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Readmissions are a heightened focus under the Affordable Care Act. Initiatives are in place to reduce hospital admission through improving transition in care. During this course the speaker will discuss CMS quality initiatives, care transition, projects and barriers. This presentation reviews the key elements to tackling Avoidable Readmissions. 1. Learn to summarize the CMS quality initiative for healthcare reform related to hospital readmissions 2. Learn to identify underlying causes and barriers related to readmissions 3. Learn to state current CMS research projects and pilot programs 4. Learn to identify hospital and SNF strategies for collaboration
Citation preview
Hospital Readmission Roulette
HARMONY UNIVERSITYThe Provider Unit of
Harmony Healthcare International, Inc. (HHI)Presented by:
Diane Buckley, BSN,RN RAC-CT Director of Quality & Performance
Improvement
Hospital Readmission Roulette
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Speaker Bio
Director of Quality and Performance Improvement for Harmony Healthcare International, Inc.Over 25 years in the healthcare industry
Nurse ManagerDirector of AdmissionsDirector Case ManagementManager of Quality & Risk ManagementTraining and development of training modules for
Critical CareHome CareLTCHAcute CareLong-Term Care and Case Management
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Hospital Readmission Roulette
Disclosure: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose:Planners:
Elisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTBeckie Dow, RN, RAC-MTKeri Hart, MS CCC, SLP, RAC-CT, Kristen Mastrangelo, OTR/L, MBA, MHA Christine Twombly, RNC, RAC-MT, LHRM
Presenter:Diane Buckley, BSN, RN, RAC-CT
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Harmony Healthcare International, Inc.
Hospital Readmission RouletteDisclosure Speaker: Diane Buckley, BSN, RN, RAC-CT
The speaker has no relevant financial relationships to disclose
The speaker has no relevant nonfinancial relationships to disclose
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Harmony Healthcare International, Inc.
Hospital Readmission RouletteCriteria for Successful Completion
Complete Sign-in and Sign-Out on Attendance FormAttendance for entire sessionCompletion and submission of speaker evaluation form
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Hospital Readmission RouletteObjectives:
The learner will be able to summarize the CMS quality initiative for healthcare reform related to hospital readmissionsThe learner will be able to identify underlying causes and barriers related to readmissionsThe learner will be able to state current CMS research projects and pilot programsThe learner will be able to identify hospital and SNF strategies for collaboration Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
Hospital Readmission Roulette
Reducing Re-hospitalizations among Medicare beneficiaries has become a high priority for policymakers and the Center for Medicare & Medicaid Services (CMS)
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Hospital Readmission Roulette
Hospital Readmissions are seen as an important indicator of care quality and account for billions of dollars in annual Medicare spending (MedPac, 2007)
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Hospital Readmission Roulette
Hospitalizations and Rehospitalizations are symptomatic of multi process defect in the health care system due to lack of:
Timely or equitable access to careEffective handoffs and coordination of careSafe carePatient centered and appropriate end of life care
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Hospital Readmission Roulette
Five most common Medical condition for Readmission:
Heart FailurePneumoniaCOPDPsychosesGI problems
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Hospital Readmission Roulette
Five most common surgical procedures:
Cardiac stent placementMajor hip or knee surgeryVascular surgeryMajor bowel surgeryOther hip or femur surgery
Hospitalization of Nursing Home Residents CommonExpensiveOften Traumatic to resident and familyTense with many complications
DeliriumPolypharmacyFallsIncontinence and catheter useHospital acquired infectionsImmobility, De-conditioning, and Pressure Ulcers
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Reducing Potentially Avoidable Hospitalization
Reducing Potentially Avoidable Hospitalization
Some Hospitalizations of NH Residents are Avoidable
As many as 45% of admissions of nursing home residents to acute hospitals may be inappropriate (Salibaet al, J AmerGeriatrSoc 48:154-163, 2000)
In 2004 in NY, Medicare spent close to $200 million on hospitalization of long-stay NH residents for “ambulatory care sensitive diagnosis”
Grabowski et al, Health Affairs 26: 1753-1761, 2007
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Why do Re-admissions happen?
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Why do Re-admissions happen?
Discharge from Hospital is critical and requires adequate planning and preparations to avoid
Medication errorsPoor discharge planningInadequate arrangementsPoor communicationAdverse events
Why do Re-admissions happen?Medication Errors: The patient is discharged without prescriptions for the proper mix and doses of medication, or lacks instructions for taking them, or new prescriptions may interfere with existing medications.Poor Discharge Planning: There is little or no effort to plan follow up care, including scheduling necessary doctor’s appointments.
