Readmissions Activity Profile- Translating Data Into Improvement

1. Readmissions Activity Profile- Translating Data Into Improvement April 11 & 12, 2013

2. Putting a Human Face on the Problem:James and Martha • James, 68 years old, lives at home with wife Martha • Admitted to the hospital with shortness of breath • Diagnosis: pneumonia + underlying onset of heart failure • Instructed on new medications + diet before discharge • Told to see his physician in the office in two weeks • After returning home reminded to schedule physician’s office • Finally able to set up a visit for three weeks later • Never filled furosemide Rx; thought the expense unnecessary • Noticed swelling in legs; didn't want to bother "busy doctor" • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

3. Putting a Human Face on the Problem:James and Martha James readmitted to hospital after 11 days • Increased SOB, mildly elevated BNP • Weight increase of 25 lbs, marked edema lower legs • Stress level high; blood pressure elevated, new drug added Martha admitted for emergent surgery; James still in the hospital • After James’ discharge he began eating fast food • Worried about his wife, juggled visits to her bedside,managed the roofing project on their home • Martha came home from the hospital, James readmittedwith exacerbation of his HF • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

4. Putting a Human Face on the Problem:James and Martha How many opportunities for an intervention can you identify in the story of James and Martha? • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

5. Aims • 1- Deeper Dive into the Readmissions Activity Profile • -Analyzing and translating that data into action • 2- Overview of Interventions to reduce readmissions • 3- Identification of an intervention to implement and/or a target area to focus on based on data from the Readmissions Activity Profile

6. Translating the Data Into Action • Our goal is to translate Readmissions Activity Profile data into real quality improvement efforts • We will work through the Profile and identify some opportunities for improvement • Use this data and this tool to guide your QI efforts and help you focus on which areas you have the most potential for improvement in

7. Today we will review 6 tabs of the Readmissions Activity Profile • Use this worksheet to identify opportunities for improvement • Coaching sessions

8. Service Line Tab • First high level overview of your readmissions activity during this time frame • Get a first glance at how many readmissions chains your organization had during this time period -by service line -how you compare to other hospitals in the state -by observed/expected ratio

11. Service Line Tab

12. Translating Data Into Improvement • Observed/Expected (O/E) Ratio- Anything 1 or above is a red flag, may be an opportunity- but it’s the O/E plus the readmissions chains that gives an indicator for improvement • This is your first high level view of where potential opportunities for improvement in your organization • Do you have any specific focus on these service lines now?

13. Index APR DRG Tab • Sort by Readmission Chains (descending) to see the highest level of APR-DRG’s going down- this will show you your top 5 APR-DRGs • -The 3 methodology offers 314 APR-DRGs total • -Looking at your top five- are there any surprises for you? Top 5 APR-DRGs in Illinois

16. Index APR DRG Tab

18. Point of Origin/Discharge Status Tab • Shows you where your patients are coming from and where they are going upon discharge • Look at these next two tabs together- note this only includes top 25 APR-DRGs and you can see where patients are coming from and where they are going upon discharge • Where are these patients coming from? • Where are they going? • Sort for high frequency origins/discharge destinations

21. Point of Origin/Discharge Status Tab

22. Top Readmit APR-DRG Tab • Highlights the % of time the index admission is the reason for a readmission within the 30-day timeframe. • Most QI people gravitate to this report because it highlights that the index admission more likely than not is readmitted for the exact same diagnosis within that 30-day timeframe. -Could be due to medication, home health, or other community connections to these patients • This again gives you an opportunity to evaluate if what we are doing with the community is making a difference or do we need to rethink about it.

24. Top Readmit APR DRG Tab

25. Patient Level Tab • Real drill down opportunities on this tab • Opportunity for Case Management/chart review • Sort by your top APR-DRGand start looking for trends..

