Care Transitions: Best Practices in Reducing Readmissions

1. Care Transitions: Best Practices in Reducing Readmissions Roland A. Grieb, MD, MHSA Medical Director, Indiana Medicare Quality Improvement Organization Nancy Meadows, RN, BS Clinical Specialist, Care Transitions Initiative May 5, 2011

2. Disclosures The speakers for this CME activity have no relevant financial relationships with commercial interests to disclose.

3. Objectives • Provide an overview of the Medicare Quality Improvement Organization (QIO) work being done as part of the Centers for Medicare & Medicaid Services (CMS) Care Transitions Initiative • Explain some of the commonly utilized evidence-based care transition models and interventions • Share key successes and challenges identified through participation in the transitions sub-national theme

4. PoorDischargeCoordination Poor Discharge Coordination NO Medication Reconciliation NO Personal Health Record NOPersonal Health Record NO Coordinated Care Plan Poor Care Coordination NO Medication Reconciliation NO Personal Health Record Problems Affecting Care Transitions Patient • OUTPATIENT: • Home • PCP • Specialty • Pharmacy • Other Services • Care Giver ICU ER In-Patient HHA SNF Patient Source: Case Management Society of America (CMSA)

5. Background • Re-hospitalizations are: • Frequent • Approximately 20% of Medicare beneficiaries discharged from a hospital are readmitted within 30 days • Costly • Account for $17B in annual Medicare spending • Excludes costs associated with other payers Source: Jencks et al. N Engl J Med 2009; 360: 1418-1428. .

6. Background • Potentially avoidable • 75% identified as potentially preventable based on 3M report to the Medicare Payment Advisory Committee (MedPAC 2007) • 14-46% noted as potentially preventable in retrospective clinical review • Allow for actionable improvement • Research and quality improvement initiatives have shown >30% reduction of 30-day readmission rates for various patient populations

7. Rates of Re-hospitalization within 30 Days after Hospital Discharge Jencks S et al. N Engl J Med 2009;360:1418-1428 Source: Jencks et al. N Engl J Med 2009; 360: 1418-1428.

8. Why Do Hospitals Have Unwanted Readmissions? Poor Provider-Patient interface Medication management, no effective patient engagement strategies, unreliable follow-up Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers Lack of community infrastructure for achieving common goals Taken from: The Care Transitions Theme:Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH, and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at: http://www.cfmc.org/caretransitions/learning_sessions.htm

9. What’s the Hold Up? If re-hospitalizations are prevalent, costly, potentially avoidable, and actionable—what’s the hold up? • Providers: Lack of financial incentives and/or decentives • State: Lack of population-based data, fragmented payer systems • Community: Difficult to engage organizations across the continuum (silos), lack of Information Technology (IT) acceptance, connectivity and infrastructures, lack of reimbursement

10. Health Care Reform: Promote Better Care After Hospital Discharge • By linking payments between hospitals and other care facilities, reform is intended to accomplish the following • Promote coordinated care after discharge from the hospital • Encourage investments in hospital discharge planning and transitional care to ensure that avoidable readmissions are prevented What’s in Reform for My Community? www.whitehouse.gov

11. Structure of Health Care Incentives • Expansion of pay-for-performance (P4P) to value-based purchasing (VBP) • Bundled payment pilots • Potential avoidable admissions, readmissions, and sites of care • Fixed hospital payments • Increasing focus on “cost and comparative effectiveness”

12. Evolution of Health Service Delivery • Shift of accountability and financial risk (clinically and economically) across the continuum of care • Shift to episodes of care • Shift to outcomes of care

13. A Major Focal Point of Interest National Quality Forum (NQF) included improved care transitions as 2009 and 2010 priority goals The Joint Commission has included and is expanding as part of National Patient Safety Goals (NPSGs) New CMS quality reporting of 30-day readmission rates (AMI, HF, and Pneumonia) Addresses many of the hospital- and health care-acquired conditions for which CMS is now and proposing to withhold payment Focus of numerous pilots, projects, and demonstrations August 2008, CMS focus for QIOs in 9th Scope of Work (SOW)

