learning √ √ √ √ √
Provide Real-time Patient Centered Handover Communications √ √ √ √ √
Ensure timely Post- Transition Care Follow-Up √ √ √ √ √
Ensure staff ready and capable to care for the patient √ √ √
Engage the patient and family members in a partnership to create an overall plan of care
√ √ √ √ √
Obtain a timely consultation when the patient’s condition changes √ √ √ √
Identify patients at high risk of rehospitalization and implement interventions to reduce risk
√ √ √ √ √
Coordinate care across acute care and outpatient providers and settings
√
InterventionsAcute Care• Providing from three to 30-day supply of medications at transition home• Health plans overriding their formulary • Switch from brand to generic medications e.g., 8 medications 40 dollars a month• Follow-up appointments made prior to the patient transition• Nurse calls patients 48 hours post transition• Home visits to patient within 1 to 2 days of transition• Extended care, home health and health plan case managers make visits to hospitalized
patients and discuss case with the hospital team• Patients/care givers assist in design of educational materials• Standardization of communication handover• Transitions to nursing homes between 11am and 2pm• Non nursing staff conducting Teach Back• Standardized transition form• Case managers in emergency department• Integration of interventions in EMR
InterventionsExtended Care/LTAC• Total implementation of INTERACT
– Standardized communication– Standardized process for determining
transfers to hospital– Care paths
• Consistent assignment/consolidated med pass
• Verbal communication prior to transition• Work with patient/care giver to make follow-
up appointment to PCP• Call patient 48-72 hours after transition home• Shift huddles to discuss high risk residents• Standardized transition form
Home Health Care• Front load visits• Sliding scale medications• SBAR communication• After hours care-24-7• Telehealth• EMR bracelet • Standing orders• Program redesign to incorporate
patient coaching model• Emergency department liaison• Standardize transition form
Teach Back • Explain needed information to the patient or family
caregiver
• Ask in a non-shaming way for the individual to explain in his or her own words what was understood
• If a gap in understanding is identified, offer additional teaching or explanation followed by a second request for Teach Back
Schillinger D et al. Closing the loop: physician communication... Arch Intern Med. 2003;163:83-90.
Teach Back: Measuring Patient Understanding
Teach Back questions for patients with HF:
1. What is the name of your “water pill”?
2. What weight gain should you report to your doctor?
3. What foods should you avoid?
4. Do you know what symptoms to report to your doctor?
• Goals• Increase the use of strategies and tools that may help reduce
ACT of nursing home residents by utilizing the INTERACT TOOL KIT, and
• Decrease the number of potentially avoidable ACT of nursing home residents that result in emergency room visits and/or hospitalizations.
http://www.qualitynet.org/dcs/ContentServer?c=MQTools&pagename=Medqic%2FMQTools%2FToolTemplate&cid=1211554364427
INTERventions to reduce Acute Care Transfers
INTERventions to reduce Acute Care Transfers
• Communication about residents with acute changes in condition among staff at the nursing home as well as between the nursing home and hospital;
• Care paths for common acute conditions in nursing home residents that guide treatment in the nursing home when feasible; and
• Advance care planning that will assist in reducing potentially avoidable acute care transfers of residents who are terminally ill and/or on a palliative care plan
To improve the quality of care people receive at the end of life through effective communication of patient wishes, documentation of medical orders and a promise by health care professionals to honor these wishes.
http://www.ohsu.edu/polst/
Standardization of communication and information between sending and receiving organizations– Acute and Post Acute Care providers
identified critical information– Implementing into EMRs and
electronic communication between providers
Does not replace verbal handover communication
Additional Community Initiatives
• FUSE• Patient coaching provided by area agencies on aging• Call to Care• Aligning processes with between healthcare and
community based organizations and resources• SOAR (Stepping Stones to Recovery)• Medication Reconciliation across the continuum of care• Many more
Mi Medicare FFS
30-Day All Cause Readmission Rate by Quarter among Medicare (FFS) Beneficiaries Discharged from a Michigan hospital between January 1, 2008 and June 30, 2010
Qtr. 1 2008
Qtr. 2 Qtr. 3 Qtr. 4 Qtr. 1 2009
Qtr. 2 Qtr. 3 Qtr. 4 Qtr. 1 2010
Qtr. 215
16
17
18
19
20
21
22
23
24
25
Rea
dm
issi
on
Rat
e (%
)
MI STA*AR
TEAM CO-OPERATIVE to prevent rehospitalization
HEALTH CARE/COMMUNITY
I continue to believe that if we keep doing the right thing , for the right reasons , with the right resources , at the right time .....we will achieve good outcomes
Deborah Hall Turner
