Partnering with Home Care to Reduce Hospital Readmissions

1. Partnering with Home Care to Reduce Hospital Readmissions Carmela Coyle Maryland Hospital Association September 18, 2013

2. Readmissions • What are they? • Inpatient hospital admission that occurs within 30 days of discharge from a previous inpatient hospital admission

3. Why Readmissions? • Frequent • Costly • Performance highly variable • Able to be reduced • ….a pressing issue in Maryland

4. Readmissions are Often a Result of Poor Transitions in Care • Delayed Transmission of Information • Few primary care physicians report having a discharge summary by first follow up visit • Delayed Post-Discharge Follow Up • 50% of readmitted Medicare patients had a physician follow up visit between the day of discharge and day of readmission • Medication Errors & Adverse Events • 19% of Medicare discharges followed by an adverse event within 30 days—2/3 are drug events

5. Are All Readmissions Avoidable? • Many readmissions are preventable • No one knows how what proportion are truly avoidable • While many drivers of readmissions are outside of the hospital’s control, there are actions that hospitals can take to improve care transitions • Breakthrough performance is seen when providers across settings collaborate • Hospitals, physicians, home health agencies, nursing homes, behavioral health, and pharmacists

6. Readmission Rates Are Highly Variable Source: Dartmouth Atlas 2011

7. Readmission Rates are Highly Variable - Maryland Source: Delmarva Foundation for Medical Care, Medicare Quality Improvement Organization for Maryland.

8. Impact of Reducing Readmissions • A measurable reflection of care across settings • Reflection of fragmented delivery system • Improvement on readmission rates would likely reflect: • Improvement in provider - patient communication • Improvement in provider - provider communication • Improvement in linkage to follow up care • Engagement of patient/caregiver in self-management • Impact on acute-care utilization (ED, admissions)

9. Big Picture • Readmissions occur due to numerous factors- understanding “root causes” of readmissions is a critical first step to solve the problem of readmissions • Reducing readmissions cannot be done within the walls of the hospital • Aligning providers across settings to coordinate care transitions improvement efforts will create a multiplier effect and accelerate momentum

10. Readmissions in Maryland: Data

11. Maryland Data: Days Between Discharge and Readmission Source: Delmarva Foundation for Medical Care, Medicare Quality Improvement Organization for Maryland.

12. Maryland Data: Diagnosis-Specific Readmissions Source: Delmarva Foundation for Medical Care, Medicare Quality Improvement Organization for Maryland.

13. Maryland Data: Post-Acute Readmissions Source: Delmarva Foundation for Medical Care, Medicare Quality Improvement Organization for Maryland.

14. Readmission Payment Policy for Hospitals

15. Maryland Payment Initiatives • Admission Readmission Revenue (ARR) • Same hospital all-cause 30 day readmissions • Began in FY 2012 • 31 hospitals • Total Patient Revenue (TPR) • All inpatient and outpatient admissions • Began with one hospital over twenty years ago • Expanded to 10 hospitals (mostly rural) in FY 2011

16. Hospital-based Readmission Strategies • Risk screen patients and tailor care • Establish communication with PCP and home care • Use “teach back” to educate patient, family, and/or caregivers • Use multidisciplinary clinical teams to coordinate patient care • Discuss end-of-life treatment wishes • Comprehensive discharge planning • Schedule and prepare follow up appointment(s) • Help patient manage medications • Conduct patient home visit • Conduct telephone follow up

17. Looking Beyond Hospital Walls • “Rehospitalization is a system issue and the problem does not lie with one organization or one provider, but with the community and the local health care system. Addressing this issue will require organizations and providers to work together.” - Anne-Marie Audet, VP, The Commonwealth Fund

18. Transitions: Handle with Care MHA’s Cross-Setting Statewide Initiative

19. MHA’s Two-Part Strategy • Mobilize providers across setting to work on improving care transitions & provide quality improvement technical assistance • Learning Sessions • Webinars • Direct Technical Assistance • Engage state-level leadership to provide visibility and mobilize solutions to common systemic challenges • Care Transitions Steering Committee

20. Transitions Require Partnerships • Transitions in care by definition involve a transfer of care management responsibilities from one provider to another • Efforts to improve care transitions require “senders” and “receivers” to effectively communicate and coordinate • Often, transitions occur as a one-way handoff of referral with minimal information

21. Partnering “Senders” & “Receivers” • The Transitions: Handle with Care campaign is working to establish and strengthen “cross-continuum” partnerships between hospitals and post-acute and community based providers at every hospital in Maryland • Cross-continuum teams work together to: • Establish close working relationships • Identify specific opportunities for collaboration • Share readmission reduction tools, such as risk assessment or patients education materials

22. Cross-Continuum Team Principles • The cross-continuum team meetings are a venue for quality improvement • The “receiver” defines what information they need to assume care of the patient • Sending and receiving providers form collegial working relationships, open & easier lines of communication

23. Participating Hospitals

24. Cross-Continuum Collaboration

25. Opportunities for Collaboration • 34 of 36 hospitals have cross-continuum partnerships with over 315 providers • Reach out to your area hospitals, offer to attend next cross-continuum meeting • Bring your agency’s readmissions analysis, strategies • Review recently readmitted patients & identify specific opportunities for improvement

26. Recommendations • Know your data • Join a cross-continuum team • Identify opportunities to improve transitions and handoffs • Share your successes & tips to accelerate progress toward common goal

27. Final Thoughts • “The sooner we can all own up to our role, the sooner we can tackle this problem together.” -Risa Lavizzo-Mourey, MD, President & CEO, Robert Wood Johnson Foundation

28. Thank you! • Questions? • For more information: http://www.mhaonline.org/quality/transitions-handle-with-care