CARE TRANSITIONS TASKFORCE – IMPROVEMENT WORK AT SFGH Larissa Thomas, MD | Michelle Schneidermann, MD | Karishma Oza, MPH

SFGH Division of Hospital Medicine

Outline

Background on care transitions Dashboard data Care Transitions Taskforce Work

Taskforce structure Inpatient work High risk work Outpatient work

What leads to problem transitions?

Discharge process Discharged quicker and sicker? Ineffective communication between sending and receiving

providers? Insufficient coordination and community referrals?

Patient factors: self-management skills/health literacy, confidence, what to watch for (“red flags”)

Medications: too many, inadequate access, or unclear instructions

Lack of access: to timely follow-up and/or advice line

SFGH Care Transitions Taskforce: Vision

SFGH Care Transitions Taskforce

Aim statement: Reduce all-cause 30 day readmissions for patients

discharged from San Francisco General Hospital by 15 percent from a baseline of 12.3 percent to 10.4 percent by December 2014.

Through: Coordination along care continuum

Promotion of best practice standards

Identification and referral of high risk patients

Provision of timely performance feedback

30-Day Readmission Rate: SFGH

12.49% 12.65%

12.88%

14.49%

13.02%

13.55% 13.46%

12.25%

11.00%

11.50%

12.00%

12.50%

13.00%

13.50%

14.00%

14.50%

15.00%

2012-1 2012-2 2012-3 2012-4 2013-1 2013-2 2013-3 2013-4 Quarter

Care Transitions dashboard draft | Karishma Oza, Michelle Schneidermann, MD & Larissa Thomas, MD | Mar. 2014 Source: LCR

30-Day CMS Readmission Rate for Core Measures

19.1% 20.5%

27.7% 27.0% 32.5%

37.9%

32.7% 33.6%

20.0%

15.6%

19.5%

24.0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

2011Q2-2012Q1 2011Q4-2012Q3 2012Q2-2013Q1 2012Q3-2013Q2

Pneumonia CHF MI n=47

n=15

n=5

n=8

n=23

n=48 n=45

n=20

n=12

REGION 2011-Q2-2012Q1 2011Q4-2012Q3 2012Q2-2013Q1 2012Q3-2013Q2

Pneumonia 19.0% 18.7% 17.2% 17.4%

CHF 25.1% 26.7% 25.1% 25.0%

MI 20.3% 23.4% 22.9% 22.8%

CALIFORNIA

Pneumonia 18.6% 18.5% 18.3% 18.1%

CHF 26.4% 26.5% 26.2% 26.0%

MI 20.6% 20.1% 19.9% 19.9%

n=41

n=13

n=7

Source: CMS/Quality Net

30-Day Readmission Rate by Service

0%

5%

10%

15%

20%

25%

30%

35%

CAR FPR GYN MED NEU NSU NUR OBS OPH ORT OSU OTO PED PSU TRA URO

Service

2013-1 2013-2 2013-3

2013 median rate for all services: 7% (Q1), 9% (Q2), 8% (Q3)

Service 2013-1 2013-2 2013-3

CAR 39 42 49

FPR 29 42 65

GYN 4 3 1

MED 124 166 174

NEU 6 11 3

NSU 10 16 13

NUR 24 20 24

OBS 5 3 6

OPH 1 0 0

ORT 9 19 21

OSU 1 1 1

OTO 2 0 1

PED 13 9 8

PSU 3 4 4

TRA 20 30 45

URO 3 7 4

# of Readmissions by Service:

Source: LCR

30-Day Readmission Rate by Unit

Increased for 5A, 5D Stayed relatively the same for 4B, 5C Declined for 4D, 6A

11% 10%

14%

11%

13%

7% 8%

10%

13% 14% 15%

7%

11%

9%

15% 14%

16%

4%

0% 2% 4% 6% 8%

10% 12% 14% 16% 18%

4B 4D 5A 5C 5D 6A Unit

2013-1 2013-2 2013-3

Care Transitions dashboard draft | Karishma Oza, Michelle Schneidermann, MD & Larissa Thomas, MD | Mar. 2014 Source: LCR

30-Day Readmission Rate for Top 5 Index DRG Associated with Readmission

Index DRG 2013-1 2013-2 2013-3 Average

CHF NOS 22% 20% 39% 27%

PNEUMONIA ORGANISM NOS 15% 14% 17% 15%

ABDOMINAL PAIN-SITE NOS 11% 24% 20% 18%

ALCOHOL WITHDRAWAL 15% 21% 20% 19%

SHORTNESS OF BREATH 17% 13% 21% 17%

Care Transitions dashboard draft | Karishma Oza, Michelle Schneidermann, MD & Larissa Thomas, MD | Mar. 2014 Source: LCR

30-Day Readmission Rate: Homeless Patients

21%

17% 18% 16%

17% 18%

14% 16%

0%

5%

10%

15%

20%

25%

2012-1 2012-2 2012-3 2012-4 2013-1 2013-2 2013-3 2013-4

2012-13 readmit rate

• Steady decline since Q12012 • 2012-2013 average rate: 17%

Care Transitions dashboard draft | Karishma Oza, Michelle Schneidermann, MD & Larissa Thomas, MD |Mar. 2014 Source: LCR