26. Trends to look for-Patient Level Tab • Frequent flyers • Age/severity of illness/LOS • -This could give you a sense of palliative care opportunities or how you are addressing end of life care • -Or conversely, are we admitting patients who are not that sick and may not have had to be an admission? • Sort by readmit to same facility • Where are they coming from/going to • -Family/Caregiver issues? • Sort by physician to see if anyone is frequent • Sort by payer • drilling into this data will likely draw you to your medical records for more answers

27. Patient Level Tab

28. Putting a Human Face on the Problem:James and Martha How many opportunities for an intervention can you identify in the story of James and Martha? • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

29. Translating Data Into Improvement • Now that we have all of this GREAT data…What do we do with it?! • Lets look at a few specific tabs and discuss some interventions you can implement to help curb any negative trends that you may have discovered • WARNING…There is no one • “Magic Bullet” Translating Data Into Improvement

30. ServiceLine/Index APR-DRG Tabs • Do you have a specific focus on any of these service lines or APR-DRGs? • -If not you may need to re-evaluate where your readmissions efforts are directed • -Use these tabs and this Profile to make your case that improvement opportunities exist in these areas. Pitch it to the quality committee, your CEO, your CNO or CMO • -RCA of your last 10 readmissions (top APR-DRG) Translating Data Into Improvement

31. Service Line/Index APR-DRG Tabs Improvement Activities • 1. RCA • 2. Present this data at a Quality Committee and/or board level • 3. Engage your front line staff with this data • 4. Choose one of these top APR-DRGs as a pilot population for new QI projects to reduce readmissions • 5. Implement a risk assessment on patients who are admitted with one of your top 5 APR-DRGs Translating Data Into Improvement

32. Assess Risk for Readmission • Risk assessments are needed to help teams to appropriate transitional care resources • Number of risk-assessment tools are reported in the literature (BOOST, LACE, Transitional Care Model (TCM), etc.) • Inconsistencies regarding which characteristics and/or variables are most predictive of patients who are at risk for readmissions • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

33. Point of Origin/Discharge Status Tab • Improvement opportunities such as forming coalitions or regular meetings with skilled nursing facilities/home health to create ways to work together- what community based services do you need to improve your relationship with? • Use this information to reinforce the importance of care coordination • Use this data to start the conversation or identify a specific focus or problem area Translating Data Into Improvement

34. Point of Origin/Discharge Status Tab Improvement Activities • 1. Schedule F/U appt. with PCP prior to discharge (all DC/pilot high risk) • 2. Establish/Strengthen relationship with SNF/Home Health • -Interact II • 3. Ensure that the discharge summary gets to the PCP promptly • 4. Standardize your discharge checklists and transfer forms • 5. Establish a Cross Continuum Team Translating Data Into Improvement

35. Physician Follow-Up Care National Medicare analysis found 50% of patients who were re-hospitalized within 30 days did not have an intervening physician visit between the date of discharge and readmission to the hospital. MedPAC Report to Congress, Promoting Greater Efficiency in Medicare. June 2007

36. Scheduling MD Follow-Up Care • There is much debate about when to schedule the follow-up appointments with an MD after patients are discharged • Look at your own patterns, see when patients are readmitted • Teams have succeeded in successfully scheduling appointments prior to the patient leaving the hospital by partnering with providers to create a simplified process for scheduling • Front-loading clinical and support services in the immediate post-hospital period has proven to be effective • Hospital staff should collaborate with physician practices to create processes for assigning patients to a primary care provider • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

37. INTERACT stands for “Interventions to Reduce Acute Care Transfers” • It is a quality improvement program designed to improve the care of nursing home residents with acute changes in condition by: • -Identifying situations that commonly result in transfers to the hospital • -Working together to manage them effectively and safely in the nursing home without transfer whenever possible http://interact2.net/ • Herndon, Laurie. “Working with SNFs .” AHA/HRET HEN Week. PowerPoint presentation. Hyatt Regency, Chicago, IL. 20 March 2013.