14. The Indiana Opportunity: Care Transitions 2008-2011

15. Key Elements to Improvement • Examine current state of readmissions and discharge processes • Assess and prioritize improvement opportunities • Develop an action plan of strategies to implement • Monitor and evaluate progress

16. Key Elements to Improvement • Identify the opportunity! Assessment, review, and redesign of provider-specific policies and processes that include (at a minimum) the following areas • Patient and caregiver education and communications • Medication reconciliation and safety • Symptom management • Discharge treatment plan and follow-up care • Sharing and transfer of vital patient information

17. Examine Current Rate of Readmissions • Readmission rates by diagnoses • Readmission rate by practitioners • Readmission rates by readmission source • Readmission rates at different time frames

18. Assess and Prioritize Focus on: • Specific patient populations • Stages of the care delivery process • Hospital organizational strengths and available resources • Hospital priority areas and current and upcoming quality improvement initiatives

19. Hospital Readmission Rates Patients discharged 1/1/2007—12/31/2007 within the HSA

20. HSA Admission Sources: Discharges and Re-hospitalizations

21. HSA Re-hospitalizations: Top 10 MS-DRGs

22. Patient’s Perspective of Care SurveyHospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Hospital Compare September 2008

23. Patient’s Perspective of Care SurveyHospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Hospital Compare September 2008

24. Source: Improving Care Transitions. Jane Dorman. Care Management Institute, Kaiser Permanente. January 13, 2010.

25. Typical Failure Modes in the Transition Process • Medication errors and/or adverse events • Poor, incomplete, or missing discharge instructions • Lack of follow-up appointment • Follow-up scheduled too long after hospitalization • Inadequate or lack of outpatient management • Ineffective provider-to -provider communications (skills and tools) • Confusion over self-care instructions • Lack of adherence to medications, therapies, and diet • Lack of social support

26. Develop an Action Plan • Learn from where failures lie • Develop community connections to eliminate barriers to successful care transitions • Develop strategies and interventions to engage patients, families, and caregivers in addressing the issue

27. Targeted Areas for Improvement  Communication  Medication reconciliation  Patient empowerment and self-management skills  Physician follow-up  Plan of care

28. Major Strategies to ReduceAvoidable Readmissions • During Hospitalization • Use a multi-interdisciplinary care team approach • Risk screen patients • Risk assessment of patients for “end-of-life” discussions • Establish effective communication • Use of “teach-back” and coaching skills to educate patients and caregivers

29. Major Strategies to ReduceAvoidable Readmissions • At Discharge • Implement comprehensive and patient-tailored care plans • Use “teach back” and coaching skills to educate patients and caregivers • Schedule and prepare patients and caregivers for “early” follow-up appointments • Medication reconciliation and patient medication self-management techniques • Facilitate discharge communications with post-acute care providers

30. Major Strategies to ReduceAvoidable Readmissions • Post Discharge • Promote patient and caregiver self-management • Coaching home visits and/or telephonic follow-up • Telehealth for at-risk patients • Personal Health Records for information management • Emergency Care Plans and Zone Tools for symptom management

31. Major Strategies to ReduceAvoidable Readmissions • Post Discharge • Verification that follow-up appointments are scheduled • Timely transmission of discharge summaries to primary care physicians • Early physician follow-up • low risk 0-14 days • high risk 0-7days • Establish community networks

32. Major Interventions

33. Major Interventions

34. Major Interventions

35. Major Interventions

36. CMS’s Table of Interventions http://www.cfmc.org/caretransitions/files/Care_Transition_Article_Remington_Report_Jan_2010.pdf

37. Monitor and Evaluate Progress • Critical element often not thought out • Informs hospital leaders of the efficacy of strategies • Helps guide implementation of additional strategies • Readmission data can be tracked and reported as quality indicator to the following • Hospital boards • Quality committees • Front-line and clinical staff

38. Intervention Pilots in Our Community

40. Summary of Preliminary National Results

41. Total Participating Providers Among 14 Communities • 70 Hospitals • 277 Skilled Nursing Facilities • 316 Home Health Agencies • 89 Other types of providers (Dialysis, Hospice, etc.) • 1,125,649 Medicare Beneficiaries

