Reducing Readmissions: National Priorities and Lessons Learned

1. Reducing Readmissions: National Priorities and Lessons Learned Denise Remus, PhD, RN Improvement Advisor, Cynosure Health / HRET HEN

2. Partnership for Patients The 40/20 Goal Keep patients from getting injured or sicker. Reduce preventable hospital-acquired conditions by 40%. 1.8 million fewer injuries to patients, with more than 60,000 lives saved over the next three years. Help patients heal without complication. Reduce all hospital readmissions by 20% . 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

3. 40/20 Goal

4. AHA HRET HEN 34 states and territories / 1,600+ hospitals

5. Hospital Engagement Network Improvement Capacity Structure Hospitals or Hospital Systems Improvement Leader Fellow and Collaborative Teams State Hospital Association Comprehensive Data System Improvement Advisor Institute for Healthcare Improvement AHA/HRET Hospital Engagement Network Team

6. Readmissions are Common and Costly Medicare rehospitalizations within 30 days after Hospital Discharge $17.4 Billion

7. Rates still too high…

8. With minimal improvement Latest Hospital Compare release 2008-2011 compared to 2007-2010 showed (30-day readmits): • AMI rates fell by only 0.1% to 19.7% • HF rates fell by only 0.1% to 24.7% • PN rates increased by 0.1% to 18.5% Only 10 hospitals in the U.S. had better than expected in all three areas

9. New Hampshire Hospitals… Hospital Compare contains data from 26 NH hospitals, many with cases to small to calculate rates. In the latest release: • AMI rates ranged from 16.4% to 21.2% • HF rates ranged from 20.2% to 25.9% • PN rates ranged from 16.1% to 20%

10. Challenges continue

11. Actual Discharge Form Project RED Brian Jack, MD

12. We have knowledge… Models for Improving Care Transitions • Care Transitions Intervention • Transitional Care Model • Project RED (Re-Engineered Discharge) • Project BOOST (Better Outcomes for Older Adults through Safe Transitions) • Transforming Care at the Bedside (TCAB) • STAAR (State‐Action on Avoidable Rehospitalizations) • INTERACT II (Interventions to Reduce Acute Care Transfers) – SNF based

13. Are we using it? “Yes” • Three New Hampshire Hospitals have readmission rates BETTER than the U.S. rate • No NH hospitals were significantly worse

14. Are we using it? “Maybe” • In a recent study, 90% of hospitals agreed or strongly agreed they had written objective of reducing preventable readmissions (for AMI or HF) • The majority of hospitals reported having quality improvement teams in place, 87% for HF and 54% for AMI Bradley, et al, July 2012, Contemporary Evidence about Hospital Strategies for Reducing 30-Day Readmissions, Journal of the American College of Cardiology

15. Are we using it? “No” The same study found • Fewer than half the hospitals (49.3%) partnered with community physicians • Only 23.5% partnered with other local hospitals • Inpatient and outpatient prescription records were electronically linked 28.9% • Discharge summary was always sent directly to primary care physician by only 25.5% of hospitals Bradley, et al, July 2012, Contemporary Evidence about Hospital Strategies for Reducing 30-Day Readmissions, Journal of the American College of Cardiology

16. We must improve – 40/20 Goal Reduce Harm by 40% and Reduce Readmissions by 20%

17. A New Path

18. Leadership Engagement • Create a sense of urgency • Build will • Shared, common vision for the future • All – board, leadership, physicians, front-line staff and caregivers

19. Bricklayer #1 “Putting a brick on top of another... Isn’t that obvious?”

20. Bricklayer #2 “Building a wall for the west side of a church”

21. Bricklayer #3 “Creating a cathedral that will stand for centuries and inspire people to do great deeds”

22. What percentage of the people you are trying to engage are: Putting one brick on top of another? Building a wall for a church? Creating a cathedral?

23. Build Your Infrastructure • Quality improvement expertise • Quality improvement plan • Teams • Resources • Partners

24. Implement Best Practices

25. Identify High Risk Patients

26. Use a Risk of Readmission Assessment Tool • Project BOOST 8P Screening Tool • Problem medications • Psychological • Principal diagnosis • Polypharmacy • Poor health literacy • Patient support • Prior hospitalization • Palliative care Project Red Risk Factors • Depressive symptoms • Limited health literacy • Frequent hospital admissions • Unstable housing • Substance abuse

27. Risk Stratify: Identify those at high risk and communicate to all providers Nielsen GA, Rutherford P, Taylor J. How-to Guide: Creating an Ideal Transition Home. Cambridge, MA: Institute for Healthcare Improvement; 2009. Available at http://www.ihi.org.

28. Potential Process Measure Indicator Name Formal Assessment of Patient's Risk of Readmission (Project RED/BOOST/Other) Numerator Number of patients who have risk of readmission assessed using standard tool (e.g., TARGET Assessment 8P scale or similar) Denominator All eligible patients

29. Patient Self Management Skills

30. Medication reconciliation and education

31. Assess health literacy Health literacy measurement tool, available in English and Spanish, from AHRQ

32. Teach-back Teach-Back guide from Medicare Quality Improvement Organizations National Coordinating Center for the Integrating Care for Populations and Communities Aim (ICPCA)

33. Potential Process Measure Indicator Name Patients Receiving Complete Discharge Education Verified by Teach-Back Numerator Patients receiving complete discharge education verified by Teach-Back Denominator All eligible patients

34. Coordination of Information Across the Continuum of Care

35. Patient-Centered Record Project RED – After Hospital Care Plan Example

36. Patient-Centered Record Coleman Personal Health Record

37. Timely Communication to Other Providers • Send completed discharge summary to primary care physician within 48 hours of discharge • Use a concise, standardized discharge transfer form

38. Potential Process Measure Indicator Name Completion of Discharge Bundle (Project BOOST or model you are using) Numerator Number of discharge care plans with all elements present (Project BOOST or model you are using) Denominator Number of discharge care plans

39. Adequate Follow-up and Community Resources

40. Identify resources needed • Primary care physician • Medical home • Home care • Family care giver • Community support (neighbor, friend, church) • Financial resources

41. Timely and adequate follow-up • Open access to appointments – schedule before patient leaves • Leverage IT – technology innovations to assist in communication and exchange of information • Follow-up phone calls – use care coordinators, possibly automated calls

42. Potential Process Measure Indicator Name Timely Transmission of Transition Record (Inpatients) Numerator Patients who had a transition record transmitted within 24 hours of discharge Denominator All discharged inpatients

43. Measure

44. Select Measures • For each clinical topic, must report data for at least 1 Process Measure and 1 Outcome Measure

45. We have to pick up the pace…

46. Race to reduce readmissions • Focused progress and results oriented goals • Need baseline data – prefer Calendar year 2011, could use first 6 mo of 2012 • Monitor improvements July to Dec 2012 • Small tests of change and frequent scale • Bi-weekly Race Checkpoint Calls • Readmissions Listserv Readmission Sprint

47. Outcomes • 30 or 15 day readmissions • All patients or specific conditions such as HF, AMI, PN, COPD • Consider simple metric – all readmissions / all discharges Track Readmissions

48. What can you do by December 31, 2013?

49. New Hampshire Go for the Gold!