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Why do Re-admissions happen?
In half of all Medicare 30-day readmissions, patients had not seen their regular medical doctor or any health provider following discharge.Inadequate arrangements: Family members and other caregivers lack information or are unable to care for the patient after discharge.
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Why do Re-admissions happen?
Poor Communication: Providers delay providing discharge instructions, or fail to provide them at all.Lack of discharge summaries to community physicians and post-acute care providers.Too many cases of community providers that have no reports, test results, or other history when seeing the patient at first post discharge visit. Patients may not have received information on how to have a successful recovery.
such as alerting them about symptoms that may need medical attention in an outpatient setting.
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Hospital Readmission Roulette
Research Recommendations:Interventions at time of DischargeReliable & prompt follow-up care by primary care physiciansAggressive Management of chronicle illness
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Hospital Readmission RouletteSome Readmission to the hospital are plannedOther are avoidable and the result of
Poor quality of care/ uncoordinated care
Variation in readmission rates by hospitals and geographical regionsReadmissions rates can be reduced with application of evidenced based guidelines and enhanced care coordination
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Medicare readmission rates for Skilled Nursing Facilities to hospitals increased 30% from 2000 to 2006
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Hospital Readmission Roulette
Hospital Readmission Roulette
1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion
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Hospital Readmission Roulette
~ 10% - 25% of long stay NH residents are admitted to an acute hospital over a 5-month period
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Hospital Readmission Roulette
June 2007 & 2008 Medicare Payment Advisory Commission (MedPAC) Report to Congress highlighted avoidable Rehospitalizations as an area of high cost and low qualityPrompted leaders of healthcare systems across the country to focus on avoidable Rehospitalizations in anticipations of potential changes in the market
2009 Re-Admissions emerged as a Major Quality Initiative of Healthcare Reform.Reducing Re-hospitalization is an important element of President Obama’s February 2009 proposal for financing Health Care Reform.
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Hospital Readmission Roulette
12 million fee-for-service Medicare beneficiaries were analyzed per New England Journal of Medicine
20% who had been discharged were Re-hospitalized within 30 days ( 1 in 5 discharges)34% were Re-hospitalized within 90 days51% within 1 year13% of the readmissions - $12 billion worth – were “potentially avoidable,” (IPPS rule).
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Hospital Readmission Roulette
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Hospital Readmission Roulette90% Re-hospitalizations within 30 days are unplanned75% of Readmissions preventable equating to $12 Billion a year to Medicare spending68.9% of patients discharged with a medical condition, were re-hospitalized or died within one year of discharge53% re-hospitalization of Discharges after a surgical procedure
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Hospital Readmission Roulette50% of re-admissions within 30 days had no bill for a physician visit70% surgical patients were admitted for a medical condition such as pneumonia and UTI 19% of Medicare discharges are followed by an adverse advent with 30 days:
2/3 Drug Events that are preventable
Payers & Policymakers are targeting Readmissions to reduce healthcare expenditures & improve quality of care and patient outcomes Rehospitalization has become a focus for Medicare, other payers, and quality care organizations do to its Clinical and Financial impact.
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Hospital Readmission Roulette
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Hospital Readmission Roulette
The Affordable Care ActFrom a Policy perspective performance variation indicated lack of reliable attention to executing successful transition out of the hospital and into the next care settingSeveral provisions regarding improving Care Transition, Care Coordination and Reducing readmissions
HEALTHCARE POLICY PRIORITY
Affordable Care ActAccountable Care Organizations (ACO)Bundled PaymentsStrategic Partnership
Clinical & Financial Performance Data
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Healthcare Policy PriorityBesides the penalties, the Obama administration is ramping up other efforts to reduce readmissions.
