Heart Failure Readmission Reduction Project & Summit

1. Heart Failure Readmission Reduction Project & Summit Susan Schow, MPH Epidemiologist Maine Health Data Organization March 30, 2010

2. Heart Failure Readmission Reduction Project and Summit • MQF- funded project using Chapter 270 data to explore link between: • Hospital performance on HF-1 measure, • Hospital performance on Care Transitions Measures, and • Medicare’s Hospital 30-day Readmission Rates for Heart Failure

3. Heart Failure Readmission Reduction Project and Summit • Evaluation of data and visits to selected hospitals to: • provide opportunity to better understand the relationship between measures, patient experiences, and long-term outcomes • Share data, results of visits, and lessons learned with healthcare community (including hospitals, long term care, and home health) • “A rising tide lifts all boats”

4. MHDO’s Hospital Quality Data:“Chapter 270” Mandated Reporting • Collect quality data measures from hospitals: • CMS core measures (AMI, HF, PN, SCIP) (July 2005) • Nursing Sensitive Indicators (Jan. 2006) • Healthcare Associated Infection data (Jan. 2007) • Care Transition Measures (Jan. 2008) • Nurse Perceptions of Culture of Safety (Jan. 2009)

5. Heart Failure 1 - Measure • The HF-1 measure focuses on self-care teaching and six areas that need to be addressed prior to discharge: • Medications • Diet • Activity • Follow-up • Weight monitoring • Management of worsening symptoms

6. Care Transition Measures (CTM) • CTM (3-question patient survey) measures appropriate transitional care as evaluated from patient perspective • CTM is strongly associated with post discharge use of both hospital and emergency services • Currently 18 months of CTM data available

7. Data Evaluation • Evaluation of HF-1 Discharge Instruction measure showed an area for potential improvement • Evaluation of CTM data showed variation in patient perception of preparation for transition • Identified hospitals with mean scores significantly different than their peer group for both measures

8. Heart Failure Readmission Reduction Project and Summit • Recognized opportunity to improve the level of “transitional care” given to patients prior to discharge • Dovetails with CMS publishing 30-day Readmission Rates for Heart Failure

9. Hospital Visits by MQF’s QI Nurse • Selected nine hospitals for visit (9 of 36 acute care hospitals = 25%) • Ensured equal representation by peer grouping and by district • Dual goals: • Identifying best practices by asking top performers to share process improvement strategies at summit • Identifying opportunities for improvement through on–site process review meetings with heart failure teams

10. Readmissions • 20% of Medicare Beneficiaries readmit within 30 days of discharge • 33% readmit within 90 days; 56% within year • Readmissions have a 0.6 day longer LOS than other patients in the same DRG • Medical causes dominate readmissions • Estimated cost to Medicare: $15 to $18.3 billion in annual spending Sources:1 Jencks, S., Williams, M., & Coleman, E. (2008). “Rehospitalizations among Patients in the Medicare Fee-for-Service Program,” NEJM, Volume 360:1418-1428, April 2, 2009, Number 14.2 Medpac (June 2007). "Report to the Congress: Promoting Greater Efficiency in Medicare,“ pp 103-120.

11. Highest Rates and Most Frequent Reasons for Rehospitalization

13. Key Area for Improvement • 50% of all patients re-hospitalized within 30 days of medical discharge had no bill by a physician between discharge and rehospitalization • 52% of CHF patients had no bill by a physician between discharge and rehospitalization • Potential implications: • Seeing a physician post discharges may have a protective effect on readmitting to the hospital. • Critical window within the 30-day period

15. CMS Plans • Process: • Provide risk-adjusted readmission rates confidentially to hospitals • Followed by publicly report readmissions rates • Followed by payment reform (reduce payments) • Medicaid is likely to consider similar approaches • Other payers will follow • State public reporting is moving forward in many states: • Public reporting will be helpful to hospitals in addressing performance improvement Source: Medpac (June 2007). "Report to the Congress: Promoting Greater Efficiency in Medicare.“ p. 105.

