Realtime Readmissions Feedback at PENN Medicine – Making the Data “Actionable”

1. Realtime Readmissions Feedback at PENN Medicine –Making the Data “Actionable” University of Pennsylvania Health System Presented by: Victoria L. Rich, PhD, RN, FAAN Chief Nurse Executive University of Pennsylvania Medical Center

2. Who we are PJ Brennan, MD Chief Medical Officer & Senior Vice President University of Pennsylvania Health System Victoria Rich, PhD, FAAN, RN Chief Nursing Executive, University of Pennsylvania Medial Center Associate Professor, University of Pennsylvania School of Nursing Joan Doyle, MBA, MSN, RN Executive Director, Penn Home Care and Hospice Services University of Pennsylvania Health System Assistant Dean for Clinical Practice, University of Pennsylvania School of Nursing Linda May, PhD Principal CFAR

3. Penn Medicine — Philadelphia, PA School of Medicine University of Pennsylvania Health System Penn Home Car & Hospice Services Hospital of the University of Pennsylvania Pennsylvania Hospital Penn Presbyterian Medical Center #9 US News Magnet Adult admissions — 77,500 Employees — 12,700 Admissions — 18,000 Employees — 450

4. Penn Medicine is working to improve Transitions-in-Care from hospital to home — and prevent readmissions The aim is to keep patients safe and stable and give them a safe “medical landing” Preadmission Hospital Stay Post-acute Care “Medical Landing” Discharge Admission It’s the right thing to do for our patients — AND we’re trying to get ahead of the curve for the new world of healthcare What we’re learning will give us a head start in a new healthcare environment of ACOs and bundled payments.

5. Realtime readmissions feedback is at the heart of our model for Transitions-in-Care UPHS Transitions Model — Seven “Levers” Real-time readmis-sions feedback to actively manage patients Interdis-ciplinary care planning Links to post-acute follow-up services Primary care follow up Educa-tion & red flag mgmt Med mgmt across the contin-uum Screen for patients at greatest risk

6. It starts with the daily readmissions reports — but the report is the “least” of it Full report is distributed each morning to Discharge Planners, Homecare and others. Each hospital unit gets a tailored version, with just its own patients. But …

7. Today’s talk about making the realtime readmissions data actionable has three parts 1 “Changing the way we work” 2 “Speaking with a united clinical voice” 3 “Mobilizing other people’s energies”

8. 1 Changing the way we work

9. In-the-moment and long term Long-term changes to clinical practice Tools, standards, education, faster turnaround, tighter feedback loops — based on opportunities we see in the data Daily Troubleshooting Readmissions data are available in time to take action on specific cases Real-time readmis-sions feedback Interdis-ciplinary care planning Links to post-acute follow-up services Primary care follow up Med mgmt across the continuum Education & red flag mgmt Screen for patients at risk

10. “ Findings with feet … ” — Executive Administrator

11. Daily troubleshooting At the System Level On the phone with each other daily to troubleshoot specific patients On the Individual Hospital Units This got picked up at the system level

12. Long-term changes to clinical practice For example, here’s how Hospice is changing the way It works …

13. What’s next? Two things on our plate … ? ? Who’s responsible? If the daily readmissions report goes to “everyone,” it might as well go to “no one.” How can we share their readmissions data so it’s “hearable” and “actionable”? ? ? What actions are “automatically” taken for a readmitted patient? How can we tap into what the service lines are already planning to do? ? ? How can we shape what they’re doing? What interventions are triggered — Homecare referral? Patient education? Discharge safety check? Follow-up phone call?

14. A funny thing is happening along the way — we’re breaking down our silos and collaborating in new ways From To DischargePlanners ServiceLines UnitLeadershipTrios Homecare/ Hospice

15. So, what does it take to make the readmissions data “actionable”? Daily troubleshooting to take action on specific cases 1 Changing the way we work Tracking and trending the readmissions data to identify longer-term interventions Realtime readmissions data — the report is the “least” of it Making changes to clinical practice — tools, standards, education, faster turnaround, tighter feedback loops Along the way, breaking down our silos and collaborating in new ways

16. It takes a village — and the village is here today Med/Surg UBCLs — Medicine Residents Quality Track and their unit-based partners: • CRCs/SWs • Pharmacists • Educators/ Clin Specs • AP Nurses • Infection Control HCHS, GSPP and other post-acute providers IBC, AETNA Other outpatient stakeholders People who have been developing tools & resources CMO/CNO Alliance Other senior leaders from CRM/SW, IS, HR, Pharmacy, Quality, HCHS, Operations Transitions Steering Group

