Region 2’s Approach to on the Reducing Readmissions

1. Region 2’s Approach to on the Reducing Readmissions Craig S. Kovacevich, MA Associate Vice President Waiver Operations & Community Health Plans Office of the President The University of Texas Medical Branch at Galveston Wednesday, August 20, 2014

2. Regional Health Partnership: Region 2 UTMB 2

3. Regional Health Partnership: Region 2 • 16 counties • Population of nearly 1.5 million people • Covers nearly 14,500 square miles • Urban and rural with varying infrastructure challenges • 25% of population is uninsured • 27% of population is on Medicaid or Medicaid/Medicare (dual eligible) • More than 50% of the region is designated as Health Professional Shortage Area in Primary Care and/or Mental Health Shelby Nacogdoches San Augustine Sabine Angelina Newton Polk Jasper Tyler San Jacinto Hardin Orange Liberty Jefferson UTMB Brazoria Galveston

4. RHP 2 Community Needs Assessment • Access barriers • Personal resource challenges (i.e. transportation) • Lack of insurance coverage • Health care workforce shortages • Physicians (primary and specialty care) • Mental/behavioral health providers • Allied health professionals (mid-level providers, nurses, etc.) • Dentists • Community Health Workers/Patient Navigators • High ED utilization and 30-day readmission rate • Chronic disease Incidence • Diabetes • Heart & vascular related diseases • Mental health related morbidity and mortality

5. RHP 2 Regional Goals and Objectives Expand access to and coordination of: Patient-centered primary care Behavioral health care services Health promotion and disease prevention Specialty care services Chronic disease management Improve quality of care through: Continued process improvements Collaborative learning opportunities Development of innovative solutions Grow health system resources by: Expanded and enhanced healthcare workforce training Educate future healthcare professionals through interdisciplinary training that contemplates tomorrow’s delivery system

6. RHP 2 Readmissions Learning Collaborative Goals: Expand quality improvement reporting capacity by improving utilization of people, processes and technology…with an end goal of reducing as many avoidable readmissions as possible Share best practices, provide education and training to clinical and administrative staff and design more timely and efficient data collection systems…with an end goal of reducing as many avoidable readmissions as possible Learn about content and about rapid cycle improvement from subject matter experts, project staff/learning collaborative coaches and each other…with an end goal of reducing as many avoidable readmissions as possible Incorporate the BOOST model (Better Outcomes for Older adults through Safe Transitions) from the Society for Hospital Medicine as a framework for addressing Preventable Readmissions…with an end goal of reducing as many avoidable readmissions as possible

7. RHP 2 Readmissions Learning Collaborative Three “In-Person” Meetings: January, May and August 2014 14 different organizations have actively participated, including Public and Private Hospitals, Critical Access Hospitals, Physician Group Practices and Behavioral Health Centers Sharing of challenges and successes by all participating organizations – even if they do not have DSRIP projects directly tied to readmissions Calls are held twice a month (first call of the month: project status updates; second call of the month: “push” of information on performance improvement topics) BOOST Model “Areas of Focus” 8P Risk Scale - Prior Hospitalization, Problems with Medications, Psychological, Principal Diagnosis, Physical Limitations, Poor Health Literacy, Patient Support and Palliative Care General Assessment of Preparedness (GAP) Tool for Clinical Assessment -Done at minimum on three (3) occasions: admission, nearing discharge and discharge Patient Preparation to Address Situations Successfully (Patient PASS) - Patient’s perception of their condition(s) and requirements for self-management Teach-back - To discover what the patient really understands about their condition, hospitalization, home treatment and follow-up care

8. RHP 2: Our “Shared” Opportunities Development of competencies for new reimbursement models and population health management Establishment of new affiliations and community relationships to improve coordination of and access to healthcare services Engagement of regional stakeholders, including additional providers, community organizations and patients Advancement of the “Triple Aim” in through enhanced collaboration: Improve the patient experience via quality and overall satisfaction Advance the health outcomes of populations Reduce the per capita cost of care

9. Readmissions Case Study #1 57 year old male with a history of COPD Medicare patient Five (5) admissions in a six (6) week span (totaling 11 inpatient days) • All admissions for shortness of breath/COPD exacerbation • Teach-back and clear discharge plan documented for each discharge • Follow-up phone calls made Were any of the readmissions preventable?

10. Readmissions Case Study #1 (continued) 57 year old male with a history of COPD Six (6) previous admissions in 2014 History of Medication non-compliance Limited funds spent on cigarettes and marijuana History of non-compliance with fluid restrictions and dietary recommendations Home Health (HH) and Community Health Program (CHP) referrals were made The readmissions were not avoidable Patient deemed hospital dependent due to: • Non-compliance of medical orders and recommendations • Rapid disease progression Determination of hospital dependency allows for: • More appropriate use of inpatient resources and planning • Recognition that HH and CHP are sometimes not able to solve readmissions due to patient non-compliance

11. Readmissions Case Study #2 30 year old female with a history of Crohn’s Disease Managed Medicaid patient Five (5) day index (initial) admission • Teach-back and clear discharge plan documented for discharge • Follow-Up phone call(s) made • Patient discharged with Narco for pain (40 tab) Patient readmitted after 10 days for Abdominal pain (before outpatient follow-up visit could occur) Was the readmission preventable?

12. Readmissions Case Study #2 (continued) 30 year old female with a history of Crohn’s Disease Documentation shows that she had severe disease Pain was uncontrolled Patient was not hospital-dependent Patient referred to Community Health Program (CHP) during readmission This readmission was avoidable Determination of non-hospital dependency made: • Patient initially discharged with inadequate pain medication • Documentation of pain indicated a stronger Rx required • Referral to CHP should have been made at initial discharge vs. at readmission discharge • During follow-up call, patient indicated concerns with pain that should have triggered an ambulatory appointment or outreach visit by CHP personnel.

13. Thank You Please visit our regional website at: http://www.utmb.edu/1115/