Giving out $500 million to help hospitals and other health-care providers improve the transitions of patients out of hospitals
And the administration has approved 154 “Accountable Care Organizations,” which are collaborations of hospitals, doctors and other health-care providers that receive financial incentives for preventing costly episodes such as readmissions
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Hospital Readmission Roulette
CMS actively working to change payments to hospitals to incentivize readmission reductionHospitals with high rates of preventable readmission will have payments reduced
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Hospital Readmission Roulette
CMS has undertaken several initiatives to reduce readmissions among the Medicare fee- for- service (FFS) population
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Hospital Readmission Roulette
Initiatives:Reporting hospital readmission rates through Hospital CompareFunding hospital level improvements through partnership program Changing Payment Policies through the Hospital Readmission Reduction ProgramVarious Shared Savings Initiatives
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Hospital Readmission Reduction Program
Hospital Readmission Reduction Program
Section 3025 of The Affordable Care Act added section 1886(q) to the Social Security Act establishing the Readmission Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012
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Hospital Readmission Reduction Program
Hospital Readmission Reduction Program
FY 2013 IPPS Final Rule finalized the following policies
Which hospitals are subject to the Hospital Readmission Reduction ProgramThe Methodology to calculate the hospital readmission payment adjustment factorWhat portion of the IPPS payment is used to calculate the readmission payment adjustment amountA process for hospitals to review their readmission information and submit correction to the information before the readmission rates are to be made public Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38
Hospital Readmission Reduction Program
Hospital Readmission Reduction Program
FY 2014 IPPS Final Rule finalized changes to the methodology to calculate the hospital readmission adjustment factor.
Readmission Adjustment Factor:FY 2013, the higher of the Ratio or 0.99 (1% reduction)FY 2014, the higher of the Ratio or 0.98 (2% reduction)
Penalties will increase to a maximum of 2 percent for FY 2014 & 3% for FY 2015CMS considering similar payment reduction based on high readmission rates after joint replacement, stenting, heart bypass and stroke
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Hospital Readmission Reduction Program
As of October 1, 2012 a substantial number of hospitals began receiving reduced payments from Medicare due to high readmission rates within 30 days of dischargeApproximately 2,200 hospitals (2/3 of all hospitals) received a reduction in reimbursement for fiscal year 2013 (ranging up to the maximum 1%)
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Hospital Readmission Reduction Program
Significant number of hospitals have been working on innovative programs using a wide variety of approaches based on the Hospital Reduction Program
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Hospital Readmission Reduction Program
Major Points are emerging from current initiatives:
The reason for admissions aren't what people generally assumeClear communication during transition is keyHospital and health systems are forming collaborations with nursing homes and home care agencies, including monthly council meetings to look at problem cases together and explore the story behind the story
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Hospital Readmission Reduction Program
Major Points are emerging from current initiatives (continued):
Hospitals are developing innovative services to offer needed support to patients without necessarily admitting themHospitals and health systems are revamping transfer forms and educational materials to support smooth transitions and consistency between different settings
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Hospital Readmission Reduction Program
Major Points are emerging from current initiatives (continued):
Hospitalists in the post-acute setting play a valuable role in reducing readmissionsHospital and health systems boards need to develop a consistent strategy for post acute care
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Hospital Readmission RouletteHospital Readmission Reduction Program
Post Acute Hospitalist Are Practicing In:
Skilled Nursing Facilities Post Acute RehabilitationPost Acute Psychiatric facilitiesCustodial nursing care Assisted LivingInpatient Hospice facilities
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Hospital Readmission Roulette
IPC The Hospitalist Company in CA is larger single-specialty group practice with over 1,200 full time Hospitalist nationwide and several hundred part time.
5 years ago accounted for 5% in post acuteToday increased to 20% of post acute
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Hospital Readmission Roulette
Barrier Faced by HospitalistMajor barrier to information flow between settings is a lack of compatibility between electronic records, even if the software is from the same companyThe standard hospital discharge form is designed as a succinct record of care the patient received while hospitalized, but is not designed as a road map for care the patient needs to receive after discharge Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
Hospital Readmission Roulette
Barrier Faced by Hospitalist (continued)
Privacy issues add another layer of complexity. Communication is horrible from hospital to the post acute care setting initiating let to dedicated post acute hospitalist practices. Patient are in the same practice and they meet weekly providing an effective handoff.
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Hospital Readmission Roulette
Hospital and other organizations have implemented additional strategies:
Enhanced patient educationIncreased post-discharge follow up careIncreased coordination with outpatient providers (Bradley et. al., 2012)
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Hospital Readmission RouletteSeven Principles key to Reducing Readmissions
Seven Principles key to reducing readmissions from SNF with using “SNF-ist” of “Hospitalist” were developed by a Hospitalist Kevin Sundbye, MD from Stormont-Vail Healthcare in Topeka, KS
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Hospital Readmission RouletteSeven Principles key to Reducing Readmissions
Fax needed medication to the pharmacy the day before discharge so medication are on hand when patient arrivesProvide written prescription for pain medication before the patient leaves the hospitalHave the doctor at the hospital contact the nursing home doctor who will be responsible for the patient.
