IMPACT: Improving Care Transitions Risk Stratification Tool

1. IMPACT: Improving Care TransitionsRisk Stratification Tool Elya Moore, PhD Deputy Director Whatcom Alliance for Health Advancement Presented at Washington State Hospital Association Safe Table, 7/10/13

2. IMPACTIMProvedCare Transitions • Contract with Centers for Medicare and Medicaid Services (CMS) • Part Community-Based Care Transition Program (CCTP) • Transition services for Medicare fee-for-service beneficiaries • IMPACT Aims • empower patients and their family members to understand their health so they can actively maintain and manage it • to reduce preventable hospital readmissions An initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital re-admissions by 20 percent over a three-year period. Goals are to reduce hospital re-admissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measurable savings to the Medicare program. Presented at Washington State Hospital Association Safe Table, 7/10/13

3. Risk Stratification Tool • Goal: To quickly and accurately identify Medicare fee-for-service beneficiaries • eligible for IMPACT • at high risk of readmission Presented at Washington State Hospital Association Safe Table, 7/10/13

4. Timeline Presented at Washington State Hospital Association Safe Table, 7/10/13

5. Tools and process Red (100-67)= STOP!!! Yellow (34-66)= CHECK! Green (0-33)= PASS… Presented at Washington State Hospital Association Safe Table, 7/10/13

6. How is it used? • A 3-Step Process • Use a subset of predictors to rank patients upon admission according to risk of readmission and sort each daily admission census according to this rank. • Display the most predictive risk factors for readmission on the census to provide further guidance to hospital personnel for triaging. • Draw from clinical experience, intuition and common sense. • Monitor, evaluate and adjust as needed Presented at Washington State Hospital Association Safe Table, 7/10/13

7. Lessons learned • Health information exchange is tantamount • Fair-weather Whatcom residents • Listen to your staff • Include social support! • Importance of inter-organizational collaboration • PeaceHealth, Northwest Regional Council, WAHA • Find your champions • Care transitions oversight group • Qualis Health • Medical and content experts Presented at Washington State Hospital Association Safe Table, 7/10/13

8. Validation Population - level • 12 readmits since started using tool • Mean score for readmitters: 35.8 • Mean score for non-readmitters: 15.1 • P value <0.001 Individual –level • 7 out of 12 readmits were in the “green” category • Lower the thresholds (>6 ED visits prev. 6 months; >3 Inpatient admissions prev. 6 months) Presented at Washington State Hospital Association Safe Table, 7/10/13

9. Next steps • Modify thresholds • Continue monitoring • Test in other populations • Make tool available to the community Presented at Washington State Hospital Association Safe Table, 7/10/13

10. Acknowledgements • Dr. Serge Lindner, MD, Center for Senior Health, PeaceHealth Medical Group • Ian Hogan, Analytic Services, PeaceHealth • Larry Thompson, Executive Director, Whatcom Alliance for Health Advancement • Discharge Referral Coordinators: Sheila Rhodes, Becky Sandall and Lynnette Treen • Northwest Regional Council: Julie Johnson, Silva Sarafian, Rosann Pauley and Victoria Doerper • Care Transitions Oversight Group, Whatcom County Presented at Washington State Hospital Association Safe Table, 7/10/13

11. Contact Elya Moore Deputy Director Whatcom Alliance for Health Advancement eemoore@hinet.org (360) 788-6560 Presented at Washington State Hospital Association Safe Table, 7/10/13

12. Questions

13. Variables in the model • Previous ED visits • Previous inpatient visits • Length of stay at previous visit • High risk diagnosis (heart failure, diabetes, cancer, stroke or COPD) • Poor social support • Palliative care • Depression, bipolar, schizophrenia or dementia • Poly pharmacy • Recent surgery (stent, hip, knee, vascular or bowel) Presented at Washington State Hospital Association Safe Table, 7/10/13