Introduction to the Acute Care Hospitalization Improvement Matrix

1. Introduction to the Acute Care Hospitalization Improvement Matrix Part I October 20, 2005

2. Objectives • Provide an overview of the CMS acute care hospitalization initiative • Discuss the Acute Care Hospitalization Pilot Project • Review the Acute Care Hospitalization Improvement Matrix & its application to Plan of Action Development • Discuss the Acute Care Hospitalization Planning Packet & how to use it

3. CMS Health Care Quality Improvement Program • Vision – The right care for every person every time • Key strategies • Performance measurement & public reporting • Process redesign • Effective use of health information technology • Organizational culture change • Priority focus for home health • Reducing acute care hospitalization

4. OBQI Definition for Acute Care Hospitalization • Percentage of home health episodes in a 12-mo period that end with hospitalization (emergent, urgent, & elective) • Numerator - all episodes with a hospital inpatient facility admission • Denominator - all episodes excluding patient deaths • Risk-adjusted

5. National Hospitalization Episode Rate

6. Outcome Performance Gap – Opportunity for Improvement Nationally, over 950,000 hospitalizations from April 2003-March 2004 25th percentile – 23.16% 50th percentile – 29.03% 75th percentile – 36.46% Source: QIES, OBQI Rollup Summary

7. Potential Cost Savings to Medicare Trust Fund • 81,318 fewer acute care hospitalization episodes from 9/2006-8/2007 • Medicare Trust Fund savings could equal $1.68 billion (Based upon length of stay average cost at $3506.00 per day)

8. Home Health Length of StayPrior to Hospitalization Source: CY2003 OASIS * Source CY2003 hospital claims for MD, MI, NY, RI, VA

9. Hospital & Home Care Primary Diagnosis Source CY2003 hospital claims for MD, MI, NY, RI, VA; all OASIS

10. Relationship of Emergent Care to Acute Care Hospitalization • Episodes with hospitalization • 66.43% also had emergent care • Episodes with emergent care • 83.73% ended with hospitalization Source: CY2003 OASIS

11. Characteristics of Hospitalized Patients • More functionally impaired prior to & at start • Fewer with moderate recovery prognosis • Fewer with good rehab prognosis • 68% - hospital discharge within 14 days Source: CY2003 OASIS

12. Literature Review • Available studies to date provide limited information on best hospitalization rates for home health patients • National and New York OBQI demonstration projects – HHAs overall were able to attain hospitalization rates in the low-mid 20% range

13. Acute Care Hospitalization • Proxy measure for deterioration in health status • Do not expect 0% • Nature of some illnesses & limits of medical science • Elective reasons for admission • Goal is to reduce avoidable hospitalizations • Prevent deterioration • Identify warning signs to trigger early intervention

14. Target Goals • CMS has established a high performance goal of 23% over the next three years • 25% of HHAs have achieved this or lower • May not be achievable for all agencies • Imperfect risk models • Greater volatility of rates for small agencies • NYS LTHHCP patient population • Caution - Should not be achieved at the cost of denying high risk patients access to home health care services or necessary hospitalization

15. Acute Care Hospitalization Pilot ProjectMarch 29, 2005 –July 11, 2005

16. VNSNY Center for Home Care Policy and Research QIOs Arizona Idaho Louisiana Maryland/DC Michigan New York Rhode Island Tennessee Utah Virginia Washington Pilot Participants

17. Big Thanks To Our Leaders & Champions! vAt Home Care vCommunity Health Center v Hospitals Home Health Care vIdeal Senior Living Center LTHHCP vLifetime Care Home Health & Hospice vSeton Home Health vSouth Nassau Communities Hospital Home Care vSt. Joseph's Certified Home Care Agency vSt. Peter's Hospital Home Care vUnivera Home Health vVNA of Albany vVNA of Staten Island vVNA of Utica & Oneida County vWinthrop Hospital Home Health

18. Background on Development • Partner with VNSNY’s Center for Home Care Policy and Research • Data Analysis • Literature Search • Consultation with Experts • VNSNY Home Health Expert Panel • Pilot Test – 113 HHAs in 12 states

19. Primary Objectives of Pilot • Review and test strategies aimed at preventing avoidable hospitalizations • Learn directly from HHAs implementing strategies • Learn from QIOs supporting HHAs • Modify/refine materials based on lessons learned in pilot test for use in the 8th SOW

20. Acute Care Hospitalization (ACH) Improvement Matrix

21. Change Binder

23. ACH Improvement Matrix: Definitions • Change Framework – entire set of change concepts organized into Areas for Improvement and Stages of Care • Improvement Matrix – “big picture” of the organization and high-level strategies • Strategy – high-level change concept; represents a series of actions designed to achieve a specific objective • Action – specific change idea that can be tested and implemented at the agency level • Tool – a form, instrument, or manual that can be used as is or modified to support strategies and actions • Resource – a reference for more information related to implementing specific strategies and actions

24. ACH Improvement Matrix: Stages of Home Health Care • Before the Home Health Agency Accepts the Patient for Care • The First 24-48 Hours at Home • Throughout the Episode of Home Care • If the Patient has Reached the Emergency Department

25. ACH Improvement Matrix Rationale: The Chronic Care Model • ¾ of hospital in-patient stays attributable to people with chronic conditions • Chronic care poorly managed in U.S. healthcare system • Need to overcome healthcare silos • Model widely used in improvement efforts across country

26. Key Findings / Issues Shaping Design of ACH Improvement Matrix • Chronic conditions • Multiple diagnoses • Transitions • Hospitalizations early in home health episode • Stages of care • Multiple factors - complexity