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Hospital Readmission RouletteSeven Principles key to Reducing Readmissions
Continued:Attempt to let the nursing home doctor know ahead of time that the patient is being discharged.Do not allow late-afternoon transfers. If you can’t have the patient at the nursing home by 4 pm, don’t send them.Anybody involved in the transfer process (doctor, nurses, social worker) can and should stop the discharge if they detect a problemUse a checklist to confirm that everything is ready and going to according to plan.
(GovernanceInstitute.com; BoardRoom Press Dec 2012)
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Hospital Readmission Roulette
The Department of Health and Human Services (HHS) has included recommendations from the Medicare Payment Advisory Commission (MedPAC) to have skilled nursing facilities (SNFs) join hospitals in accountability for avoidable 30-day hospital readmissions. As part of the 2014 budget proposal, SNFs with high rates of Medicare rehospitalizations would have payments reduced by 3 percent beginning in 2017
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Hospital Readmission Roulette
The MedPAC analysis showed that approximately 14 percent of Medicare patients discharged to SNFs were rehospitalized. To avoid penalties and ensure quality care, this budget proposal challenges SNFs to provide
Better care so residents are physically ready for discharge, Provide better family education on subjects such a medication management and Form partnerships with high-quality community services.
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Hospital Readmission Roulette
Also on the table is MedPAC’s recommendation that bundled payment for post-acute care providers be implemented in 2018, including
Long-Term Care Hospitals SNFs Inpatient Rehabilitation Facilities Home Health Providers.
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Hospital Readmission Roulette
Medicare 9th Scope of WorkBegan investigating 30-day Re-Admissions.CMS’s Fiscal Intermediaries and state based QIOs began flagging 30-day readmissions to the same facility and for same diagnosis.
AMIHeart FailurePneumonia
QIOs contact hospitals and conducted reviews of discharge plans and other documentation to identify patterns of preventable readmissions.
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Hospital Readmission Roulette
CMS will monitor the success of this project by watching the rates at which patients in these communities return to the hospital. Re-admission rates for hospitals have been tracked by CMS for some time, and will be available to consumers through the Hospital Compare Web site at http://www.hospitalcompare.hhs.gov.
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Hospital Readmission RouletteCMS included a Care Transition in its 9th Statement of work (started in 2008)
Quality Improvement Organizations (QIOs) in 14 communities are working to coordinate care and promote seamless transitions across settingsSpecifically focusing on reducing unnecessary readmissions to the hospital by improved transitions of care and greater coordination among providers
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Hospital Readmission Roulette
IHI (Institute for Healthcare Improvement) on May 1, 2009 launch the State Action on Avoidable Rehospitalizations (STAAR) Initiative
Grant support from the Commonwealth Fund.Initial phase, Two year Multi state project to reduce avoidable Rehospitalizations focusing on two components
STAAR Initiative
One of the First large-scale , multi-stakeholder effort to reduce readmissions and an early leader in encouraging the field to form state-level and local cross-setting partnership to address system issues in transitioning care across settings.
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STAAR Initiative
Aims to reduce Rehospitalizations by working across organizational boundaries and by engaging:
PayersStakeholders at the State, Regional and National levelPatient and families and caregivers at multiple care sites and clinical interfaces
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Hospital Readmission RouletteSTAAR Initiative
IHI partners with STAAR states to provide
Strategic guidance SupportTechnical assistance
To hospitals and cross-continuum teams to improve transitions in care and reduce avoidable rehospitalizations
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Hospital Readmission RouletteSTAAR Initiative
IHI (Institute for Healthcare Improvement)
Focusing on Two components:A multi-state learning community to Improve Transition of CareTargeted Technical Assistance to address systemic barriers to reducing avoidable Re-hospitalizations
STAAR Initiative1. Improve Transition of Care by
cultivating a cross-continuum learning collaborative
Participants are required to engage partners from across the continuum of care to problem solve and co-design improvements in the day to day work of providersThe initiative supports the process improvement work in hospitals and cross continuum teams by creating robust learning community
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STAAR Initiative
STAAR providesContent reviewsProcess recommendationsInventory Celebration of Best Practices and suggested measurement strategies
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STAAR Initiative
2. Engage State-level leadership to understand and mitigate systemic barriers to change
Reducing rehospitalizations in a state or region requires not only front-line process improvement, but also identification and mitigation of barriers to system-wide improvements, policy & payment reforms that will reduce fragmentation and encourage coordination across the continuum of care
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STAAR InitiativeReforms are necessary to address the shortcomings of the current volume-based incentives, and to place a premium on the quality of the patient’s experience across the continuumRehospitalization involves new behaviors, norms, relationships and partnerships to communicate and coordinate care between disciplines, settings and organizationsState-level leadership is essential to understand an act on the barriers that front line teams encounter in doing this workCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67
