Care Transitions Learning and Action Network

1. Care Transitions Learning and Action Network

2. Today’s Agenda • Welcome and Readmission Data Discussion • Rebecca Durham, HealthInsight 1:20 - 1:35 p.m. • Why We are interested in Readmissions • Michelle Carlson, HealthInsight 1:35 - 2:00 p.m. • Effective Communication Tools 2:00 - 2:20 p.m. • Michelle Carlson/Rebecca Durham Group Discussion 2:20 - 2:50 p.m. • Everyone Wrap up and Evaluations 2:50- 3:00 p.m.

3. What are our aims? • Our overall goal is to reduce 30-day hospital readmissions for Medicare FFS patients in Utah by 20% by July 31, 2014. Nationwide, about 1 in 5 Medicare beneficiaries are readmitted to the hospital within 30 days of discharge (Jencks et al., 2009). • Our objectives are to engage with care providers and communities around the state to examine the root causes of 30-day readmissions and implement evidence-based interventions to address these causes… • So that Medicare beneficiaries have improved health and spend more time at home, instead of in the hospital.

5. How are we doing? • In general, Utah has one of the lowest rates of hospital readmissions for people with Medicare in the country: ….But that is no reason to be complacent! Source: Dartmouth Atlas of Healthcare, analysis of 2009 adjusted data for US Medicare population

6. Annual All-Cause 30-Day Readmission Rates • Utah, 2011 • Hospital level: 13.4% • Range: 5.0% - 16.7%* • Clearly, there is a lot of variation amongst hospitals and some are having great success with rates below 10%! *Excluding hospitals with <100 denominator Source: HealthInsight analysis based on Medicare FFS claims for the period of 1/1/2011-12/31/2011.

7. So who gets readmitted? Source: HealthInsight analysis based on Medicare FFS claims for the period of 4/1/2009-12/31/2011. Date axis reflects year end date.

8. Where did they go when they left the hospital? • Percentage of 30-day readmissions by status at index admission discharge Source: HealthInsight analysis based on Medicare FFS claims for the period of 1/1/2011-12/31/2011.

9. How can data help us ?identify potential partners? Source: Analysis based on Medicare FFS claims for 2009.

10. How can data help us identify potential partners? Source: Analysis based on Medicare FFS claims for 2009.

11. How can data help us identify potential partners? Source: Analysis based on Medicare FFS claims for 2009.

12. How can data help us identify potential partners? Source: Analysis based on Medicare FFS claims for 2009.

13. How can data help us with root causes? • One driver of 30-day readmission rates is lack of timely follow up with outpatient care after discharge from hospital. • In Utah in 2011, • 48.5% of patients who were readmitted to the hospital within 30 days were readmitted within 10 days of discharge • 37.7% of patients who were readmitted to the hospital within 30 days were readmitted within 7 days of discharge Source: HealthInsight analysis based on Medicare FFS claims for the period of 1/1/2011-12/31/2011.

14. We are here to help! • Data and the information they generate are extremely useful for finding patterns and examining trends, and we have data that can help light the path. • But we still need YOU to walk the path with us and help us learn what we cannot from data alone.

15. Thank you! Rebecca Durham rdurham@healthinsight.org 801-892-6620

16. Community-Based Care Coordination 339 Days in the Life of Mrs. B A Medicare Beneficiary

17. Mrs. B

18. Newly Established Patient with Internal Medicine Physician • A regular source of care • Initial visit - DM, HTN, osteoporosis and hypothyroidism • DM poorly controlled, early numbness • Scheduled bi-monthly visits until DM controlled

19. Day 15 Status: Providers: Medications: Payments: Daughter: Fully functional, Helps with grandkids Takes care of her husband Internist Ophthalmologist (?) 2 HTN each 1x/d, 2 DM each 2x/d 1 osteoporosis once weekly 1 hypothyroidism 1x/d, Eye drops $180.00 Dinner weekly Worries about Dad

20. Day 60

21. Day 60 • Lacerations, abrasions, and contusions • Sutures, basic wound care • Discharged to home

22. Day 68 Status: Providers: Medications: Payments: Daughter: Homebound receiving Home Health Not feeling well Internist Physical therapist ED doctor Occupational therapist 2 HTN each 1x/d, 2 DM each 2x/d 1 osteoporosis once weekly 1 hypothyroidism 1x/d, Pain meds – every 4-6 hrs. $3,256 – ED, $476 – HHA, $99 – PCP Daily visits, doing the shopping Transportation to appts. Worried about Dad $4,011

23. Day 69 • Staph infection • Dehydration • Atrial Fibrillation • Acute Renal Failure • CHF • Pneumonia • DM – not mentioned

24. Day 82 Status: Providers: Medications: Payment: Discharge to SNF – ADLs, Depressed Internist HH Physical therapist ED doctor HH Occ therapist Hospitalist Hospital PT Cardiologist 2 HTN each 1x/d, 2 DM each 2x/d 2 HF meds – each 1x/d, Antidepressant – 1x/d, 1 osteoporosis once weekly 1 hypothyroidism 1x/d, Pain meds – every 4-6 hrs, 2 antibiotics – 1x/d and 2x/d Antidepressant – 1x/d $48,009 $52,020

25. Days 82-182: SNF • Daily PT • Excellent wound care • Has visit from PCP • Diabetes control improved • Neuropathy continues • Ambulation potential not returned to baseline

