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Care Transitions
Learning and Action Network
Today’s Agenda
• Welcome and Readmission Data Discussion– Rebecca Durham, HealthInsight 1:20 - 1:35 p.m.
• Why We are interested in Readmissions– Michelle Carlson, HealthInsight 1:35 - 2:00 p.m.
• Effective Communication Tools 2:00 - 2:20 p.m.– Michelle Carlson/Rebecca Durham
Group Discussion 2:20 - 2:50 p.m.– Everyone
Wrap up and Evaluations 2:50- 3:00 p.m.
What are our aims?
• Our overall goal is to reduce 30-day hospital readmissions for Medicare FFS patients in Utah by 20% by July 31, 2014. Nationwide, about 1 in 5 Medicare beneficiaries are readmitted to the hospital within 30 days of discharge (Jencks et al., 2009).
• Our objectives are to engage with care providers and communities around the state to examine the root causes of 30-day readmissions and implement evidence-based interventions to address these causes…
• So that Medicare beneficiaries have improved health and spend more time at home, instead of in the hospital.
How are we doing?• In general, Utah has one of the lowest rates of
hospital readmissions for people with Medicare in the country:
….But that is no reason to be complacent!
Utah US
Medical Discharges 13.1% 16.1%
Surgical Discharges 9.8% 12.7%
CHF Discharges 15.5% 21.2%
AMI Discharges 11.5% 18.5%
Pneumonia Discharges 11.2% 15.2%
Hip Fracture Discharges 8.6% 14.5%
Source: Dartmouth Atlas of Healthcare, analysis of 2009 adjusted data for US Medicare population
Annual All-Cause 30-Day Readmission Rates
• Utah, 2011– Hospital level: 13.4%
• Range: 5.0% - 16.7%*
• Clearly, there is a lot of variation amongst hospitals and some are having great success with rates below 10%!
*Excluding hospitals with <100 denominatorSource: HealthInsight analysis based on Medicare FFS claims for the period of 1/1/2011-12/31/2011.
So who gets readmitted?
Source: HealthInsight analysis based on Medicare FFS claims for the period of 4/1/2009-12/31/2011. Date axis reflects year end date.
0
2
4
6
8
10
12
14
16
18
3/31/2010 6/30/2010 9/30/2010 12/31/2010 3/31/2011 6/30/2011 9/30/2011 12/31/2011
Readmission Rates per 1,000 Beneficiaries for Selected Conditions, Utah 2009-2011
AMI
COPD
Chronic Renal Failure
CHF
Diabetes
Pneumonia
Where did they go when they left the hospital?
• Percentage of 30-day readmissions by status at index admission discharge
Source: HealthInsight analysis based on Medicare FFS claims for the period of 1/1/2011-12/31/2011.
How can data help us ?identify potential partners?
Source: Analysis based on Medicare FFS claims for 2009.
How can data help us identify potential partners?
Source: Analysis based on Medicare FFS claims for 2009.
How can data help us identify potential partners?
Source: Analysis based on Medicare FFS claims for 2009.
How can data help us identify potential partners?
Source: Analysis based on Medicare FFS claims for 2009.
How can data help us with root causes?
• One driver of 30-day readmission rates is lack of timely follow up with outpatient care after discharge from hospital.
• In Utah in 2011, – 48.5% of patients who were readmitted to the
hospital within 30 days were readmitted within 10 days of discharge
– 37.7% of patients who were readmitted to the hospital within 30 days were readmitted within 7 days of discharge
Source: HealthInsight analysis based on Medicare FFS claims for the period of 1/1/2011-12/31/2011.
We are here to help!• Data and the information they generate are
extremely useful for finding patterns and examining trends, and we have data that can help light the path.
• But we still need YOU to walk the path with us and help us learn what we cannot from data alone.
Community-Based Care Coordination
339 Days in the Life of Mrs. B A Medicare Beneficiary
Mrs. B
Newly Established Patient with Internal Medicine Physician
• A regular source of care• Initial visit - DM, HTN, osteoporosis
and hypothyroidismo DM poorly controlled, early
numbness
• Scheduled bi-monthly visits until DM controlled
Day 15
Status:
Providers:
Medications:
Payments:
Daughter:
Fully functional, Helps with grandkids Takes care of her husband
Internist Ophthalmologist (?)