STAAR Initiative
STAAR Hospital Teams focus on the implementation of four key recommended process level improvements that require extensive collaboration between the hospitals and their community partners to effectively co-design better processes
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STAAR Initiative
Perform an Enhanced Assessment of Post-Hospital NeedsProvide Effective Teaching and Facilitate Enhanced LearningProvide Real-Time Handover- CommunicationsEnsure Timely Post-Hospital Care Follow-Up
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STAAR Initiative
Perform an Enhanced Assessment of Post-Hospital Needs
Involve family caregivers and community providers as full partners in completing a needs assessment of patients’ home-going needsReconcile medications upon admission Create a customized discharge plan based on the assessment
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STAAR Initiative
Provide Effective Teaching and Facilitate Enhanced Learning
Customize the patient education materials and processes for patients and caregiversIdentify all learners on admissionUse Teach Back regularly throughout the hospital stay to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71
STAAR InitiativeProvide Real-Time Handover- Communications
Reconcile medications at dischargeProvide customized, real time critical information to next clinical care provider(s)Give patients and family members a patient-friendly discharge planFor high risk patients, a clinician calls the individual listed as the patient’s emergency contact to discuss the patient’s status and plan of care
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STAAR Initiative
Ensure Timely Post-Hospital Care Follow-Up
Identify each patient’s risk for readmissionPrior to discharge, schedule timely follow-up care and initiate clinical and social services based upon the risk assessment
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STAAR InitiativeMeasurements of Outcomes and Process Measures
Outcome Measures: Readmissions30-Day All-cause Readmissions (% of discharges with readmission for any cause with 30 days)Readmission Count (Number of readmissions: Numerator for 30-day all cause readmissions measure)
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STAAR Initiative
Outcome Measures: Patient Experience
HCAHPS Communication Questions: “During the hospital stay, how often did nurses explain things in a way you could understand?”“How often did doctors explain things in a way you could understand?”
HCAHPS Discharge Questions:“Did hospital staff talk with you about whether you would have the help you needed when you left the hospital?”“Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”
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STAAR InitiativeOutcome Measures: Patient Experience
Care Transition Measures: The hospital staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left the hospital. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.When I left the hospital, I clearly understood the purpose for taking each of my medications
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STAAR InitiativeProcess Measures:
Enhanced Admission Assessment for Post-Hospital Needs
Percent of admissions where patients and family caregivers are included in assessing post discharge needsPercent of admissions where community providers (e.g., home care providers, primary care providers and burses and staff in skilled nursing facilities) are included in assessing post discharge needs
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STAAR Initiative
Process Measures (continued):Effective Teaching and Enhanced Learning
Percent of observations of nurses teaching patient or other identified learner where Teach Back is used to assess understandingPercent of observations of doctors teaching patient or other identified learner where Teach Back is used to assess understanding
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STAAR InitiativeProcess Measures (continued):
Real-time Patient and Family-Centered Handoff Communication
Percent of Patients discharged who receive a customized care plan written in patient friendly language at the time of dischargePercent of time critical information is transmitted at the time of discharge to the next site of care (e.g., home health, long term care facility, rehab care, physician office) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 79
STAAR InitiativeProcess Measures (continued):
Post-Hospital Care Follow UpPercent of patients discharged who had a follow-up visit scheduled before being discharged in accordance with their risk assessment
Balancing MeasureObservation Admits
Number of Admission to observation status in the month
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STAAR InitiativeFive Steps the STAAR initiative found to be effective:
Know your dataKnow your partners-with whom you share patientsForm operational alliances to share data and improve transition processes. Form a cross continuum teamPerform a review of five recently readmitted patients, and bring to the cross continuum team meetingIdentify shared process that span the transition from the hospital to other settings, and work together to improve those processes
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Hospital Readmission Roulette
The Affordable Care Act created a formal Community Based Care Transition Program (CCTP)
The program was to test models in for improving care transition and reduce readmissions for high risk Medicare beneficiariesCCTP is part of the Partnership for Patients (P4P) a nationwide partnership aimed to reduce preventable hospital errors by 40% and reduce hospital readmissions by 20%47 organizations are enrolled and budgeted to $500 million
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Partnership For Patients (P4P)
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Partnership For Patients (P4P)
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INTERACT(Interventions to Reduce Acute Care Transfers)