17. “Changing the way we work” — lessons learned

18. But frontline actions, by themselves, aren’t enough …

19. 2 Speaking with a united clinical voice

20. The CMOs and CNOs have banded together across the continuum of care The CMO/CNO Alliance spans the care continuum: • All three hospitals • Penn’s homecare and hospice services • Penn’s rehab facilities • Physician practices

21. The CMOs and CNOs set clinical direction for UPHS — with Transitions-in-Care as a major element

22. To bring clinical strategy to the frontline, we’ve established “local leadership” on each hospital unit We needed a multi-purpose solution on the units to handle almost any Quality problem. Leadership Trio on Each Hospital Unit “ ” We call these trios “UBCLs,” for “Unit Based Clinical Leadership”

23. We started modestly on purpose so the leadership trios could learn to work with each other 13 pilot units in 2007 • Weeklyoperations meeting of the Physician Leader, Nurse Leader, Project Mgr. for Quality • Interdisciplinary rounding • Orienting house staff • Two improvement projects The job: 2007 2008 2009 2010

24. Today we’ve covered the house and the trios are ready to take on Transitions, a major system-wide initiative Today it’s 34 “official” units — and another dozen who are “operating as.” The job: Today the trios manage Quality on the unit, drawing in others as needed. UBCLs are ready this year to shoulder Transitions in Care, a major system-wide initiative. 2007 2008 2009 2010

25. “Choice within a framework” — each year we develop targets and work with the hospital units to pick theirs

26. “Focusing attention” — we negotiated a Transitions metric in every senior leader’s incentive plan METRIC: Increase referrals to post-acute services (homecare, hospice, rehab, SNF, infusion, LTAC) We’re setting the stage for a more ambitious “readmissions” metric next year. We picked this metric because it supports a key element of our Transitions model —and because Penn could measure it. Q1 Q2 Q3 Q4 HP HP HP Threshold (3%) Target (5%) HP HP High Performance (10%)

27. Quality outcomes are moving in the right direction — including the ones focused on Transitions-in-Care MORTALITY INFECTIONS LENGTH OF STAY READMISSIONS PEER RECOGNITION PATIENT & STAFF SATISFACTION REFERRALS TO POST-ACUTE CARE P4P IS ON TRACK

28. We’re getting out ahead of the budget cycleand negotiating with a united clinical voice

29. We’re bringing payers to the table Paying for the Naylor Transitional Care Program Sharing the gains A major insurance company pays Penn to provide the “Transitional Care” (Naylor model) follow-up program to its patients. Penn has also negotiated an agreement with the insurance company to share the savings when patients are able to stay out of the hospital. In this program, the same advanced practice nurse follows patients before and after discharge.

30. So, how are we aligning infrastructures and supports to make readmissions data “actionable”? CMO/CNO Alliance across the continuum of care 2 Speaking with a united clinical voice Local leadership on each hospital unit — Physician Leader, Quality Project Manager Clinical strategy — with Transitions-in-Care as a major element Realtime readmissions data — the report is the “least” of it Quality redesign to dedicate a Quality Project Manager to each hospital unit Metrics as feedback — each hospital unit and each senior leader know where they stand Negotiating the budget with a united clinical voice Aligning quality metrics across the system, including senior leaders’ incentive targets Bringing the payers to the table

31. Speaking with a united clinical voice —lessons learned To paraphrase James Carville: “ It’s the work, stupid. ”

32. But leadership at the top isn’t enough …

33. 3 Mobilizing other people’s energies and keeping the moving parts aligned

34. The Transitions Steering Group is in the integration business This interdisciplinary group of senior leaders: • Sets direction for Transitions-in-Care • Integrates the moving parts • Opens doors at the system level • Troubleshoots to keep things on track

35. We developed UPHS’ Transitions Model as a framework — with realtime readmissions feedback at the heart UPHS Transitions Model — Seven “Levers” Real-time readmis-sions feedback to actively manage patients Interdis-ciplinary care planning Links to post-acute follow-up services Primary care follow up Educa-tion & red flag mgmt Med mgmt across the contin-uum Screen for patients at greatest risk

36. We’re mobilizing “other people’s energies.” Our biggest job is keeping them aligned. Knowledge-Based Charting (HER protocols & tools) under development Penn Medicine Leadership Forum “action learning” Transitions projects INTERNAL Unit-based Pharmacists Transitions Collaboratives — active operational arms CMO/CNO Alliance across the continuum of care Med Mgmt redesign EXTERNAL Bundled payments and ACOs are on the horizon Pay-for-performance contracts CMS penalties for readmissions will begin in 2012 Payers willing to fund follow-up programs and negotiate gain-sharing arrangements Public reporting influences patient choice

37. For example — We took advantage of Penn’s flagship leadership development program Penn Medicine Leadership Forum is targeted this year to the unit-based leadership teams — along with homecare and other partners “Action Learning” • Innovation • Strategic orientation • Execution • Relationship mgmt This year the strategic initiative is Transitions-in-Care. Each team took on a project to improve Transitions on a specific hospital unit.