Cardiology: LOS & Readmit Rate

4.6 4.3 3.4 4.0 3.6

4.5 3.8

3.0 3.2 3.4 3.9 3.6 2.8

6.8 5.7 6.3 6.3 6.5

5.4 5.2 4.4

6.5

4.5 4.7 5.5

4.3

10.9%

13.5%

11.5%

13.5% 12.5%

17.5% 16.0%

11.6% 13.1% 12.8%

17.9%

15.2%

15.8%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

0.0

5.0

10.0

15.0

20.0

25.0

Perc

enta

ge

Avg

LO

S (D

ays)

All Patients Readmitted Patients Readmit Rate

Care Transitions dashboard draft | Karishma Oza, Michelle Schneidermann, MD & Larissa Thomas, MD | Mar. 2014 Source: LCR

Proportion of SFGH Pts Attending PCH FU Appt Within 7 and 14 Days (2013 Average)

14-day FU appt rates approx. double 7-day rates

12% 11%

22%

13%

25%

16%

24%

18%

9% 10%

30%

12% 17%

23% 19%

47%

27%

47%

34%

42%

33%

17%

25%

57%

37% 34%

0%

10%

20%

30%

40%

50%

60%

7 Days 14 Days

Care Transitions dashboard draft | Karishma Oza, Michelle Schneidermann, MD & Larissa Thomas, MD | Mar. 2014 Source: LCR

Care Transitions Taskforce: Work to Date

INPATIENT improvement work Partnering with IT to build Standard d/c summary template within the EMR ePDP and d/c instructions within the EMR

Development of medical student and housestaff curricula on care transitions resources and best practices National best practice standards for all patients Red flag identification for high risk patients

In process: Requirement to complete d/c summary on day of d/c Standardization for PCP communication

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CURRENTLY: medicine dept has excellent d/c summary template based on best practices. Problems: not user friendly, can choose whether or not to complete as prompted, not used by services other than medicine.

GOAL: build standardized template based on consensus guidelines directly into EMR. Benefits: User friendly, required by all services, force function to promote completeness.

Care Transitions Taskforce: Work to Date

HIGH RISK PATIENTS improvement work Risk prediction tools Developed a modified BOOST 7P’s tool Partnering w/IS to build LACE index into EMR

SFGH Transitional Care RN program Extending length of intervention Adding a CHF focus Adding a pharmacist to the team Piloting Meducation software

Partnering w/SF Community Care Transitions Program

BOOST at SFGH

Psychological Disease Principal Diagnoses OR Prior

Hospitalization in the last 6 months Polypharmacy and Problem

Medications Insufficient Patient Support Need for Palliative care Polysubstance abuse Placement

SFGH Transitional Care Nursing Program

What: RN-based intervention to prevent readmissions for high risk

patients Who qualifies:

>55 yrs old w/core measure diagnoses or referral from inpatient providers

Intervention: During hospitalization: coaching/motivational interviewing,

expanded med rec, and care plan. Additional teaching and pharmacy intervention for CHF.

Post-discharge phone calls: within 48 hours and then weekly phone calls for 30 days.

Care coordination with outpatient & community-based providers Warm-line

SFGH Transitional Care RN Program: Patient Characteristics

18%

73%

7% 2% Language

Chinese English Spanish Other

62%

38%

Gender

Male Female

Variable Values

Number of patients* 1419

Age, in years (average) 60

Male (%) 62%

Female (%) 38%

LANGUAGE:

Chinese (n, %) 259 (18%)

English (n, %) 1033 (73%)

Spanish (n, %) 104 (7%)

Other (n, %) 23 (2%)

*Between Oct 2012 and Oct 2013 Source: TCN Database

126

135 137

109

137

126

98

136

SFGH Transitional Care RN Readmission Rates & Timeline

18%

10% 9%

6%

11%

8%

5%

8%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sept-13 Oct-13

Perc

enta

ge CCTP partnership started

CHF booklet implemented

Pharmacy pilot started

TAACT Collaborative

Source: TCN Database

Inclusion criteria & recruitment protocol implemented

SF Community Care Transitions Project

ACA initiative: CMS pays CBOs to do transitions work 9 hospitals and 8 CBOs in partnership with DAAS

Target: Medicare FFS beneficiaries Intervention: Social workers provide coaching, care

coordination, and service package: 14 d. home delivered meals Up to 6 hrs/day homecare 2 roundtrip visits to clinic appointments Linkage to case management as needed after 45 days

Care Transitions Taskforce: Work to Date

OUTPATIENT improvement work Taking Accountability for Ambulatory Care Transitions

(TAACT) collaborative Primary care-based pilot utilizing complex care management

teams to do transitions work Admission list developed with IT, sortable by clinic and

PCP (lives in EMR) Primary care integration working group to focus on

standards: Scheduling post-discharge follow-up appointment Content& documentation of post-discharge follow-up appts Use of non-physician personnel to provide post-discharge f/u

Admission List, Sortable by PCC or PCP

26

Care Transitions Taskforce: Next Steps

Data dashboard: Generate & present reports Look at specific high risk populations – homeless & marginally housed,

patients w/substance use disorders, hot-spotters Chart reviews & deeper dives of readmitted patients

High risk patients: Finalize & validate risk prediction tool Work with pharmacy leadership to expand resources for patients

with polypharmacy or high risk medications Work w/cardiology and administration to improve outpatient care of

complex HF patients Partner with DPH Primary Care Integration Group and

Transitions Dept. to scale up outpatient interventions Standardize follow-up of pending studies, explore options for a

post-discharge “warm line”