Joseph Ouslander, MD, Director of Boca Institute for Quality Aging at Boca Raton Community Hospital, created a program aimed at reducing the number of hospital admission from nursing homes
INTERACT
INTERACT was initially designed as “Toolkit” in 2007 Evolved into a full Quality Improvement Program that will assist nursing homes in meeting the federal requirement for QAPI program
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INTERACTDesigned to improve the early identification, evaluation, management documentation and communication about acute changes in condition of residents in nursing homesThe goal is to improve care by reducing the frequency of potentially preventable transfers to the acute care hospital and related complications leading to increase health care expenditure
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INTERACT
Program includes Evidenced Based and Expert recommended Tools Strategies to implement themRelated educational resources
The tools are to be integrated into everyday care and be incorporated into your facility’s quality improvement program
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INTERACT
Tools:Quality Improvement ToolsCommunication ToolsDecision Support ToolsAdvance Care Planning Tools
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INTERACTImplementation Elements
Advance Care Planning should begin at the time of or shortly after admission and continued through out the resident stay. The INTERACT Advanced Care Planning Tool aides in developing a person centered care planMedication Reconciliation Worksheet is designed to help with safe medication orders at the time of admission
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INTERACT
Implementation Elements (continued)
Stop and Watch Tool to be used by CNAs to identify changes in resident and clearly communicate those changes to the licensed staff. The tool also can be used with staff who have direct contact with resident and may observe changes (Rehab, environmental services, dietary)
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INTERACTImplementation Elements (continued)
Once a nurse is alerted to a change in condition the Care Paths and Change in Condition File Cards can be used as decision support tools to help with the recognition, management and reporting of specific symptoms and signs. Include criteria for notifying primary care clinician
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INTERACT
Implementation Elements (continued)
SBAR Form and Acute Change in Condition Progress Note to enhance the evaluation of and documentation with acute changes and improve the communication utilizing a structure.Transfer Checklist and Transfer Forms used to communicate clearly and succinctly information that is critical for the ED and other hospital staff to care for the resident.
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INTERACT
Quality Improvement ToolsThe Hospitalization Rate Tracking ToolQuality Improvement Tool
Both tools assist with:Tracking, trending, and benchmarking measuresConducting root cause analysis that identify areas for improvement
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INTERACTFour Key Strategies for implementation essential for success
Make INTERACT an integral component of QAPI programIntegrate the INTERACT program and tools into everyday careTools are visible and accessible for everyday careCulture Change-change takes time and to be mindful of this
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INTERACT
Commonwealth Fund Project Results
100 bed Nursing Home the average reduction of 0.69 hospitalizations/1000 resident days equates
25 fewer hospitalizations in a year$125,000 in savings to Medicare Part A (conservative)The Interventions as implemented as part of the project cost $7,700 per a facilityThe savings could aide the facility infrastructureCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96
Hospital Readmission Roulette
Medicare Readmission Rates showed Meaningful decline in 2012 per a publication of the Center for Medicare & Medicaid Services, Office of Information Products & Data Analytics
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Hospital Readmission Roulette
Descriptive analysis of 30-day, all cause hospital readmission rate patterns from 2007-2012 .Population: Medicare FFS beneficiaries experiencing at least one acute inpatient hospital stay.
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Hospital Readmission Roulette
Method: Chronic Condition Data Warehouse claims, estimate unadjusted, monthly readmission rates for the nation, within the Dartmouth Hospital Referral Region (HRR), and compare participating and non-participating hospitals in the Partnership for Patients(P4P) program (overall and by number of inpatient beds at each facility)
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Hospital Readmission Roulette
Results:From 2007-2011 the national 30-day all cause hospital readmission rate averaged 19% 2012 readmission rate averaged 18.4%
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Hospital Readmission RouletteCurrent Readmission Rates
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Hospital Readmission Roulette
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Hospital Readmission Roulette
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Hospital Readmission Roulette
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HEALTHCARE POLICY PRIORITY
CMS hopes to lower Hospital readmissions Rate by 20% by 2013 utilizing evidenced based interventions
HEALTHCARE POLICY PRIORITY
The Affordable Care Act established the Hospital Readmission Reduction Program (HRRP) which ties payment to Performance on MeasuresHRRP begins October 1, 2012Lowers Medicare payment rate for hospitals with greater than expected readmission rates for specific conditions
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HEALTHCARE POLICY PRIORITY
Conditions beginning FY 2013Heart FailureAcute Myocardial InfarctionPneumonia
These three conditions made up approximately 10% of hospital discharges in 2009
(Avalere analysis of 2009 Medicare 100 Percent Standard Analytic files claims data from CMS.)