27. ACH Improvement Matrix:Areas for Improvement • Promoting Patient Self-Management • Implementing Evidence-Based Practices & Guidelines • Using Systems and Technology to Promote Effectiveness and Efficiency • Improving Care Delivery Systems & Mobilizing Community Resources • Creating a Culture of Quality

28. Evidence Base for Change Strategies • Face validity - “No-Brainers” • Urgent Care Plan • Patient Tracking System • Front-End Strategies • Discharge planning • Transitions • Long-Term Strategies • Evidence-based disease management • Self care management

29. Area for Improvement Example: Improving Care Delivery Systems & Mobilizing Community Resources

30. Example: Strategies, Actions and Tools • Strategy D1: Work with hospitals to make discharge planning more effective for homecare (Tool #61, 62, 63) • Discharge checklist • Transition protocol for patients coming from hospital • Pre and post hospital discharge assessment and education • Advance practice nurses or transition coaches • Multi- disciplinary management teams • Strategy D.2: Establish transition protocol for transfers from hospital or other facilities (e.g., SNF) to homecare (Tool # 6, 64, 65, 66) • Full medication reconciliation • MD verification and communication • Reconnect patient to primary care physician

31. ACH Pilot: Most Frequently Used Strategies • Use evidence-based risk assessment tools to identify high-risk patients and incorporate risk factors into individualized patient care plans • Equip patients and caregivers with information and options to address immediate/urgent care needs • Use evidence-based, condition-specific/problem-specific interventions • Implement systems to identify and track patients at increased risk for hospitalization and related problems

32. ACH Pilot: Most Frequently Used Actions • Identify/adapt/adopt an evidence-based assessment tool to identify patients who are at risk of hospitalization and train physicians in its use • Establish individualized urgent/emergent care contact plan for each patient • Establish patient/caregiver understanding of high-risk health conditions and signs/symptoms of worsening conditions • Identify/adapt/adopt evidence-based guidelines, protocols, interventions, and monitoring for disease-and problem-specific conditions

33. Application of the Improvement Matrix to OBQI Process

34. OBQI and the Improvement Matrix • Where & how to start – key issue • Comprehensive Change Framework • Represents excellent system of care required to make transformational change • Not intended to do everything • Add strategies over time • Issues not the same in every agency • The OBQI process along with some additional diagnostic tools can help narrow the focus

35. Acute Care Hospitalization Planning Packet • Risk-adjusted Outcome Report • Descriptive Outcome Report • Case Mix Report • Outcome & Case Mix Tally Reports in Workbook format • Case Mix Analysis Report – hospitalized versus non-hospitalized patients

36. Acute Care Hospitalization Planning Packet • Plan of Action Template • Sample Risk Assessment Tool • Process of Care Investigation Audit Tool • ACH Improvement Matrix • ACH Tools & Resources

37. Case Mix Analysis Tool • Provides comparison of risk factors for hospitalized and non-hospitalized patients within your Case Mix Report

38. Case Mix Analysis Tool -Example

39. Case Mix Analysis Tool -Example

40. Act Plan Study Do Act Plan Study Do Act Plan Study Do OBQI Outcome Enhancement Process Collect & transmitOASIS data Monitoractionplan Measurepatientoutcomes Interpretoutcomereports Implementaction plan Specifytargetrate Developaction plan Identifyproblems/strengthsand best practices Investigatecareprocesses

41. Next Steps for Plan of Action Development Interpret Outcome Reports & Specify Target Rate for Agency • Compare agency risk-adjusted rate to other agencies in state & other benchmarks (e.g., 23%) • Average rate is not necessarily the goal • Extend the review of the case mix report to examine case mix differences between patients who are and are not hospitalized • Can help focus process of care investigation • Excel-based tool or gather during process of care investigation

42. Target Setting • Major Component of Plan of Action development • Expectations for reductions should be based on agency’s baseline rate • Reaching the ultimate desired target rate should be expected over time

43. Next Steps for Plan of Action Development Investigate Care Processes • Begin with an organizational assessment • Use information from case mix analysis & outcome reports • Construct audit tool • Use Tally Workbook to identify 30 cases to sample for record review

44. Next Steps for Plan of Action Development Identify Problems/Strengths and Best Practices • Identify the problem or strength • Specific Actions from the Change Framework can be considered for clinical best practices, especially those from • Promoting patient self-management • Implementing evidence-based practices and guidelines

45. Next Steps for Plan of Action Development Develop Action Plan • Specific Actions can be considered for intervention activities to implement clinical Actions (best practices), especially system changes • Using systems and technology • Improving care delivery systems • Creating a culture of quality • Strategy Combinations Identified Identifying patients at risk and implementing Actions to address the risk • Disease management • Transition from hospital to home health care

46. Next Steps for Plan of Action Development Implement & Monitor • Implement the Action Plan • Emphasize small test of change before full-scale implementation • Monitor the Action Plan • Measure outcome and process • Measurement strategy provides examples

48. Questions Feedback Suggestions Recommendations

49. Website Resources • MedQIC Website – www.medqic.org • IPRO – www.ipro.org • Joint Effort New York (JENY) Website - http://jeny.ipro.org • Home Health Compare - www.medicare.gov/hhcompare/home.asp

50. Contact Information Sara Butterfield , RN, BSN, CPHQ, CCM / Project Director Phone: 518-426-3300 ext. 104 Email: sbutterfield@nyqio.sdps.org Christine Stegel RN, MS / Performance Improvement Coordinator Phone: 518-426-3300 ext. 113 Email: cstegel@nyqio.sdps.org Susan Hollander MPH, CPHQ / Assistant Director Phone: 516-326-7767 ext. 241 Email: shollander@nyqio.sdps.org