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Project BOOST Reducing Readmissions

Project BOOST Reducing Readmissions. Mark V. Williams, MD, FACP, FHM Professor & Chief, Division of Hospital Medicine Northwestern U. Feinberg School of Medicine Principal Investigator, Project BOOST. A Problem for a long time.

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Project BOOST Reducing Readmissions

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  1. Project BOOSTReducing Readmissions Mark V. Williams, MD, FACP, FHM Professor & Chief, Division of Hospital Medicine Northwestern U. Feinberg School of MedicinePrincipal Investigator, Project BOOST

  2. A Problem for a long time • Rosenthal, J. M. and D. B. Miller "Providers have failed to work for continuity." Hospitals 53(10): 79-83. Continuity of patient care between different health care settings has been advocated for nearly 20 years, but little has been done to effect it. The study described here emphasizes the current lack of effort by health care providers in hospitals and nursing homes to find a workable solution. 1979

  3. June 2007 MedPAC Report • Medicare pays for ALL admissions regardless • Initial stay or readmission for same condition • 17.6% of admissions result in re-admissions within 30 days (6% in 7 days) • = $15 billion in spending • Future • “CMS proposes to require that all general acute hospitals conduct a CARE assessment on every Medicare beneficiary being discharged.” • Continuity Assessment Record and Evaluation • Public Disclosure of readmission rates • Lower case payments for readmissions

  4. 1 in 5 Medicare patients rehospitalized in 30 days • Half never saw outpatient doc • 70% of surgical readmissions–chronic medical conditions • Costs $17.4 billion

  5. Rates of Rehospitalization within 30 Days after Hospital Discharge Jencks S, Williams MV, Coleman EA. et al. N Engl J Med 2009;360:1418-1428

  6. Health Affairs 2010; 29:57-64

  7. Average LOS: US Hospitals > 65 = 12.6 to 5.5 days DeFrances et al, Adv data, 2007 Jul 12;(385):1-19

  8. Harlan M. Krumholz, MD, SM research group • Observational study of 6,955,461 Medicare FFS hospitalizations for HF; 1993 and 2006, with 30-day f/u. • Mean age = 80 • 52% Htn, 38% DM, 37% COPD • LOS 8.8 days down to 6.3 • In-hospital mortality declined from 8.5% to 4.3% • 30-day mortality declined from 12.8% to 10.7% • Discharges to SNF increased from 13% to 20% • Discharge to home decreased from 74% to 67% • 30 day readmission increased from 17.2% to 20.1% • Post-discharge mortality increased from 4.3% to 6.4%

  9. Preventable Admissions • Hospital inpatient care is the most expensive type of health care • > 4 million Preventable Admissions • Cost nearly $31 Billion • Heart Failure and Pneumonia • Half of the $ problem • COPD – 16% • Diabetes – 13% • Elderly – 2/3 of these hospitalizations - 1 in 5 Medicare admissions

  10. Care Coordination Failure? • 5 commercial disease management companies, 3 community hospitals, 3 AMCs, 1 integrated delivery system, 1 hospice, 1 long term care facility, 1 retirement community across U.S. • No cost savings • 2 reduced hospitalizations • Sickest patients benefited

  11. HospitalCompare.gov

  12. Readmission ReductionCBO - $7.1B savings over 10 yrs • Hospital Quality & Performance Based Payments • All DRG payment amounts in hospitals with excess readmission are reduced by a factor determined by the level of “excess, preventable readmissions” • Effective 2013 • Excess = ratio of actual to expected (risk-adj) • Reduction of 1%, 2%, and 3% first 3 years

  13. Readmission Reduction Program • NQF endorsed measures • Initially AMI, HF, pneumonia • Expand in 2015 to 4 more conditions • COPD, CABG, PTCA, Other Vascular • Measures must have exclusions for readmissions unrelated to prior discharge • e.g. transfers, planned readmissions • Readmission time window specified by Secretary • 30 days in NQF measures • Report all-payer readmission rates publicly

  14. Measures – AMA PCPI • Care Transitions • Work Group • Performance Measure Set • Reconciled medication list • Transition record • Timely transmission • Discharge Planning/Post-Discharge Support for Heart Failure Patients

  15. Hospital Discharge - currently “Random events connected to highly variable actions with only a remote possibility of meeting implied expectations.” Roger Resar, MD Agent of Tremendous Change and Global Innovation Seeker Luther Midelfort – Mayo Health System Senior Fellow, IHI

  16. Dangers of Discharge • 19% of patients had a post discharge AE • - 1/3 preventable and 1/3 ameliorable Ann Intern Med 2003; Vol. 138 • 23% of patients had a post discharge AE • - 28% preventable and 22% ameliorable CMAJ 2004;170(3)