42. Preliminary Results*: CY 2007 compared to CY 2009 14 Care Transitions Communities in contrast to 56 Comparison Communities Measure CT Theme (Comparison) CT Theme (Comparison) Absolute Change Relative Change % readmitted -0.08% (+0.30%) -0.39% (+1.91%) Readmissions/1000 -2.96/1000 (-0.36/1000) -4.75% (+0.15%) -4.59% (-2.11%) Admissions/1000 -15.23/1000 (-7.62/1000) Taken from: The Care Transitions Theme:Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at: http://www.cfmc.org/caretransitions/learning_sessions.htm *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.

43. Preliminary Results*: CY 2007 compared to CY 2009 14 Care Transitions Communities in contrast to the Nation Measure CT Theme (National) CT Theme (National) Absolute Change Relative Change % readmitted -0.08% (+0.05%) -0.39% (+0.24%) Readmissions/1000 -2.96/1000 (-1.93/1000) -4.75% (-3.34%) -4.59% (-3.77%) Admissions/1000 -15.23/1000 (-11.8/1000) Taken from: The Care Transitions Theme:Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at: http://www.cfmc.org/caretransitions/learning_sessions.htm *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.

44. Preliminary Results*: CY 2007 compared to CY 2009 Transitions: Hospital—Skilled Nursing Facility (SNF)—Hospital Drivers: Lack of Standard and Known Process, Information Transfer Measure CT Theme (Comparison) CT Theme (Comparison) Absolute Change Relative Change % discharged to SNF +0.56% (+0.81%) +3.79% (+6.57%) SNF readmission rate -0.41% (+0.75) -1.09% (+4.64%) Taken from: The Care Transitions Theme:Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at: http://www.cfmc.org/caretransitions/learning_sessions.htm *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.

45. Preliminary Results*: CY 2007 compared to CY 2009 Transitions: Hospital—Home Health—Hospital Drivers: Lack of Standard and Known Process, Information Transfer, Patient Activation Measure CT Theme (Comparison) CT Theme (Comparison) Absolute Change Relative Change % discharged to HH +0.4% (+1.13%) +1.67% (+8.49%) HH readmission rate -0.47% (0.00%) -1.87% (+0.30%) Taken from: The Care Transitions Theme:Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at: http://www.cfmc.org/caretransitions/learning_sessions.htm *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.

46. Preliminary Results*: CY 2007 compared to CY 2009 14 Care Transitions Communities in contrast to 56 Comparison Communities Measure CT Theme Comparison Average Cost Savings/Beneficiary† $15.23 $6.91 Average Cost Savings/Community† $835,441 $132,482 $7,419,003 Total Cost Savings† $11,696,180 † This measure represents cost savings associated with readmissions only. Taken from: The Care Transitions Theme:Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at: http://www.cfmc.org/caretransitions/learning_sessions.htm *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.

47. National Results • Hospital readmissions work reduces hospital ‘admissions’ • Population-based measures of readmission going down • Population-based measures of admission also going down • Nursing Home and Home Health utilization has increased slightly while 30-day readmission rates for Nursing Home and Home Health have decreased • Preliminary cost-savings are very promising Taken from: The Care Transitions Theme:Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at: http://www.cfmc.org/caretransitions/learning_sessions.htm

48. Challenges to Care Coordination • Workforce and provider shortages (e.g., supply of physicians or places to go for medical care) • Limited access to specialty care • Limited financial capacity • Under-resourced infrastructures • Populations with multiple chronic conditions • Isolation and sometimes large areas due to geographic and travel distances

49. Challenges to Care Coordination • Lack of coordination and communication across information systems and between providers • Health care professionals are not necessarily trained in care coordination • Broadband availability

50. Strengths Needed in Health Care Systems • Becoming innovative to meet new changes and challenges • Improving communications across large, complex and /or multiple delivery systems • Establishing strong primary care physician infrastructure • Building and encouraging effective multiple disciplinary teams and networks to ensure access and improve quality of care