Reducing Avoidable Readmissions for the Rural Population

1. Reducing Avoidable Readmissions for the Rural Population INDIANA RURAL HEALTH ASSOCIATION June 7, 2011 Nancy Meadows, RN, BS Project Director Robbin Lubbehusen, BA Project Manager Health Care Excel

2. Background Approximately 18% to 20% of Medicare beneficiaries who are discharged from a hospital are readmitted within 30 days (MedPAC, 2007; Jencks et al., 2009) Readmission rates vary significantly across hospitals and states, as well as across diagnoses, even after adjusting for disease-specific and severity-related differences

3. The primary component of reducing readmissions in rural settings is the ability to coordinate care and ensure the patient has access to health care services and community support.

4. It’s all about patient safety! Developing high quality care transitions Transmitting and communicating essential data elements to practitioners involved in a patient’s care across all settings Structuring organizational and community delivery systems to promote seamless transitions across care settings Reviewing coverage and limitations that affect access to care and services Helping patients and caregivers understand what should expect at the next care setting(s)

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

6. Predictions Abound Despite Uncertainty Source: Health Care Advisory Board (2010). Playbook for Accountable Care, Road Map for the Transition to Total Cost Accountability. The Health Care Advisory Board: Washington, D.C.

7. Challenges to Care Coordination in Rural Hospitals 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 Predominately older populations with multiple chronic conditions Isolation and sometimes large geographical areas and travel distances

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

9. Strengths of Rural Health Care Systems History of becoming innovative to meet challenges Absence of large, complex systems Patients are less scattered among multiple delivery systems Culture of community collaboration Less competition Strong primary care physician infrastructure

10. Strengths of Rural Health Care Systems Established multiple disciplinary teams and networks are often in place to ensure access and improve quality of care Rural cultural norms contribute to a level of community engagement leading to a shared interest in accomplishment

11. Actions for Rural Providers • Develop plans that expands the organization’s mission and philosophy to include care coordination across health care setting and identifies strategic options. • Identify, collect, report, & monitor to improve quality and improve efficiency in discharge redesign • Develop community partnerships and public health support for more effective community-focused interventions • Meet with physicians, purchasers, payers, and consumer advocates for focused discussions on drivers of unnecessary admissions and readmissions • Assess financial position and opportunities for improvement; designate funding for chronic and transitional care management

12. 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

13. Key Elements to Improvement • 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

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

15. 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

16. 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 • Lack of social support • Confusion over self-care instructions • Lack of adherence to medications, therapies, and diet • Ineffective provider-to -provider communications (skills and tools)

17. Patient Literacy and Adherence: An important role in Care Transitions “We must close the gap between what health care professionals know and what the rest of America understands.” Dr. Richard Carmona, U.S. Surgeon General 2002-2006

18. Why are literacy and adherence important in patient care?Challenges for Improvement • Written and verbal patient instructions • Often complex • Delivered rapidly • Easy to forget in stressful situation • Increasing complex health care system • More medications • More tests and procedures • Greater self-care requirements

19. Develop an Action Plan Develop community connections to eliminate barriers to successful care transitions Develop strategies and interventions to engage patients, families, and caregivers in addressing the issue

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

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

22. 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 follow-up appointments • Medication reconciliation and patient medication self-management techniques • Facilitate discharge communications with post-acute care providers

23. 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

24. Major Strategies to ReduceAvoidable Readmissions • Post Discharge • 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

25. Major Interventions

26. Major Interventions

27. Major Interventions

28. Monitor and Evaluate Progress • Critical element often not thought out • Informs hospital leaders of the efficacy of strategies • Helps guide implementation of additional strategies • Prioritize and report readmission data as quality and safety indicators • Hospital boards • Quality committees • Front-line and clinical staff

29. Critical Access Hospital Quality Readmission Project • Indiana Rural Hospital Flexibility Grant Program (Flex Program) / State Office of Rural Health (SORH) • Statewide quality project focusing on Critical Access Hospital (CAH) readmission rates, specifically Heart Failure and Pneumonia • Five-year grant period (September 2010 – August 2015) • In collaboration with the Indiana Rural Health Association, Health Care Excel (HCE) is leading the project; providing support to CAHs in implementing quality/patient safety projects focused on reducing avoidable readmissions through improvements in discharge processes

30. Critical Access Hospital Quality Readmission Project • Technical assistance provided to CAHs with project activities implementation, beginning with assessment/review of: • Current admission, discharge & medication reconciliation protocols • Care pathways • Best practices • Organizational services supporting the transition from hospital to home

31. Critical Access Hospital Quality Readmission Project • Increase efficiency of transitional care planning of CAHs and between health care settings, HCE’s project activities will focus on improving performance in the following areas: • Shift-to-shift communication of discharge plan and patient education needs • Patient medication reconciliation tools • Patient discharge information • Patient education/health literacy • Collaborative partnerships among providers • Personal health information

32. Critical Access Hospital Quality Readmission Project • Project Impact Measures • Total # of CAHs participating in statewide QI project • Total community population services • Total patients service • Number of CHF/PN Readmissions • Cost of CHF/PN Readmissions • Average Inpatient LOS for CHF/PN • Bed Utilization for CHF/PN

33. Critical Access Hospital Quality Readmission Project • Hospitals participating in 1st year of the project (Sept 2010 – August 2011) • Decatur County Memorial Hospital – Greensburg • Margaret Mary Community Hospital – Batesville • Putnam County Hospital – Greencastle • Rush Memorial Hospital – Rushville • St. Vincent Dunn Memorial Hospital – Bedford • Sullivan County Memorial Hospital – Sullivan • White County Memorial Hospital – Monticello

34. Critical Access Hospital Quality Readmission Project • Hospitals participating in 2nd year of the project (Sept 2011 – August 2012) • Bloomington Hospital of Orange County – Paoli • Harrison County Hospital – Corydon • IU Health Blackford Hospital – Hartford City • St. Vincent Mercy Hospital – Elwood • St. Vincent Salem Hospital – Salem • Grant cycle year-end 2015: Participation of all of Indiana’s 35 Critical Access Hospitals (CAH) in project

35. Critical Access Hospital Quality Readmission Project • HCE will continue to work with CAHs beyond project year • Continue to provide technical assistance and education to CAHs on sustaining improvements accomplished during the first year • Facilitate these participating CAHs in mentoring those that are new to the project by sharing best practices, lessons learned, barriers encountered and solutions to barriers

36. Questions? This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-IN-TRAN-10-008 02/23/2010