  17. Dangers of Discharge • 1095 of 2644 (41%) inpatients discharged with test result pending •  - 191 (9.4%) potentially required action •  - Survey of MDs involved: almost 2/3 unaware of results •  - Of these: 37% actionable and 13% urgent • Ann Intern Med 2005;143(2):121-8

  18. Dangers of Discharge • ¼ of discharged patients require additional outpatient work-ups • > 1/3 not completed • Increased time to post-discharge f/u associated with lack of work-up completion • Availability of discharge summary increased likelihood of work-up being done Arch Intern Med. 2007;167:1305-1311

  19. Hospitalist to PCP • Info transfer and communication deficits at hospital discharge are common • Direct communication 3-20% • Discharge summary availability at 1st post-discharge appt 12-34%; 51-77% at 4 weeks • Discharge summaries often lack info • Dx test results (33-63%), hospital course (7-22%), discharge meds (2-40%), pending test results (65%) • Follow-up plans (2-43%), Counseling (90-92%) Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW JAMA 2007;297:831-41.

  20. Discharge Summary J Gen Intern Med 2009;24:1002-6 “Discharge summaries are grossly inadequate at documenting both tests with pending results and appropriate f/u providers.”

  21. Northwestern Solution • Significantly improved the quality and timeliness. • Better documentation of f/u issues, pending tests, and info provided to patients and/or family. • PCPs more satisfied with timeliness and quality • >95% of discharge summaries completed in < 1 week Journal of Hospital Medicine 2009;4:219

  22. Discharge Planning - is it THE answer? • 21 RCTs: 4509 medical, 2285 med-surg; 440 Ψ • LOS: mean decrease -0.91 (95% CI: -1.55 to -0.27) • Readmission rates: RR 0.85 (0.74 to 0.97) • Elderly medical pts: mortality RR 1.04 (0.74 to 1.46) • Discharged to home: RR 1.03 (0.93 to 1.14) • Improved patient satisfaction • Subset analysis: improved functional status Cochrane Database of Systematic Reviews 2010;1

  23. Randomized 363 patients age > 65 • “Comprehensive discharge planning” and home follow-up with APNs • ~70% completion rate • Readmissions at 24 weeks 20% vs 37% • Reduced multiple readmissions 6.2% vs 14.5% • Prolonged time to first readmission • Medicare reimbursements cut in half

  24. Elderly patients transitioning to SNF/home • Randomized: Intervention group paired with “Transition Coach” vs. standard care • Empowerment and education: 4 pillars • Facilitate self management/adherence • Maintain a personal health record • Timely follow-up • Knowledge and management of complications • Education during hospitalization • including meds and med reconciliation • Phone calls and personal visits by TC post discharge • Reduced rehospitalization and costs Arch Intern Med 2006;166:1822-1828

  25. Arch Intern Med 2006;166:1822-1828 Results RehospitalizationIntervContP(adj)OR (95%CI) Within 30d 8.3 11.9 0.048 0.59 (0.35-1.00) Within 90d* 16.7 22.5 0.04 0.64 (0.42-0.99) Within 180d* 25.6 30.7 0.28 0.80 (0.54-1.19) Costs($)IntervContUnadjLog Transformed At 30d 784 918 0.048 0.06 At 90d 1519 2016 0.02 0.02 At 180d 2058 2546 0.04 0.049 *Also significantly improved for “Rehospitalization for same diagnosis as index admission.”

  26. Or should it be a Pharmacist? • N=221 randomized at UCSF • All receive pharmacist facilitated discharge • 110 got 2 day phone call by pharmacist: • Check on clinical status • Remind about follow-up • Check on medications (did they obtain them; any problems taking them; any side effects; did they know which to take and how; etc…) Am J Med 2001;111(9B):26S-30S

  27. Results • Contacted 79 or 110 • 25% had questions about their meds • 11% had questions about their care • 11% had questions about follow-up • 19% had been unable to get their meds • 15% reported new problems • Greater satisfaction in intervention group: 86% vs. 61% very satisfied (p=0.007) • 10% vs. 24% patients came to ED at UCSF at 30d (p=0.005) • 15% vs. 25% rehospitalized at 30d (p=0.07)

  28. Pharmacy Literature • Schnipper et al: • N = 178 medical patients randomized • Intervention: • Med reconciliation done at d/c by Pharmacist • Pharmacist counseling at d/c and 3day follow-up call • At d/c, pharmacist recommended med changes in 60% • At 3d call, unexplainable discrepancies between d/c meds and reported home meds in 29% • At 30d • Fewer preventable ADEs: 1% vs. 11% (p=0.01) • Fewer preventable med related ED visits: 1% vs. 8% (p=0.03) • 49% had med discrepancies! • No difference in total ADEs, health care utilization, patient satisfaction, or med adherence Arch Intern Med 2006;166:565-71

