Follow Through is Everything

Care Transitions: Length of Stay and Readmission ManagementLeslie Foti, RN BSN ACM

Presenter Disclosures

Leslie Foti, RN BSN ACM

No relationships to disclose.

Why Do Care Transitions, Length of Stay (LOS), and Readmission Matter?

Setting the Table

New Payment Structure: Incentivizing Value and Quality

It’s Here!• Hospital Value-Based Purchasing • Pay-for-Performance• Readmission Penalties• Increased Scrutiny of Utilization

Why Does Length of Stay (LOS) and Readmission Matter?

• Financial Sustainability• Appropriate Stewardship of

Resources• The Right Thing to Do for

the Patient!

What are Care Transitions?

• “Transition of Care – The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another” (CMS, 2010)

• Goal – the shortest, safest, most efficient hospital stay with discharge to a level of care that has the needed resources and knowledge to manage the patient’s care outside of the hospital setting

Who “Owns” Care Transitions?

a) Case Managementb) The Health Care Teamc) The Patient and Familyd) All of the Above

What is the Target?

MS-DRG MS-DRG TitleGeometric mean LOS

061 ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W MCC 5.8062 ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W CC 4.2063 ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W/O CC/MCC 3.0064 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC 4.7065 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS 3.5066 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC 2.5069 TRANSIENT ISCHEMIA 2.2

Transition Needs of the Stroke Population

Stroke - a leading cause of serious

long-term disability

To Coordinate … in an Average of 2-6 days!

• Ancillary Services– Therapy– Dietician– Pharmacy– Case Management

• Teaching– Core Measures for Stroke– New Diagnoses– New Medications– New Diet– New Equipment

To Coordinate … in an Average of 2-6 days!

• Screen and Assess for : – Depression– Caregiver Burden• Respite care• Support groups

– Discharge needs• Support• Level of care • Resources• Financial Barriers

Integrate & Deliver Services in Alignment with LOS Goals

Communication, Coordination, Collaboration

Managing LOS

• Ensure everyone knows the goal!• Create systems that ensure all patient

needs are addressed without over utilization

• Know the players on your team & ensure they know what position they’re playing!

• Establish a consistent communication plan

Managing LOS

• Basic Nursing Care – advancing diet, activity, weaning medications and O2, and Teaching!

• Special vigilance with longer ICU, intermediate stays

• Dysphasia – PEG or not to PEG? Adequate intake on modified diets

• Look at your weekends – is it a black hole?

Managing LOS

• Newer Anticoagulants• Financial Barriers• Delirium, Dementia, &

Restraints• Managing Patient and Family

Expectations

Reducing Readmission Starts with Discharge Preparation

30% of acute stroke patients experience a hospital readmission

within 90 days of discharge (Roger, et al., 2011)

Discharge – Where the Ideal Meets Reality

• Home discharge – we must prepare the patient and family to self-manage their care– Willingness & Readiness– Teaching is Vital!– Access to Care• Do they have a PCP?• Can they afford their medications?• What to do with the VA?!?

– Home Health vs. Outpatient therapy

Readmission Reduction Strategies for the Home Discharge• Structured Teaching

–Teach Back• Discharge Instructions

– Should include EVERYTHING they need to know!• What to know about risk factors, lab targets,

medications, signs and symptoms• Who to contact with phone numbers

• Follow-up appointments made prior to discharge

• Post Discharge call backs within 24 hours• Respite and Support Resources

Discharge – Where the Ideal Meets Reality

Facility Discharge –LTACH, Acute Rehab, SNF, Custodial Care - which level?• What Impacts the Determination

– Acuity– Payer– Support system– Increased scrutiny of acute rehab– Observation status– Patient ability to participate in therapy

Readmission Reduction Strategies for the Facility Discharge

• Choose the RIGHT level of care

• Handoff to post hospital care providers

• Discuss custodial care early if it is anticipated

• Family conferences and palliative care

Other Strategies

Consider: • Partner with post hospital care providers and

support them with stroke specific education• Telephonic support for 30 days post discharge• Reassess for Cognitive Decline, Depression,

Caregiver Burnout with every follow up

Thank you!

References & Links• Centers for Medicare and Medicaid (CMS), (2011). Eligible professional meaningful use menu set measures measure 8 of 10, stage 1,

transition of care summary. E.H.R Incentive Programs. Retrieved from http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/8TransitionofCareSummary.pdf

• CMS, (2013). Hospital value-based purchasing program. Department of Health and Human Services Centers for Medicare & Medicaid Services. Retrieved from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf

• CMS, (2013). FY 2014 final rule tables. Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

• CMS, (2015, January 26th). Fact sheets: better care. smarter spending. healthier people: paying providers for value, not volume. Retrieved from http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

• Coleman, E.A., Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), p. 556-7.

• Olson, D.M., Prvu Bettger, J. , Alexander, K.P., Kendrick, A.S., Irvine, J.R. , Wing, L., … Graffagnino, C. , (2011). Transition of care for acute stroke and myocardial infarction patients: from hospitalization to rehabilitation, recovery, and secondary prevention. Agency for Healthcare Research and Quality, Publication No. 11(12)-E011.

• Mozaffarian D, Benjamin EJ, Go AS, et al., (2015) Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation,e29-322

• Naylor, M.D., Aiken, L.H., Kurtzman, E.T., et al., (2011) The importance of transitional care in achieving health reform. Health Affairs (Millwood)30 (4), p. 46-54.

• Poston, K. M., Dumas, B. P., & Edlund, B. J., (2013). Outcomes of a quality improvement project implementing stroke discharge advocacy to reduce 30-day readmission rates. Journal of Nursing Care Quality, 29 (3), p. 237-44.

• Roger, V.L, Go, A.S., Lloyd-Jones, D.M., Adams, R.J., Berry, J.D., Brown, T.M., Carnethon, M.R., … Wylie-Rosett, J., (2011).Executive summary: heart disease and stroke statistics—2011 update: a report from the American Heart Association. Circulation 123 (4):459-463.

• Links: Joint Commission Core Measures: http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx

• Joint Commission Comprehensive Stroke Center requirements: http://www.jointcommission.org/certification/advanced_certification_comprehensive_stroke_centers.aspx