CTIC of Southeast Michigan

1. CTIC of Southeast Michigan Feb. 17, 2016 Gloria Pizzo, R.N., BSN Senior clinical quality consultant, MPRO

2. What We know: A Review of the Data • Medicare Readmission Penalties • Year 4: Oct. 1, 2015 – Sept. 30, 2016 • Up to 3 percent reduction in all Medicare payments for hospitals with high 30-day readmissions for AMI, HF, PNA, COPD and hip/knee replacement • 2,592 hospitals penalized; losing $420 MILLION • http://khn.org/news/half-of-nations-hospitals-fail-again-to-escape-medicares-readmission-penalties/

3. SNF Utilization Patterns Are Increasingly Visible • SNF hospitalizations cost more than average • Hospitalization of patients from SNF/LTC averages $11,255 • Average Medicare hospitalization cost is $8,447 • 33% higher • OIG November 2013

4. Why Is This Important? • CMS has data on all SNF readmissions - reported quarterly for U.S. and state-by-state • CMS defined a SNF 30-day all cause readmission measure Oct. 2015 • Public reporting of SNF readmissions (Oct. 2017) • 2% withhold of SNF payments (Oct. 2018) • Projected penalties to total $2.2 billion over 10 years • Office of the Inspector General’s Nov. 2013 report analyzed hospitalizations from SNFs; SNF by SNF

5. “Potential for Efficiency Improvements in Post Acute Care Utilization...” • “Conditions for which post acute care accounts for a large percent of episode payments provide hospitals with a stronger incentive to efficiently manage post acute services.” • CMS technical guidance on MSPB

6. Top Diagnoses Leading to Hospitalization from SNF • OIG November 2013

7. Cost of Hospitalization From SNF • Reason for Hospitalization Total Cost $/Hospitalization • Sepsis $3 billion $17,430 • Pneumonia $850 million $9,500 • CHF $640 million $8,700 • Asp. Pneumonia $618 million $12,200 • Complications $450 million $14,600 • OIG November 2013

8. It’s Time To Get Serious… • 6 very important messages • Readmission reduction “pays” – at least inaction hurts • Hospitals must update & standardize transitional care processes • Reducing readmissions is a cross-continuum effort • Attend to non-clinical needs for post-hospital supports & services • Start working on all best ideas • Reducing readmissions requires better data

9. Know Your Data • Using data to dispel assumptions, expand opportunities for focus.

10. CTIC Community

11. CTIC Acute Care Providers • Beaumont Health Farmington Hills • Beaumont Health Dearborn • Beaumont Health Taylor • Beaumont Health Trenton • Beaumont Health Wayne • Garden City Hospital • St. Mary’s Hospital of Livonia • St. Joseph Mercy Hospital Ann Arbor • Henry Ford Hospital Wyandotte

12. CTIC All-Cause 30 Day Readmission Rates(Q42012-Q32015)

13. CTIC All-Cause 30 Day Readmission Rates(Q42012-Q32015)

14. CTIC Admissions(Q42012-Q32015)

15. CTIC Admissions (Q42012-Q32015)

16. All-Cause 30 Day SNF Readmissions(Q42012-Q32015)

17. All-Cause 30 Day SNF Readmissions(Q42012-Q32015)

18. CTIC All-Cause 30 Day HHA Readmissions (Q42012-Q32015)

19. CTIC All-Cause 30 Day HHA Readmissions (Q42012-Q32015)

20. All-Cause Readmission Within 30 Days of Index Discharge by Top 10 Diagnosis Related Group (DRG) Oct. 1, 2014 - Sep. 30, 2015

21. Factors Contributing to All-cause 30-day Readmissions A structured case series across 18 hospitals • 250 (47 percent) deemed potentially preventable • Found an average of nine factors contributed to each readmission • Assessed factors related to five domains • 73% - Care transitions planning & care coordination • 80% - Clinical care • 49% - Logistics of follow up care • 41% - Advanced care planning & end of life • 28% - Medications • 250 readmissions identified 1,867 factors! • There is never one reason for readmission… • Feingenbaum et al Medical Care 50(7): July 2012 from Kaiser Permanente

22. Develop A Multifaceted Portfolio of Efforts • Improve facility-based care processes for all patients • Collaborate with cross-setting partners, including payers • Provide enhanced services • Use data, analytics, flags, workflow prompts, automation • Dashboards to support continuous improvement, ensure reliability, drive to results • There is no single bullet; we are engaged in system transformation.

23. Improve Standard Care for All: Standard Discharge • Have a process • Know your data: Track rates & review readmissions • Assess & reassess patients for post-hospital needs • Engage patients and caregivers • Teach self-care to patients & caregivers • Provide a written discharge plan for all inpatients • Communicate effectively with “receiving” providers • Know the capabilities of area providers, including support services • Arrange for post-acute services, including support services • http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-32.pdf

24. Effect of Hospital-SNF Referral Linkages on Readmission • MI Tri-County SNF Collaborative efforts are working! • “Stronger hospital-SNF linkages were found to reduce readmission rates” • “The greater proportion of discharges a hospital sends to a single SNF, the lower the rate of readmission” • Specifically lower rates of immediate bounce-backs (days 0-3) • Effect of hospital-SNF referral linkages on readmission • Rahman et al, December 2013

25. INTERACT II • “Interventions to Reduce Acute Care Transfers” • Developed by Dr. Joe Ouslander & colleagues • Quality improvement approach & tools • Focused on identifying changes early & providing staff tools to act on those observations • Provides protocols for managing common issues on-site • Supports improved communication between SNF-ED • Increase hospital awareness of SNF capabilities • Advanced care planning • Adaptations to assisted living & home health care settings

26. SNF Circle Back–Warm Handoffs • SNF Circle Back Questions (hospital calls back SNF 3-24h after d/c) • Did the patient arrive safely? • Did you find admission packet in order? • Were the medication orders correct? • Does the patient’s presentation reflect the information you received? • Is patient and/or family satisfied with the transition from the hospital to your facility? • Have we provided you everything you need to provide excellent care to the patient?

27. Getting Back Home Program • Comprehensive discharge planning: appointments, medication management, services made • Review all information with resident, family, caregiver • Direct contact after SNF discharge • Follow–up phone call next day • Once a week for a month • Once a month for three months

28. Patient Engagement and ActivationAsk Your Patients “Why” • Understand the “story behind the chief complaint” • Interview patients, caregivers for the “story” • Ask patients & support persons why they returned, if readmitted • Ask patient & support persons what help they need; share with them their needs/risk assessment • Use teach-back, target the appropriate “learner”

29. Save the Date • MPRO’s 2016 Care Coordination Summit • A Focused Approach: Hypertension and Diabetes • Crystal Gardens Banquet Center, Howell, MI • June 2, 2016 • More information to come