16. Transitional Care • Set of actions to ensure coordination and continuity of care as patients transfer between locations or levels of care • Patients vulnerable: • Functional loss, pain, anxiety or delirium • Unprepared for what will transpire and their roles in process (caregivers also unprepared)

17. Literature • “Comprehensive Discharge Planning With Post Discharge Support for Older Patients with CHF” • Evaluated effects on CHF readmission rates (meta analysis: 18 studies, 8 countries) • Found 25% relative reduction in risk of readmission • A trend towards 13% relative reduction in all cause mortality • Improvement in Quality of Life scores (in a smaller subset of studies) • Without increase to cost of medical care • Specific to CHF patients, >=55 years old, moderate to severe symptoms and LV systolic dysfunction 1 Phillips C,.et al, JAMA, 2004

18. Responsible for Care Beyond Your Care Setting • Ensure safe and effective transfers to the receiving care setting mandated per standards by: • Joint Commission for Accreditation of Healthcare Organizations • DHHS Conditions for Participation • Gaps in performance measurement identified by Institute of Medicine • to assess quality across multiple care settings • Patient and Caregiver are often the only common thread weaving across settings • Uniquely positioned to report on quality of care transition

19. Development of Care Transition Measures Survey • Focus groups = four domains identified • Info Transfer • Confusion over appropriate Rx regimen • Patient and Caregiver Preparation • No understanding of what takes place in next care setting and their role • Care plans developed requiring caregivers participation without conferring with caregivers • Support for Self-Management • Inability to access practitioners with knowledge of recent care impedes patients’ ability to manage own care

20. Development of Care Transition Measures Survey • Focus groups = four domains (continued) 4. Empowerment to Assert Preferences • Patients attempt to assume more active role in care or to assert preferences repeatedly discouraged by practitioners or institutions • CTM Development • Rigorous psychometric testing • Validated for poorer outcome patients (underserved, sicker and older populations) • Aligns with the tenets of patient-centered care • Items “actionable” to help guide quality improvement • Scores responsive to changes in care process

21. Care Transition Measures • NQF endorsed 3-question survey of patients conducted 48 hrs to 6 weeks post discharge • Q1 - “The hospital staff took my preference and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital” • Q2 - “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health” • Q3 - “When I left the hospital, I clearly understood the purpose for taking each of my medications”

22. CTM: Uses Likert 4-Point Scale • Responses to questions: • “Strongly Disagree” = “1” • “Disagree” = “2” • “Agree” = “3” • “Strongly Agree” = “4” • “Don't Know” / “Don't Remember” / “Not Applicable” = “99” • Left answer blank = “9”

23. CTM Score Associated with Post Discharge Use of Hospital and ED • Shown to discriminate between patients who did and did not have subsequent ED visit/ rehospitalization for index condition • Q2 - “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health” • Significantly associated with subsequent emergency visits • Of those who agreed, 15.5% had ED visit • Of those who disagreed, 38.5% had ED visit 1 Coleman, E., et al, Medical Care, March 2005

24. CTM Score Associated with Post Discharge Use of Hospital and ED • Studied specifically for diabetes and CHF patients following discharge because: • High likelihood of requiring follow-up care • High likelihood of requiring medication adjustment as result of hospitalization • Need for ongoing self-management • Correlation between CTM scores and subsequent use of ED • Predictive of return to ED within 30 days • p = 0.004 (hint: p-value scores <0.05 are significant ) 1 Coleman, et al, Home Health Care Services Quarterly, Vol. 26, No. 4, 2007

25. HCAHPS® - Similar But Different • Hospital Consumer Assessment of Health Plan Survey (HCAHPS®) primarily addresses patient satisfaction • CMS developed with the Agency for Healthcare Research and Quality (AHRQ) • Since 2007, Inpatient Prospective Payment System (IPPS) hospitals must submit HCAHPS to receive full annual payment (reduced by 2% for non-reporting). Critical Access Hospitals may voluntarily report

26. HCAHPS® - Similar But Different • The two HCAHPS discharge questions are typically summed up under the category of : • “Were patients given information about what to do during their recovery at home?” • Discharge related questions: • Q19: During your hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital? • Yes, No • Studies say having opportunity to speak with doctors/nurses not rated as important as opportunity to actively prepare for care in next setting and role in self-care.

27. HCAHPS - Similar But Different • Discharge related question: • Q20:During your hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? • Yes, No • Studies identify patient’s frustrations centered more on identifying whom to contact for symptoms rather than knowing the symptoms • Understanding medication instructions is not assessed by HCAHPS • Not known whether HCHAPS items predict recidivism (CTM does) 1 Parry, C, et al, Medical Care, March 2008

28. CTM-3: Sufficient Number of Surveys • CTM sampling patterned after the HCAHPS survey: • CMS requires at least 300 completed HCAHPS surveys over four quarters: • “necessary to ensure adequate statistical power to compare hospitals to one another and to national benchmarks” • For those not collecting 300 completed surveys, CMS notes that: • Results are based on between 100 and 299 completed surveys or • Results are based on less than 100 completed surveys 1From: Mode and Patient-mix Adjustment of the CAHPS® Hospital Survey (HCAHPS) April 2008

