PUTTING THE PIECES TOGETHER:REDUCING AVOIDABLE READMISSIONS

More Findings from Miami

Project Background

“Making the health care delivery system work reliably for very sick Medicare beneficiaries requires linking all clinical care providers and ensuring that transitions are thoroughly reliable. This work can only succeed when all of the community is engaged and working together, so the QIOs will serve to catalyze and coordinate the work across all care settings in the community.”

Barry M. Straube, M.D. Director & Chief Clinical Officer

Office of Clinical Standards & Quality for CMS

Care Transitions GoalsImprove 30-day rehospitalization rates

• Improve AMI, PNE, and HF readmission rates

• Improve the number of physician follow-up visits among the patients who have been discharged from the hospital

• Improve hospital performance of patient satisfaction (HCAHPS) for patients receiving information about discharge and medications

Plan

Providers

Beneficiaries

Physicians

Stakeholders

Provider-Associated Readmissions (last claim)*

Provider Community

None 30.3% ↑

Home (including ALF) * 23.6% ↑

SNF 13.4% ↓

Outpatient 12.0% ↑

HHA 11.4% ↓

Other 9.3% ↓

Totals 100.0%

*Physician claims assigned to associated category/provider

Provider-Associated Readmissions

Readmission Risk Modeling• Based on beneficiaries' claims 2007-2008

• Tests patient characteristics to determine non-diseased based disparities

• Tests the impact of:– Primary discharge diagnosis– Services utilized during hospital stay– Co-existing conditions defined during index hospitalization

NOTE: All diagnoses fields were classified using the CMS-HCC risk-adjustment model. Revenue & procedure codes were classified using utilization flags developed for the Healthcare Cost & Utilization Project (H-CUP), sponsored by the Agency for Healthcare Research & Quality (AHRQ).

–Age –Dual eligibility–Gender –ESRD–Race/ethnicity –Length of stay

Results: Patient Characteristics• Dual eligible• ESRD• Longer length of stays (>5.65)• Prior readmission(s) in last 6 months• Males (slight)• African American (slight)

Results: Primary Discharge Diagnosis• Congestive heart failure*• Major psych disorders*• Cardio-respiratory failure/shock*• Metastatic cancer/acute leukemia#

• Chemotherapy/neoplasms#

• Artificial openings for feeding/elimination* Impacts greatest number of patients# Greatest risk for readmission

Results: Service Utilization• Emergency department*• EKG*• Coronary care*• Respiratory therapy*• Ultrasound• Renal dialysis#

• Mental health & substance abuse#

* Impacts greatest number of patients# Greatest risk for readmission

Results: Co-existing Conditions• Cardiac / Respiratory / Vascular*• GI / GU• Mental Health #

• Nutrition / Skin / Blood Disorders• Cancer#

* Impacts greatest number of patients# Greatest risk for readmission

The Care Transition SolutionDefining the

Problem

Discharge Process Mapping

Cause & Effect Diagram

(Fishbone):Prioritizing the

Problems

Root-Cause Investigation -

Verifying with Data

Recommended Solutions

Cost-Benefit Analysis

Action Plan for Improvement

Lessons Learned: Modifications to the Action Plan

Root-Cause Resolution: Control

Plan

SNFs HHAs / ALFs

Hospitals Out-Patient Facilities

Community

Patient empowerment

Physicians

Framework• Adapted Eric Coleman’s*

Care Transitions InterventionSM (CTI)• CTI addresses patient empowerment through

the intervention’s four pillars:– medication reconciliation, – physician follow-up, – disease management, – maintaining personal health record.

* www.caretransitions.org

Interventions• Provider-specific (based on findings)• Collaboratives• Care Transitions InterventionSM

– Coaching – 5th & 6th Pillars

• Educational Updates – Providers & Beneficiaries

Findings/Results

NOTE: All data represents 6-month periods through designated month unless otherwise stated.

Community 30-Day Readmission Rate

18%

19%

20%

21%

22%

23%

24%

Community 6-Month Period Ending Goal

21.84%

FL 18.99% (1/10)

74.93% 75.66%

74.14% 73.83%

70.0%71.0%72.0%73.0%74.0%75.0%76.0%77.0%78.0%79.0%80.0%

D/C Information Med Management

Beneficiary Satisfaction (HCAHPS)

Diagnosis-Specific 30-Day Readmission Rates

22.8%

29.3%

17.6%

10.0

15.0

20.0

25.0

30.0

35.0

Perc

enta

ge

AMI HF PNEFL (1/10): AMI 20.4% HF 24.9% PNE 18.5%

% Physician Follow-Up Visits

Mar-08

Apr-08

May-08

Jun-08

Jul-0

8

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-0

9

Aug-09

Sep-0960%

65%

70%

75%

80%

71.43%

MD Follow-Up and Not Readmitted (Discharged to home after index)