38. “Test beds” — each team tested an aspect of the Transitions Model. All over the place, but look at the energy! Transitions Projects for Penn Medicine Leadership Forum Medication management across continuum New approaches to interdisciplinary care planning Post-discharge phone calls Real-time readmission analysis and intervention Team-based Discharge Planners Patient & family education, with emphasis on self management Discharge “time out” safety check Improve internal Transitions End-of-life goals of care “Opt-out” for homecare referral Follow-up appointments with primary care House staff awareness of homecare & hospice services Discharge summary follows patient to post-acute services Screening tool for post-acute referrals Real-time readmis-sions feedback Interdis-ciplinary care planning Links to post-acute follow-up services Primary care follow up Med mgmt across the continuum Education & red flag mgmt Screen for patients at risk

39. To pull it all together, we turned the teams’ work into an integrated Transitions process for the health system Preadmission Hospital Stay Post-acute Follow-up Medical “Landing” Discharge Admission Work as far “upstream” as possible — prior to admission where that makes sense. Risk stratification 1 Screening on admission      Daily review of realtime readmissions report 2 Interdisciplinary rounds 3 Plan of care looks ahead to post-discharge  Referral to post-acute care as early as feasible  4 Patient and family education Education for post-discharge care and meds, with emphasis on self management  5 Med reconciliation on discharge 6 Discharge communication 7 Discharge safety check (for high-risk patients) 8 Discharge summary to primary care & post-acute Schedule appointment with primary care(for high-risk patients) 9 10 Follow-up phone calls (for high-risk patients)

40. We can’t implement the new Transitions process all at once — so where to start? The readmissions data helped us decide where to focus first: The “big three” diagnoses that will affect CMS payments for readmissions in 2012 — Heart Failure, Heart Attack, Pneumonia Two Penn service lines with the biggest impact on those three diagnoses — Cardiac and Oncology Readmits and the top 10-20% at greatest risk for readmission

41. We’re learning a lot from the readmission data. Some things have surprised us … The “big three” diagnoses that will affect CMS payments for readmissions in 2012 — Heart Failure, Heart Attack, Pneumonia Two Penn service lines with the biggest impact on those three diagnoses — Cardiac and Oncology Readmits and the top 10-20% at greatest risk for readmission Link between Oncology and Pneumonia. Analysis of our Pneumonia readmits shows that almost a third are on the Oncology service. Readmits are younger than we expected. Two-thirds are younger than 65. One-third are younger than 49. And overall analysis of readmits shows that 30% are Oncology

42. So, how are we using other people’s energies to make the readmission data “actionable”? Transitions model as a framework — seven “levers” that make the biggest difference 3 Mobilizing other people’s energies Tapping into other people’s projects and efforts — and keeping the moving parts aligned Realtime readmissions data — the report is the “least” of it Leadership development in “action-learning” mode Tracking and trending the readmissions data to figure out where to focus first

43. Mobilizing energies — lessons learned

44. It takes a village — and the village is here today Med/Surg UBCLs — Medicine Residents Quality Track and their unit-based partners: • CRCs/SWs • Pharmacists • Educators/ Clin Specs • AP Nurses • Infection Control HCHS, GSPP and other post-acute providers IBC, AETNA Other outpatient stakeholders People who have been developing tools & resources CMO/CNO Alliance Other senior leaders from CRM/SW, IS, HR, Pharmacy, Quality, HCHS, Operations Transitions Steering Group

46. This is our moon shot…

48. Patient Navigation • There is no accepted definition • Role established in 1990 by a Harlem physician to assist indigent cancer patients. • However, “Navigators do things for patients by working with the patients and others in both the social network of the organization and in the community.” • Health Services Research Trust

49. Emerging Roles for Nurses Across the Care Continuum Inpatient Care setting Across settings Outpatient

50. A. Inpatient Inpatient Care Coordinator Also Called: Primary Care Coordinator, Patient Care Coordinator, Unit Based Care Manager, Hospital-Based Case Manager Capsule Description: Serves as a primary contact for physicians and other care providers; responsible for managing patient care needs and progress, care plan development and discharge planning Key Functions/Attributes: - Interacts with patients and families throughout the length of stay - Collaborates with other medical staff face-to-face as needed Individuals Commonly Deployed: Social Worker, Case Manager, RN with BSN, RN with MSN and CNL licensed