Reducing Patient Readmissions

1. Reducing Patient Readmissions Keys to Improving Patient Care

2. Overview • Impact of the Patient Protection and Affordable Care Act (PPACA) on your facility • Critical strategies to reduce readmissions Reducing Patient Readmissions / 2

3. Objectives • Review the impact of PPACA • Identify key strategies and tactics for reducing readmissions that can be applied in their organizations • Describe actionable strategies for engaging community organizations across the continuum of care • Strengthen patient involvement in their care Reducing Patient Readmissions / 3

4. Health Care Reform Legislation • March 23, 2010=PPACA • Paying for quality instead of quantity • Financial penalties • Community based care transitions program Reducing Patient Readmissions / 4

5. Affordable Care Act and Reducing Readmissions • §3026 • http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/index.html?itemID=CMS1239313 • §3501 • http://www.ahrq.gov/qual/patientsafetyix.htm • §399KK • http://www.pso.ahrq.gov/ • §3025 Reducing Patient Readmissions / 5

6. Patient Safety Organization (PSO) Role • §399KK implementation • ACA designates PSOs to help hospitals • Department of Health and Human Services supports the PSOs • To find a PSO • http://www.pso.ahrq.gov/listing/psolist.htm • Eligible hospitals • http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_FourthQuartileHospsbyState.pdf Reducing Patient Readmissions / 6

7. Readmission Reduction Program • NQF endorsed measures • Report all-payer readmission rates publicly • Excess vs. expected • For more information: www.QualityNet.org Reducing Patient Readmissions / 7

8. 2012 Hospital-Specific Report Example Reducing Patient Readmissions / 8

9. The Reason Behind Readmissions • Hospitals have responsibilities, but they are not alone • Readmissions occur when: • Patients don’t understand or can’t comply with discharge instructions • Patients in some communities lack access to primary care, post-acute care, pharmacies • Patients have multiple diagnoses that make them more vulnerable to complications Reducing Patient Readmissions / 9

10. Published Evidence • Four broad categories • Enhanced care and support during transitions • Improved patient education and self-management • Multidisciplinary team management • Patient-centered care planning at the end of life Reducing Patient Readmissions / 10

11. Key Strategies and Tactics (continued) • Assess your risks • Patient • Hospital • Financial • http://rarereadmissions.org/ • Understand your readmission history • Evaluate potential cause and appropriateness of recent readmissions • http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx Reducing Patient Readmissions / 11

12. Key Strategies and Tactics (continued) Timely discharge summaries Lengthen the handoff process Provide medication on discharge Make a follow-up plan before disharge Telehealth Identify frequent flyers Reducing Patient Readmissions / 12

13. Key Strategies and Tactics (continued) Understand what’s happening post-discharge Provide home care on wheels Consider physician medication reconciliation Ensure patients understand Focus on highest-risk patient Listen to the patient Reducing Patient Readmissions / 13

14. Where the Gaps Are: Other Factors No longer does one practitioner typically take responsibility for the discharge and follow-up Discharging practitioners may be unfamiliar with the capacity to provide care in settings to which they send patients Lack of a universal electronic health information system The revolving door of skilled nursing facilities Reducing Patient Readmissions / 14

15. The Best Transition… Is only as good as the reception into the next setting of care. Boutwell A and Johnson MB: STAAR Issue Brief: Reducing Barriers to Care Across the Continuum–Working Together in a Cross-Continuum Team. STAAR Issue Brief Series 2010 Number 3. Available at http://www.ihi.org/offerings/Initiatives/STAAR/Documents/ STAAR%20Issue%20Brief%20-%20Cross%20Continuum%20Teams.pdf Reducing Patient Readmissions / 15

16. Cross-Continuum Teams (CCTs) Key component of the State Action on Avoidable Rehospitalizations (STAAR) initiative Team composition Infrastructure Reducing Patient Readmissions / 16

17. Cross-Continuum Teams Multi-stakeholder team Provides oversight and guidance Known as the “STAAR Effect” New competencies developed Reducing Patient Readmissions / 17

18. Key Changes • Enhance assessment of post-hospital needs • Effective teaching and learning • Ensure follow-up • Real-time handovers Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Avoid Rehospitalization. Cambridge, MA: Institute for Healthcare Improvement; June 2012. Available at ww.IHI.org Reducing Patient Readmissions / 18

19. Transitions Home Collaborative Getting Started Executive leader selected Sponsor convenes the team Opportunities for improvement identified Aim statement developed Kick-off meeting Reducing Patient Readmissions / 19

20. CCT Recommendations Meet regularly Visit each other’s sites Complete periodic diagnostic interviews Add patients and family members Reducing Patient Readmissions / 20

21. Questions to Ask How can we get timely and relevant information from community providers? Do we have universal patient-friendly education materials for common conditions in all settings? Are staff members competent in effective teaching and facilitating learning? Reducing Patient Readmissions / 21

22. Questions to Ask (continued) Have we co-designed real-time handover communications Do we utilize universal format for patient care plans? Who is the best clinical provider to complete follow-up phone calls? How do we collaborate with payers and post-acute providers to determine eligibility for certain populations? Reducing Patient Readmissions / 22

23. Where the Gaps Are: Health Literacy “Health (il)literacy”: Nearly half of adults have trouble understanding simple health information (procedure consent, prescriptions, oral instructions) Less than half of patients discharged from academic general medicine know their diagnoses, treatment plans, or side effects of prescribed medications Reducing Patient Readmissions / 23