Best Practices

Physician Status: Impact on Readmissions

Mar-08

Apr-08

May-08

Jun-08

Jul-0

8

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-0

9

Aug-09

Sep-09

Oct-09

Nov-09

0%

5%

10%

15%

20%

25%

30%

35%

40%

40%

45%

50%

55%

60%

65%

70%

75%

80%35.01%

15.08%

21.46%

61.98%

65.67%

30-Day Readmission Rate by Physician Follow-UpNo MD Follow up 30-day Readmission RateHas MD Follow up 30-day Readmission RateCommunity 30-Day Reamission Rate% Physician Follow-Up (patients d/c home)

6 Months Ending

30 D

ay R

eadm

issi

on R

ate

Mar-08

Apr-08

May-08

Jun-08

Jul-0

8

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-0

9

Aug-09

Sep-09

Oct-09

0%

10%

20%

30%

40%

50%

50%

60%

70%

80%

90%

32.61%

13.82%

16.85%

71.30%

76.77%

PNE 30-Day Readmission Rate by Physician Follow-Up

No MD Follow up30-day Readmission Rate Has MD Follow up 30-day Readmission Rate

PNE 30-Day Readmission Rate % Physician Follow-Up (patients d/c home)

6 months ending

Rat

e

Mar-08

Apr-08

May-08

Jun-0

8Ju

l-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-0

9

Feb-09

Mar-09

Apr-09

May-09

Jun-0

9Ju

l-09

Aug-09

Sep-09

Oct-09

0%

10%

20%

30%

40%

50%

60%

70%

40%

50%

60%

70%

80%

90%

100%60.61%

15.22%

25.22%

56.80%

73.60%

AMI 30-Day Readmission Rate by Physician Follow-UpNo MD Follow up30-day Readmission Rate Has MD Follow up 30-day Readmission RateAMI 30-Day Readmission Rate % Physician Follow-Up (patients d/c home)

6 Months Ending

Rat

e

Mar-08

Apr-08

May-08

Jun-08

Jul-0

8

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-0

9

Aug-09

Sep-09

Oct-09

10%

20%

30%

40%

50%

60%

70%

30%

40%

50%

60%

70%

80%

90%

100%

56.70%

21.49%

30.31%

66.98%

71.39%

HF 30-Day Readmission Rate by Physician Follow-UpNo MD Follow up 30-day Readmission Rate Has MD Follow up 30-day Readmission Rate

HF 30-Day Readmission Rate % Physician Follow-Up (patients d/c home)

6 Months Ending

Rat

e

Condition Categories:30-Day Readmission Rate by

Physician Follow-Up

Impact of Physician Follow-Up on 30-Day Readmission Rates

Data period: October 2008 – September 2009

0%

10%

20%

30%

40%

50%

60%50.86%

18.01%

Community: Congestive Heart Failure(6.49% of all discharges)

Community: No Physician Follow UpCommunity: Physician Follow Up

0%

10%

20%

30%

40%

50%

60%

29.66%

10.79%

Community: Vascular /Circulatory

Disease(3.81% of all discharges)

Community: No Physician Follow-UpCommunity: Physician Follow-Up

(statistically significant differences at p ≤ 0.05)

0%

10%

20%

30%

40%

50%

60%

39.32%

13.40%

Community: Arrhythmias

(3.79% of all discharges)

Community: No Physician Follow-UpCommunity: Physician Follow-Up

Impact of Physician Follow-Up on 30-Day Readmission Rates

Data period: October 2008 – September 2009

0%

10%

20%

30%

40%

50%

60%51.25%

13.76%

Community: Acute Coronary Syndrome

(2.36% of all discharges)

Community: No Physician Follow-UpCommunity: Physician Follow-Up

0%

10%

20%

30%

40%

50%

60%

29.33%

9.28%

Community: Chronic Atherosclerosis(2.03% of all discharges)

Community: No Physician Follow-UpCommunity: Physician Follow-Up

0%

10%

20%

30%

40%

50%

60%

34.78%

9.38%

Community: Stroke

(2.13% of all discharges)

Community: No Physician Follow-UpCommunity: Physician Follow-Up

(statistically significant differences at p ≤ 0.05)

Impact of Physician Follow-Up on 30-Day Readmission Rates

Data period: October 2008 – September 2009

(statistically significant differences at p ≤ 0.05)

0%

10%

20%

30%

40%

50%

60%

36.36%

16.12%

Community:Pneumonia

(5.03% of all discharges)

Community: No Physician Follow-UpCommunity: Physician Follow-Up

0%

10%

20%

30%

40%

50%

60%

42.42%

15.57%

Community:COPD

(4.75% of all discharges)