29. The 5 “Stages of Data”Where Is Your Facility? • Denial • “Those aren’t MY numbers” • Anger / Resentment • “Who got those numbers?” • Bargaining • “How about if we re-run it again??…” • Depression (?!!) • “Why are we even doing this?…” • Acceptance • “How can we get better?” “Stages of Grief” – E. Kubler-Ross – adapted by M. Albaum MD

30. Parametric and Nonparametric Data Analysis • HF-1 data is interval (continuous) data • Intervals between any two adjacent values on a measurement scale are same • Use parametric statistics (mean, std. deviation, etc.) • CTM data is ordinal (categorical) data • Values represent a rank ordering of observations rather than precise measurements (e.g., CTM data scores of 1=strongly disagree, 2=disagree, 3=agree, 4=strongly agree) • You can count and order ordinal data, but you cannot perform mathematics on it • Use non-parametric statistics

31. CTM Data Non-parametric Statistical Analysis • Used binomial distribution comparing proportion of patients answering with score = 4 to the proportion answering anything else (scores = 1, 2, 3) • So compared proportion answering “strongly agreed” to those answering anything else (i.e., “agree,” “disagreed,” “strongly disagreed”) • Maine is an overachiever (as usual) 

32. CTM Data Non-parametric Statistical Analysis • Using binomial distribution (for non-parametric data) • Calculated proportion (“strongly agreed”) and upper and lower confidence intervals for: • Each hospital; • Each peer group of hospitals, and • Maine statewide • For each CTM question (1, 2, 3) and for Total CTM score

33. Hospital Data: Evaluated by Hospital Peer Groupings • Peer Group A • 250–606 beds (MMC, EMMC, CMMC, MGMC) • Peer Group B • 79–233 beds (Aroostook, Mercy, Mid Coast, Pen Bay, SMMC, St Joseph, St Mary, York) • Peer Group C • 53-70 beds (Cary, Franklin, Goodall, ME Coast) • Peer Group D • 38-55 beds (Inland, Miles, NMMC, Parkview, Stephens)

34. Hospital Peer Groupings - Continued • Peer Group E = Critical Access Hospitals • 25 beds or less (Blue Hill, Bridgton, CA Dean, Calais, Down East, Houlton, Mayo, Millinocket, MDI, Pen Valley, Red-Fairview, Rumford, Sebasticook, St Andrews, Waldo ) • Peer Group F = Psychiatric Hospitals • Acadia, Dorothea Dix, Riverview, Spring Harbor • Peer Group H = Rehabilitation Hospitals • New England Rehabilitation

41. CTM Correlation With Readmissions • Performed correlation analysis using Pearson correlation coefficient - a measure of the extent to which two variables “vary together.” The value of any correlation coefficient must be between -1 and +1. • Used CTM Total score probability from each hospital • Compared to CMS 30-day Risk-adjusted Readmission Rate for Heart Failure from Hospital Compare website

42. CTM Correlation With Readmissions • Best correlation coefficient R = 0.00347 (for CTM Question 1) • CTM Correlation (R) • Q1 = 0.00347 • Q2 = 0.00196 • Q3 = -0.01469 • Total CTM = -0.00230

43. Evaluate Correlation Coefficient (Cohen, 1988) R = 0.003 No Correlation

44. Why No Correlation Seen • Dates for data sets not comparable: • CTM = January 2008 to July 2009 • Readmission Rates = July 2005 to June 2008 • Literature indicates CTM predictive of risk/performance at the level of the patient, but not at level of the hospital? • If able to identify specific patient CTM survey results and track patient readmission status • “Gold standard”

46. CHF Burden: Nursing Facilities, Residential Care Facilities, and Home Care • Medicaid Policy Cooperative Agreement Project – “Congestive Heart Failure Prevalence in Maine Long Term Care” • Prepared by Catherine McGuire, Cutler Institute and Muskie School of Public Service

47. Nursing Home Admissions • For State Fiscal Year 2009, there were 16,073 admissions to nursing homes. The majority of admissions (88%) are from hospitals • CHF was indicated on 23% admissions • CHF prevalence was consistent for admissions from: • hospitals, • other nursing homes, • and other sources • Admissions from home and assisted living/ residential care were less likely to have a CHF diagnosis

48. CHF Prevalence in Maine Nursing Facility Admissions by Source, SFY2009

49. Nursing Home Discharges • In SYF 2009, there were 17,947 discharges; 24% had a CHF diagnosis • The majority of discharges from nursing facilities are to home (52%) • Residents discharged to hospital or deceased were more likely to have a CHF diagnosis: • Thirty percent of residents who died had a CHF diagnosis • Only 20% discharged home and 15% discharged to some other destination had CHF

50. CHF Prevalence in Maine Nursing Facility Discharges by Destination, SFY 2009