2 HTN each 1x/d, 2 DM each 2x/d 1 osteoporosis once weekly 1 hypothyroidism 1x/d, Eye drops
$180.00
Dinner weekly Worries about Dad
Day 60
Day 60
• Lacerations, abrasions, and contusions
• Sutures, basic wound care
• Discharged to home
Day 68
Status:
Providers:
Medications:
Payments:
Daughter:
Homebound receiving Home HealthNot feeling well
Internist Physical therapistED doctor Occupational therapist
2 HTN each 1x/d, 2 DM each 2x/d 1 osteoporosis once weekly1 hypothyroidism 1x/d, Pain meds – every 4-6 hrs.
$3,256 – ED, $476 – HHA, $99 – PCP
Daily visits, doing the shopping Transportation to appts. Worried about Dad
$4,011
Day 69
• Staph infection• Dehydration• Atrial Fibrillation• Acute Renal
Failure• CHF• Pneumonia• DM – not
mentioned
Day 82Status:
Providers:
Medications:
Payment:
Discharge to SNF – ADLs, Depressed
Internist HH Physical therapistED doctor HH Occ therapistHospitalist Hospital PTCardiologist
2 HTN each 1x/d, 2 DM each 2x/d 2 HF meds – each 1x/d, Antidepressant – 1x/d, 1 osteoporosis once weekly1 hypothyroidism 1x/d, Pain meds – every 4-6 hrs, 2 antibiotics – 1x/d and 2x/dAntidepressant – 1x/d
$48,009$52,020
Days 82-182: SNF
• Daily PT• Excellent wound care• Has visit from PCP• Diabetes control improved• Neuropathy continues• Ambulation potential not returned
to baseline
Day 182Status:
Providers:
Medications:
To Home
Internist HH Physical therapistED doctor HH Occ therapistHospitalist Hospital PTCardiologist
2 HTN each 1x/d, 2 DM each 2x/d 2 HTN each 1x/d, 2 DM each 2x/d 2 HF meds – each 1x/d, Antidepressant – 1x/d, 1 osteoporosis once weekly1 hypothyroidism 1x/d, Pain meds – every 4-6 hrs, 2 antibiotics – 1x/d and 2x/dAntidepressant – 1x/d
Day 182 (Continued)
Payment:
Daughter:
$34,495 – SNF$99 – PCP
Stressed outDaily visits to Dad at homeDaily visits to SNFFeels guilty about noticing that the SNF made her life easierCommitted to getting her mother “back to normal” Thinking about working part timeBudgeting for college educations
$86,614
Day 183• Home• Nauseated/poor appetite• Unsure what to eat – doesn’t feel like
eating anyway• Can’t find her teeth• Husband vague, needs help with basic
decisions• Daughter comes 2x/d; Working part-time
intends to call PCP to schedule HH again
Day 184
• Dehydration• CHF• Atrial Fib• DM
Day 190
Status:
Providers:
Medications:
Discharge to SNF
Internist HH PT
ED doctor HH OT
Hospitalist (2) Hospital PT
Cardiologist SNF PT (2)
SNFist SNF OT (2)
2 HTN each 1x/d
2 DM each 2x/d
2 HF meds – each 1x/d
1 osteoporosis once weekly
1 hypothyroidism 1x/d
1 antidepressant 1x/d
Day 190 (Continued)Day 190 (Continued)
Payment:
Daughter:
$24,281 - hospital
Stressed outDaily visits to Dad at home – looking for day care programFeels guilty about readmissionCommitted to getting her mother “back to normal” Has begun working part timeBudgeting for college educations
$110,895
Days 191-337: SNF
• Intensive PT/ gait training, self-management training
• Daughter visits often but is unable to make it daily
• Dad in daily day care – daughter considering NH
• Progressive renal failure/ heart failure• Intermittent atrial fibrillation
Day 338
• Readmission• Acute renal failure• Decompensated CHF• Acute respiratory failure• Acidosis
Day 339Status:
Providers:
Payments:
Daughter:
Deceased
Internist HH PT ED doctor HH OT Hospitalist (2) Hospital PT Cardiologist SNF PT (2) SNFist SNF OT (2) $18,393 – hospital, SNF - $50,370
Grieving Worried about Dad Worried about personal finances
$179,658
What’s Wrong?