24. The High-Risk Patient History of readmission Failed teach-back Longer stay than expected High-risk conditions Poor, disabled, or on dialysis Late follow-up after discharge Reducing Patient Readmissions / 24

25. Engaging the Patient: Health Literacy • Redflags: • Elderly • Low income • Unemployed • Minority • Did not finish high school • Immigrant • Born in U.S. but English second language • Noncompliance • Can’t name meds • “Forgot my glasses…will read later” Reducing Patient Readmissions / 25

26. Engaging the Patient: Communication • Eight steps for oral communication: • Slow down • Plain language • Pictures • Limited information • Repeat • Teach-back • Provide oral and written information • Shame-free environment Reducing Patient Readmissions / 26

27. High-Level Opportunities for Action • Execute an effective transition from the hospital to post-acute care settings • Early assessment of discharge needs • More intensive management of chronic medical conditions during hospitalization • Evidence: • Transition coaching • Nursing phone call follow-up • Hospital-generated phone call and coaching • Collaboration between sending and receiving facilities on what data is needed during transfers Reducing Patient Readmissions / 27

28. High-Level Opportunities (continued) • Facilitate timely follow-up care in the post-discharge setting • Work with outpatient providers to schedule appointments prior to discharge • Consider early follow up for “high-risk” patients, which may be hospital-generated call • Increase referral to home health when indicated • Consider enhanced outpatient support Reducing Patient Readmissions / 28

29. High-Level Opportunities (continued) • Engage patients and caregivers as active participants and managers of their care • Include medications • How to monitor for and act on clinical deterioration • Use of hospital-based enhanced assessment • Early and repeated teaching opportunities during hospitalization • Assess patient’s understanding • Condition, diet/medications, and symptoms Reducing Patient Readmissions / 29

30. Readmission Is an Opportunity Fragmentation of care lies behind many failed transitions Improving transitions will necessarily reduce fragmentation If we succeed, we have established a precedent for fixing other broken parts of the health care system Reducing Patient Readmissions / 30

31. Real World Success Stories • Improved transitions out of the hospital • Project RED • BOOST • IHI’s Transforming Care at the Bedside • Hospital to Home “H2H” (ACC/IHI) • Supplemental transitional care between settings • Care Transitions Intervention (Coleman) • Transitional Care Intervention (Naylor) • Missouri Department of Health and Human Services Reducing Patient Readmissions / 31

32. Patient and Family Engagement • Patient-Centered Care • http://www.ipfcc.org/tools/Patient-Safety-Toolkit-04.pdf • Promotion • http://www.ahrq.gov/qual/engagingptfam.htm • Principles • http://www.gwumc.edu/healthsci/departments/nursing/naqc/documents/Patient_Engagement_Guiding.pdf Reducing Patient Readmissions / 32

33. Community Engagement Know where your patients are coming from Know where your patients are going to Reducing Patient Readmissions / 33

34. Boston University Experience Testing theRe-Engineered Discharge Brian Jack, MD, Principal Investigator Associate Professor and Vice Chair Department of Family Medicine Boston Medical Center Boston University School of Medicine Reducing Patient Readmissions / 34

35. BOOST Toolkit: Primary Components • Tool for identification of high-risk patients • Patient and family/caregiver preparation • Enhanced communications • Discharge summary • Provider to provider • Patient contact • Patient resource Reducing Patient Readmissions / 35

36. Institute for Healthcare Improvement Reducing Patient Readmissions / 36

37. Hospital to Home (H2H) • Available at: http://h2hquality.org H2H is a national quality improvement initiative Goal is to reduce all-cause readmission rates in heart failure and acute myocardial infarction Uses a three-question framework Reducing Patient Readmissions / 37

38. The Care Transitions Intervention Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Int Med. 2006;166(17):1822-8. • 750 community-dwelling adults 65 years or older admitted to the study hospital with one of 11 selected conditions • Intervention: • Tools to promote cross-site communication • Encouragement to take a more active role in their care • Guidance from a “transition coach” Reducing Patient Readmissions / 38

39. Transitional Care Model Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675-84. Nurse practitioners provide inpatient assessment NPs review medications and goals Design and coordinate care with patients and providers Attend first post-discharge MD office visit Direct home care for one to three months Conduct home interviews Reducing Patient Readmissions / 39

40. Available at: http://web.mhanet.com/aspx/articles.aspx?navid=111&pnavid=4&articleid=143 Reducing Patient Readmissions / 40

41. AHRQ Web Resource www.ahrq.gov/news/kt/red/redfaq.htm • Implementing Re-Engineered Hospital Discharges (Project RED) • Training manual • After-hospital care plan samples • Tool kit • Various forms • How-to ideas • Evaluation • Cost and implementation Reducing Patient Readmissions / 41

42. Some Practical Tools • Ideal discharge checklist: Society of Hospital Medicine–Quality Improvement Tools: • www.hospitalmedicine.org • Care Transitions Program • www.caretransitions.org • “Getting Ready to Go Home”–simple checklist for patients and families at admission to help think about discharge issues: • www.hospitalmedicine.org Reducing Patient Readmissions / 42

43. Questions? “It is not the answer that enlightens, but the question.” –Eugene Ionesco Reducing Patient Readmissions / 43

44. Mission Statement sshepard@thedoctors.com (800) 421-2368, ext. 1134 Our Mission Is to Advance, Protect, and Reward the Practice of Good Medicine For additional information, go to www.thedoctors.com and click on Patient Safety. Reducing Patient Readmissions / 44