38. Vision for Cross-Continuum Teams Understanding mutual interdependencies, the hospital-based teams co-design care processes with their CCT partners and collaborate to solve problems to improve the transition out of the hospital and reception into community settings of care. • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

39. Cross-Continuum Teams • A team of staff in the hospital, skilled nursing facilities, home health care agencies, office practices, patients and family caregivers: • Provide oversight and guidance • Help to connect hospital improvement efforts with partnering community organizations • –Identifies improvement opportunities • –Facilitates learning across care settings • –Facilitates collaboration to test changes • Provide oversight for the initial pilot unit work and establishes a dissemination strategy • Convene at least monthly • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

40. Quotes from Cross-Continuum Team Members • “It is a lot of work to establish this team, but it is worth it.” • “The conversations change when everyone is at the table. It feels good to have us all in the room with the patient at the center of our work.” • “Even if we haven’t moved the numbers, we have moved the mindset.” • “Staff at different sites of care pick up the phone; they didn't before.” • “We make more referrals to home health care as a result of the improved communications.” • “The CCT will last beyond STAAR. All future initiatives will benefit from the open communications and less silo’ed care.” • “We are making great strides in opening the communication of patient care between our diversified organizations. It is truly encouraging after 40+ years in health care to see this transformation.” • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

41. Top Readmit APR-DRG Tab • Why are patients coming back with the same index diagnosis? • -Could be severity of illness/co-morbidities • -Medication or polypharmacy? • -Poor patient/caregiver education at discharge? • -Poor continuity of care • -We aren't engaging and empowering our patients enough.. Translating Data Into Improvement

42. Top Readmit APR-DRG Tab Improvement Activities • 1. Teachback • 2. 72 hour call backs • 3. Patient/Family/Caregiver centered discharge process • 4. Get your nurses out and home health in • 5. Challenge your readmissions team to start thinking about innovative solutions to enhancing care coordination • -Graham Hospital-WRAP Program Translating Data Into Improvement

43. Follow-Up Phone Calls • Post-discharge follow-up phone calls have been frequently cited as a cost-effective method to enhance communication with the patient and families in the critical period following discharge • Follow-up phone calls give patients and caregivers the opportunity to reinforce education and assess self-care knowledge through the use of Teach Back • There is little standardization or consensus on the timing and frequency of post-discharge follow-up calls • Johnson M, Laderman M, Coleman E. STAAR Issue Brief: Enhancing the Effectiveness of Follow-up Phone Calls to Improve Transitions in Care. Cambridge, MA: Institute for Healthcare Improvement; 2012.

44. Follow-Up Phone Calls • Developing a shared set of guidelines for health care organizations and community-based organizations and payers is important – What is the optimal timing and frequency of the follow-up calls? – Who should make the call? – Which information is essential? • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

45. Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

47. Use whiteboards to communicate daily goals, expected discharge date and discharge goals, and to note questions the patient and family caregivers may have • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.

48. Patient Level Tab • Frequent flyers • Severity of illness (palliative care opportunities) • Physician trends • Case Manager Involvement • Drilling into this data will likely draw you to your medical records for more answers Translating Data Into Improvement

49. Patient Level Tab Improvement Activities • 1. Use this tab as a compass to your medical records • 2. Daily Patient Care Rounds • 3. Evaluate your Palliative Care Services (PC Bundle) • 4. Evaluate physician activity and identify possible improvement opportunities • 5. Make this tab your Case Manager’s best friend Translating Data Into Improvement

50. Expanding the Focus of Daily Patient Care Rounds • Suggestions for developing a post-acute care plan based on the assessed needs and capabilities of the patient and family caregivers are listed below: • Develop one comprehensive assessment of patients post-acute care needs that integrates input from all members of the care team • Make sure each member of the care team is clear about what information they must bring to rounds each day (see RN example) • Change the focus on daily patient care rounds to include a dual focus of optimizing care in the hospital and decreasing the length of stay while simultaneously planning to meet the post-discharge care needs of patients and to prevent readmissions • Bradke, Peg & Rutherford, Pat. “Developing Post-Hospital Follow-Up Care Plans .” IHI Readmissions Conference. PowerPoint presentation. JW Marriott, Chicago, IL. 26 March 2013.