Conceptually…• Reactive care
– Chronic disease care in acute care settings
• Diagnosis-specific thinking– ‘Guideline-Driven Care’
• No integration of Mrs. B nor her daughter
• Multiple Transitions of Care – No coordination
What we Really Need is Intentionally Designed Care that meets the needs of patients and families..
Cause of Readmission = Poor or Non-existent Transitions of Care• Medication Problems
o Improperly managed by the HC team
o Patient non-adherence through poor understanding
• Lack of reliable follow-up careo Receiving providers unaware
• Poor patient engagemento Symptom worsening
Solutions
• Medication Problems
o Improperly managed by the HC team
o Patient non-adherence through poor understanding
• Lack of reliable follow-up care
o Receiving providers unaware
• Poor patient engagement
o Symptom worsening
1. Patient engagement and healthcare coaching
2. Handover management
3. Information transferPatient-Centered Plan of Care
*Medication List/Reconciliation
*Warning Signs
*Allergies
*List of physicians
Personal Health Record
Intervention PackagesIntervention Reference Main Tools Driver Addressed
HM (2)
PE (1)
IT (3)
Care Transitions InterventionSM
www.caretransitions.orgCoaches, personal health record, medication discrepancy tool
? XXX X
Transitional Care Nursing
www.transitionalcare.info/index.html0
Risk assessment , nursing training materials
? XXX XX
CMS Discharge Checklist
www.medicare.govPatient and family checklist of important items to address before discharge
? XXX X
BOOSTwww.hospitalmedicine.org/ResourceRoomRedesign
Screening/assessment, provider discharge checklist, transition record, teach-back instructions, data collection and tracking
XXX XX
Best Practices Intervention Package (BPIP)
www.homehealthquaqlity.org/hh/ed_resources/interventionpackages/default.aspx
Comprehensive manual for HHA process improvement includes CTI teaching
XX XX XX
INTERACT Interact.geriu.orgCommunication tools, clinical care paths, advanced care planning
XX XX
Transforming Care at the Bedside (TCAB)
www.ihi.org/IHI/Programs/StrategicInitiatives/TransformingCareAt TheBedside.htm
(Re)Admission assessment, teach-back, pt and family communication, scheduled f/u
XXX XX X
Re-Engineered Discharge (RED)
www.bu.edu/fammed/projectred/index.gtml
Nurse discharge advocate, pharmacy f/u medication teaching, PCP f/u booklet
XXX XX
Interact IIEarly Warning Tool
“Stop and Watch”
Purpose: To identify a Change in Condition with a Patient or Resident
►Can be used by ANY staff or person who has direct patient/resident contact
►Must be reported to charge nurse during shift of occurrence or sooner if indicated.
SBAR• Situation
• Background
• Assessment
• Request/Recommendation
*Originated in the US Navy Nuclear Submarine Service
Purpose: To improve communication between Nurses and MD/NP/PA (PCP)
SBAR
• Used effectively across healthcare settings to improve communication
• A great tool for new nurses to help enhance their assessment skills
• Provides standardization across settings
• Relatively easy to implement- back page is a blank progress note to reduce duplication.
LINC & Infection Control (IC)
•LINC= Linking Information Necessary for Care
-A collaborative effort by multiple stakeholders to increase communication upon transfers-Currently with UHIN working on digitizing
•Infection Control= Transfer form intended to accompany any resident/patient with an infectious condition.
- Contains definitions & standard precautions
Questions
• What processes can be improved in my setting by implementing the Interact II, S-BAR and/or the Stop and Watch tool?
• What would be the first steps in implementing these tools?
Ideas on how to use these tools in your settings ?
Please help us to improve our events.Complete your evaluation!
• The evaluation has two pages:
– The first page is completed anonymously and tells us how satisfied you are with the content and presentations you heard today. You do not need to put your name on this evaluation. Comments are welcome!
– The second page tells us how you plan to implement what you have learned today and how HealthInsight can assist you. Completing this page is necessary for you to receive CME or an attendance certificate. Please be sure to put your name and contact information at the top of this page!
• Please separate the two pages after you have filled them out and turn them in to HealthInsight staff.
Questions?Michelle Carlson
801-892-6646
Rebecca Durham
801-892-6620