Community: No Physician Follow-UpCommunity: Physician Follow-Up

0%

10%

20%

30%

40%

50%

60%

37.14%

15.85%

Community: UTI

(4.12% of all discharges)

Community: No Physician Follow-UpCommunity: Physician Follow-Up

Other Characteristics

Age Range % of all DischargesN Stays=26,850

No PhysicianFollow-Up

PhysicianFollow-Up

<65 * 14.95% 39.53% 20.31%

65 - 69 * 12.30% 23.01% 13.99%

70 - 74 * 13.96% 34.16% 12.82%

75 - 79 * 15.43% 36.61% 12.78%

80 - 84 * 17.85% 38.21% 14.63%

85 - 89 * 14.89% 40.56% 15.60%

90+ * 10.62% 38.31% 16.36%

(statistically significant differences at p ≤ 0.05)

Other Characteristics% of all Discharges

N Stays=26,850No

PhysicianFollow-Up

PhysicianFollow -Up

Race/Ethnicity African American* 5.99% 41.23% 19.55% Hispanic * 36.01% 34.84% 14.38% Caucasian* 55.08% 35.50% 15.61% Other * 2.92% 30.00% 11.02%Gender Male * 41.38% 37.12% 16.88% Female * 58.62% 34.03% 13.82%

(statistically significant differences at p ≤ 0.05)

Empowering Patients:Physician Follow-Up Care

• Educate office staff on the importance of scheduling “early” follow-up office visits.

• Reinforce with your patients the importance of making/ keeping appointments soon after discharge.

• Ask patients to take their discharge paperwork to the visit – complete a medication reconciliation.

• Give recently discharged patients appointment priority.

• Encourage patients to bring written questions to the doctor’s visit. This practice improves the effectiveness of the patient/physician communication and time management.

Coaching

Coaching Impact on Reducing Readmissions

• Offer coaching 1007+

• Coached patients 735(Acceptance rate 73%)

Plus “Nutritional Support” 0/72 = 0%

Coached Not Coached0%

5%

10%

15%

20%

25%

11.20%

20.40%

30-Day Readmission Rate

*Verified through 848 claims

Empowering Patients:Coaching

• Staff reinforces medication management with patients (including actions, side effects, and changed or discontinued meds).

• Help patients understand the importance of timely physician follow-up care (name, number, which first, time frame, etc.).

• Assist patients to set one goal for disease management (monitor weights, sodium intake, activity, etc.).

• Provide discharge instructions in patient’s/caregiver’s primary language (i.e., medication profile).

Other Findings

Comparison: All vs. Same Hospital 30-Day Readmission Rates

Mar-10Apr-0

8

May-08

Jun-08

Jul-0

8

Aug-08

Sep-08Oct-0

8

Nov-08

Dec-08Ja

n-09

Feb-09Mar-0

9Apr-0

9

May-09

Jun-09

Jul-0

9

Aug-09

Sep-09Oct-0

9

Nov-09

Dec-0910%

12%

14%

16%

18%

20%

22%

24%

All Cause / All Hospitals All Cause / Same Hospital

The Crust: Shared Problem

Hospit

al 1

Hospit

al 2

Hospit

al 3

Hospit

al 4

Hospit

al 5

Hospit

al 6

Hospit

al 7

Hospit

al 8

Hospit

al 9

Hospit

al 10

Hospit

al 11

Hospit

al 12

0

20

40

60

80

100

120

140

160

Sender Receiver

Coun

t

Impact for Hospitals• Prevent avoidable readmissions:

– Reflect quality of care and safety.– Affect the hospital’s finances and community role.

• Improves National Patient Safety Goals and HCAHPS scores.

• Hospitals can lower their unnecessary/avoidable readmission rates, but success requires leadership commitment.

QUESTIONSQA

Contact:

Susan Stone, MSN, RNProject Director – Care TransitionsDirect: 813.865.3435Email: sstone@flqio.sdps.org

This material was prepared by FMQAI, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy # FL2010F72T22211759

Health Reform Focus• HF, AMI and PNE targeted for readmission penalty (readmissions - any cause)

• Penalties begin:– FY 2013: 1% payment reduction for readmissions– FY 2014: 2% payment reduction for readmissions– FY 2015: 3% payment reduction for readmissions

• Readmission performance measures: SNFs, physicians, Medicare Advantage

• Hospital/physician payment bundling during inpatient stay (pilot test currently)

Health Reform Update*• May 27, 2010: Brian Whitman (Associate Director of

Regulatory Affairs, American College of Cardiology)• “While there are no specific details today, by law,

financial penalties for excessive readmission rates will occur. This will not go away. We need to look at this right now.”

• Still in development: penalty & risk-adjustment calculations

• Proposed rule release: March 2011 with opportunity to respond

*Hosted by H2H