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HEALTHCARE POLICY PRIORITY
Conditions Beginning FY 2015Chronic Obstructive Pulmonary DiseaseCoronary Bypass GraftPercutaneous Transluminal Coronary AngioplastyOther Vascular Conditions
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HEALTHCARE POLICY PRIORITY
Payment reduction is determined by an adjustment factor based on an assessment of excess readmissions
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HEALTHCARE POLICY PRIORITY
Hospitals with excessive readmission rates will have their Medicare payments reduced by up to
1% in fiscal year 2013 2% in 2014 3% by fiscal year 2015 and beyond
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HEALTHCARE POLICY PRIORITY
Hospitals with risk adjusted 30 day readmission performance in the lowest quartile will incur penalties against their total Medicare Payment beginning in fiscal year 2013 (starting October 1, 2012)CMS will evaluate prior year’s readmission data starting October 1, 2011
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HEALTHCARE POLICY PRIORITY
Preparing for Payment Penalties:Know your readmission metrics including original discharge disposition and origin of readmissionCalculate readmission rates by condition, physician performance and post acute care facilityIdentify opportunities based on patient demographics and common readmissionsScreen and target patients based on risk assessmentsCompare disease specific outcome measures to national and local competitor rates
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Hospital Readmission Roulette
Four stages of care that allow effective interventions
Preparation for discharge, a process starting on admission making staff aware of home environmentHand-off to the out patient physicianMedication reconciliation to make sure new prescriptions are filled and that patients are not falling back on their old medication routinesHome visits and/or phone call, daily or weekly for first 30 days
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Hospital Readmission Roulette
American Healthcare Association Goal:
Reduce Hospital Re-admissions within 30 days during a SNF stay by 15% by March 2015
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Hospital Readmission Roulette
Definition of Readmission 30 Day Readmission Measure
Readmission occurs when a patient is discharged from the applicable hospital to a non-acute setting and then is admitted to the same or another acute care hospital within 30 days for any reason
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Hospital Readmission Roulette
Definition of Readmission 30 Day Readmission Measure
Exclusion to Readmission Definition:
Transfers and planned readmissions are excluded
An exception for AMI for planned readmission for revascularization procedures (CABG PTCA)
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Hospital Readmission Roulette
1 in 5 Medicare FFS Beneficiaries are Readmitted to the hospital within 30 days
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Hospital Discharge Condition
30-Day Rate for Re-hospitalization
AMI 19.8
Heart Failure 24.8
Pneumonia 18.4
Hospital Compare National Readmission Rate: http://www.medicare.gov/Download/DownloaddbInterim.asp. Jan 20, 2012
National Transitions of Care CoalitionMedicare Transitional Care Act of 2012
Improve transition of care for high risk Medicare beneficiaries at high risk for readmission as they move from the hospital setting to
HomeSkilled Nursing facilityNext point of care
The bill is step in improving patient outcomes and reducing unnecessary health-related expensesCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 118
National Transitions of Care Coalition
The Medicare Transitional Care Act puts in place an infrastructure to promote care transition interventions that have been proven successful
Seven key elements found in evidence-based care interventions
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National Transitions of Care Coalition
Seven Essential Intervention Categories
Medication ManagementTransition PlanningPatient and Family Engagement/EducationInformation TransferFollow-Up CareHealthcare provider EngagementShared Accountability across Providers and Organizations
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Nursing Home Value-Based Purchasing Demonstration Project
CMS initiative to improve Quality and Efficiency of care to Medicare beneficiariesFinancial incentives to nursing homes that meet certain conditions providing high quality of careDemonstration includes three states: Arizona, New York, and Wisconsin
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Nursing Home Value-Based Purchasing Demonstration Project
Quality Performance Based on Four Domains:
Staffing Appropriate HospitalizationsMinimum Data Set (MDS) OutcomesSurvey Deficiencies
CMS will award points based on performance with each measure within the domainPoints will summed for an overall quality score
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Nursing Home Value-Based Purchasing Demonstration Project
For each state Nursing home scores in the top 20 %Homes in the top 20% of improvement in their scores Eligible for a share of the State’s savings pool
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Nursing Home Value-Based Purchasing Demonstration Project
Anticipate that potentially avoidable Hospitalizations may be reduced as a result of improvement of quality of careReduction in hospitalizations and subsequent skilled nursing stays result in Medicare savingsThe saving will fund the payment awards
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Hospital Readmission Roulette
Clinician and Hospital administrators are eager to find effective approaches to reduce Rehospitalizations.