  29. Pharmacists Work! • Swedish ward-based pharmacists • 16% reduction in hospital visits • 47% reduction in ER visits • Drug-related readmissions reduced 80% • Intervention group cost < control Arch Intern Med. 2009;169(9):894-900

  30. Project RED • RCT of 749 hospitalized adults • Intervention • Nurse Discharge Advocate • F/U appt, Medication Reconciliation • Patient education • Individualized instruction booklet • Pharmacist call 2-4 days post-discharge • Review medications • Limitations • Urban, academic, safety net hospital

  31. Project RED Outcomes *p < 0.05 **p = 0.09

  32. Low-cost Intervention • “user-friendly” Patient Discharge Form • Telephone outreach from a nurse post-discharge • Improved outpatient follow-up • Reduced ER visits and rehospitalizations from historical controls JGIM 2008

  33. Med Rec by PharmD • RN Care Coordinator D/C Planning • Phone Follow-up • PHR, Supplemental Discharge Form • Reduced ER visits, Reduced Readmission

  34. SHM Initiatives • Discharge Checklist Halasyamani L et al. Transition of care for hospitalized elderly patients--development of a discharge checklist for hospitalists. J of Hosp Med 2006:354. • Resource Room • Safe STEPs • Project BOOST • Better Outcomes for Older adults through Safe Transitions • John A. Hartford Foundation $1.4 million

  35. Safe STEPs • Safe and Successful Transitions for Elderly Patients • John A. Hartford Foundation Grant

  36. Safe STEP Interventions • Medication reconciliation • Pharmacy reviews: admission and d/c • Geriatric friendly medication forms • Education • Patients: pre-d/c appointment • Providers: geriatric h&p • PCP communications • “Fast facts”

  37. Safe STEPs • 237 elderly patients at three hospitals • Academic, community • 5 component intervention • Admission form with geriatric cues • Fax to PCP • Interdisciplinary worksheet • Pharmacist-physician medication reconciliation • Pre-discharge planning appointments • Reduced ED visits and readmissions by 1/3

  38. Project BOOST Team • Janet Nagamine, MD • Dan Dressler, MD, MS • Kathleen Kerr • Greg Maynard, MD • Arpana Vidyarthi, MD Tina Budnitz, MPH Eric Coleman, MD, MPH Jeff Greenwald, MD Eric Howell, MD Lakshmi Halasyamani, MD Mark V. Williams, MD

  39. Social work Case management Clinical pharmacy Geriatric medicine Geriatric nursing Health IT Blue Cross/Blue Shield United Health Health systems NQF AHRQ TJC CMS National Consumer’s League Other content experts Advisory Board Chair: Eric Coleman, MD, MPH Co-Chair: Mark V. Williams, MD with organizational representatives from:

  40. www.hospitalmedicine.org/BOOST

  41. Intervention Tailored clinical Tools: Comprehensive Risk Assessment Team-based care Patient centered discharge process 72 Hour follow-up call for “high-risk” patients Scheduled outpatient follow-up visits Standardized PCP Communication Tailored processes, work-flow Project management tools What is BOOST Today?

  42. BOOST components (cont) • Technical Support • Mentors calls, email, resources • Teleconferencing across sites • Education (webinars, newsletters) • Enduring Materials (Teachback DVD) • Peer Support • Listserv • Document sharing • Moral support • Infrastructure Development • Train the trainer curricula • Mentor Guides • Mentor University

  43. Teach Back NEW CONCEPT:Health information, advice, instructions, or change in management Assess patient comprehension / Ask patient to demonstrate Explain new concept / Demonstrate new skill Clarify and tailor explanation Patient recalls and comprehends / Demonstrates skill mastery Re-assess recall and comprehension / Ask patient to demonstrate Adherence / Error reduction Modified from Schillinger, D. et al. Arch Intern Med 2003;163:83-90

  44. Life-Cycle Project BOOST Training & Preparation Individualized Mentoring Implement intervention Keep stakeholders informed Monitor core elements Analyze data Adjust intervention components Report to stakeholders Spread gains Training-6months 6-9 months 9-12 months

  45. BOOST Network • BOOST eNewsletter • Key milestones • BOOST updates • Site status reports, aggregate outcomes • Forum for sharing ideas, challenges, mini studies • BOOST Network • E-mail, call between sites • BOOST listserv

  46. End-Result • Network of Institutions using the guide and interventions • Understanding Impact of Interventions • Understanding Implementation facilitating factors and barriers

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