26. Day 182 Status: Providers: Medications: To Home Internist HH Physical therapist ED doctor HH Occ therapist Hospitalist Hospital PT Cardiologist 2 HTN each 1x/d, 2 DM each 2x/d 2 HTN each 1x/d, 2 DM each 2x/d 2 HF meds – each 1x/d, Antidepressant – 1x/d, 1 osteoporosis once weekly 1 hypothyroidism 1x/d, Pain meds – every 4-6 hrs, 2 antibiotics – 1x/d and 2x/d Antidepressant – 1x/d

27. Day 182 (Continued) $86,614 Payment: Daughter: $34,495 – SNF $99 – PCP Stressed out Daily visits to Dad at home Daily visits to SNF Feels guilty about noticing that the SNF made her life easier Committed to getting her mother “back to normal” Thinking about working part time Budgeting for college educations

28. Day 183 • Home • Nauseated/poor appetite • Unsure what to eat – doesn’t feel like eating anyway • Can’t find her teeth • Husband vague, needs help with basic decisions • Daughter comes 2x/d; Working part-time intends to call PCP to schedule HH again

29. Day 184 • Dehydration • CHF • Atrial Fib • DM

30. Day 190 Status: Providers: Medications: Discharge to SNF Internist HH PT ED doctor HH OT Hospitalist (2) Hospital PT Cardiologist SNF PT (2) SNFist SNF OT (2) 2 HTN each 1x/d 2 DM each 2x/d 2 HF meds – each 1x/d 1 osteoporosis once weekly 1 hypothyroidism 1x/d 1 antidepressant 1x/d

31. Day 190 (Continued) $110,895 Payment: Daughter: $24,281 - hospital Stressed out Daily visits to Dad at home – looking for day care program Feels guilty about readmission Committed to getting her mother “back to normal” Has begun working part time Budgeting for college educations

32. Days 191-337: SNF • Intensive PT/ gait training, self-management training • Daughter visits often but is unable to make it daily • Dad in daily day care – daughter considering NH • Progressive renal failure/ heart failure • Intermittent atrial fibrillation

33. Day 338 • Readmission • Acute renal failure • Decompensated CHF • Acute respiratory failure • Acidosis

34. Day 339 Status: Providers: Payments: Daughter: Deceased Internist HH PT ED doctor HH OT Hospitalist (2) Hospital PT Cardiologist SNF PT (2) SNFist SNF OT (2) $18,393 – hospital, SNF - $50,370 Grieving Worried about Dad Worried about personal finances $179,658

35. What’s Wrong? Conceptually… • Reactive care • Chronic disease care in acute care settings • Diagnosis-specific thinking • ‘Guideline-Driven Care’ • No integration of Mrs. B nor her daughter • Multiple Transitions of Care – No coordination What we Really Need is Intentionally Designed Care that meets the needs of patients and families..

36. Cause of Readmission = Poor or Non-existent Transitions of Care • Medication Problems • Improperly managed by the HC team • Patient non-adherence through poor understanding • Lack of reliable follow-up care • Receiving providers unaware • Poor patient engagement • Symptom worsening

37. Solutions 1. Patient engagement and healthcare coaching 2. Handover management 3. Information transfer • Medication Problems • Improperly managed by the HC team • Patient non-adherence through poor understanding • Lack of reliable follow-up care • Receiving providers unaware • Poor patient engagement • Symptom worsening Patient-Centered Plan of Care

38. *Medication List/Reconciliation*Warning Signs*Allergies*List of physicians Personal Health Record

39. Intervention Packages

40. Interact IIEarly Warning Tool “Stop and Watch” Purpose: To identify a Change in Condition with a Patient or Resident ►Can be used by ANY staff or person who has direct patient/resident contact ►Must be reported to charge nurse during shift of occurrence or sooner if indicated.

41. SBAR • Situation • Background • Assessment • Request/Recommendation *Originated in the US Navy Nuclear Submarine Service Purpose: To improve communication between Nurses and MD/NP/PA (PCP)

42. SBAR • Used effectively across healthcare settings to improve communication • A great tool for new nurses to help enhance their assessment skills • Provides standardization across settings • Relatively easy to implement- back page is a blank progress note to reduce duplication.

43. LINC & Infection Control (IC) •LINC= Linking Information Necessary for Care • A collaborative effort by multiple stakeholders to increase communication upon transfers • Currently with UHIN working on digitizing •Infection Control= Transfer form intended to accompany any resident/patient with an infectious condition. - Contains definitions & standard precautions

44. Questions • What processes can be improved in my setting by implementing the Interact II, S-BAR and/or the Stop and Watch tool? • What would be the first steps in implementing these tools?

45. Ideas on how to use these tools in your settings ?

46. Please help us to improve our events.Complete your evaluation! • The evaluation has two pages: • The first page is completed anonymously and tells us how satisfied you are with the content and presentations you heard today. You do not need to put your name on this evaluation. Comments are welcome! • The second page tells us how you plan to implement what you have learned today and how HealthInsight can assist you. Completing this page is necessary for you to receive CME or an attendance certificate. Please be sure to put your name and contact information at the top of this page! • Please separate the two pages after you have filled them out and turn them in to HealthInsight staff.

47. Questions? Michelle Carlson mcarlson@healthinsight.org 801-892-6646 Rebecca Durham rdurham@healthinsight.org 801-892-6620