As Payers, Policy makers and Purchasers are eager to develop incentives to improve practice.
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Hospital Readmission Roulette
Transition in CareA
Culture Change
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SNF Culture Change
WHY A Culture Change? Needed in order to be successful!
The Affordable Care Act mandates that each facility have a Quality Assurance and Performance Improvement Program (QAPI)Improving Management of acute changes in condition and reducing unnecessary hospital transfers is one potential focus to meet QAPI requirements
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SNF Culture Change
Corporate Compliance program in place and supported by the organizationSupport and buy- in from senior leadership down front line staffQAPI program
Make readmission an initiative
An organization ready for changeCross the continuum collaboration
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SNF Culture Change
Know your DataPartner with Hospitals, physician offices, Home care, Hospice, Assisted Living, Acute RehabBe part of Pilot programs or initiativesImplement INTERACTTrain and Educate all employees from top down
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SNF Culture Change
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Admission ProcessReceive complete and accurate admission informationManage Admissions times and daysCustomer ServiceEstablish protocols and procedures
Handoff communication
Transition meeting scheduled with 72 hours of AdmissionINTERACT Advanced Care Planning
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SNF Culture Change
Customer Services: Making a Good Impression
Providing pre-admission contact with patient/familyStaff and room are ready to receive patientImplement a room readiness checklist
A warm home like atmosphereA welcome gift
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SNF Culture ChangeTransition Planning Meeting
Scheduled with 72 hours of AdmissionInterdisciplinaryCommunicationGoal:
Ease transition into and out of the facilityLength of StayIndividualized to each patients situation and conditionReduce readmissions to the hospital
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Hospital Readmission Roulette
SNF Culture Change (continued)Education Patient and Family through out careAccountability/Communication
Effective Hand Off of Care
Medication ManagementMultidisciplinary approachDischarge planning that starts on admission
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Hospital Readmission Roulette
SNF Structural SupportMD/PA/NP availability-“SNF-ist” or HospitalistPharmacy support 24/7 and responsivenessRespiratory Therapist and Respiratory vendor support
Training and competency
Infusion Therapy RN Support Training and competency24/7 availabilityCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 134
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Questions & Answers
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Hospital Readmission Roulette
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References & Resources
Healthcare Leader Action Guide to reduce Avoidable Readmissions, 2010 Health Research & Educational TrustReport on Medicare Compliance, “CMS Targets Readmission Through Payment, Audits; “Coaching” Model Reduces Rates.” Volume 17,Number 24. June 30, 2008Reducing Hospital-SNF 30-Day Readmission. Case Management Monthly. January 2010.
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References & Resources
Improving Care Transition and Reducing Hospital Readmission. The Remington Report. January/February, 2010 Care Transitions. Re-hospitalizations Among Patients in the Medicare Fee for Service Program. New England Journal of Medicine, April 2, 2009.Institute For healthcare Improvement: Effective Interventions to reduce Rehospitalizations, March, 2009.
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References & Resources
Hospital Collaborate with SNFs, Home Care, Hospice, to Reduce Readmission by Elaine Zablocki, National Research Corporation, December 2012 BoardRoom PressMedicare & Medicaid Research Review 2013: Volume 3, Number 2, Medicare Readmission Rates Showed Meaningful Decline 2012, Gerhardt, G., Yemane, A. Hickman, P., Oelschlaeger,A., Rollins, E., Brennan,N.Readmission Reduction Program. CMS. Gov, www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/AcuteinpatientPPS/Readmission-Reduction-Program.html
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References & Resources
State Action on Avoidable Rehospitalizations. www.ihi.org
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Questions/Answers
Harmony Healthcare International1 (800) 530 – [email protected]
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Harmony Healthcare InternationalHave you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM EVALUATION
or CASE MIX ANALYSIS
for your Facility?Perhaps your facility has potential for additional
revenue Assess your facility against key indicators and national
norms
Email us at for more [email protected]
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