Intermountain-led CMS Hospital Engagement Network Readmissions November 4, 2014 Affinity Call Andrew Masica, MD, MSCI Baylor Scott & White Health Jennifer

Intermountain-led CMS Hospital Engagement Network

ReadmissionsNovember 4, 2014

Affinity Call

Andrew Masica, MD, MSCIBaylor Scott & White Health

Jennifer Pearce, MPALois Cross, RN, BSN, ACM

Sutter Health

Outline for Discussion

• Review of the HEN Readmissions work • “Just-one-thing” Recommendations• High performers• NQF Readmission Action Team• 2014 plans for improvement:

– predictive analytics for readmissions (June)– Continue Webinars for sharing

Intermountain HEN 2012-Q2 2014 30-Day All Cause

Baseline 8.83

13.1%Decrease

Intermountain HEN 2012-Q2 2014 30-Day All Cause Readmissions

Intermountain HEN 2012-13 30-Day Medicare Readmissions

Baseline 12.3

12.8%Decrease

Intermountain HEN 2012-13 30-Day Medicare Readmissions

Intermountain HEN 2012-13 submitting 30-Day Heart Failure Readmissions

Baseline 15.4

5%Increase

Intermountain HEN 2012-13 submitting 30-Day Heart Failure Readmissions

Just One Thing MatrixRecommendations

Getting Started Working Harder Ahead of the Curve

Transitional care providers capable of performing in-person visits (e.g. home, SNF) to selected patients following hospital discharge.

Pharmacist-led medication management (reconciliation, regimen streamlining at discharge; post-discharge follow up regarding medication access and side effects(moderate level of evidence)

Robust readmission risk stratification tools.

High Performing Hospital Highlight…

30-Day All Cause Readmissions

Most Improvement

MENLO PARK SURGICAL HOSPITALSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ

OREM COMMUNITY HOSPITAL

SOCORRO GENERAL HOSPITAL

THE ORTHOPEDIC SPECIALTY HOSPITAL

BEAR RIVER VALLEY HOSPITALPROVIDENCE HOOD RIVER MEMORIAL HOSPITAL

AMERICAN FORK HOSPITAL

RIVERTON HOSPITAL

PARK CITY MEDICAL CENTER

Lowest Rates

SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ

MENLO PARK SURGICAL HOSPITAL




BEAR RIVER VALLEY HOSPITAL

PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL


RIVERTON HOSPITAL



Most ImprovementSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ


GARFIELD MEMORIAL HOSPITAL


FILLMORE COMMUNITY MEDICAL CENTER



LINCOLN COUNTY MEDICAL CENTER

PARK CITY MEDICAL CENTERPROVIDENCE HOOD RIVER MEMORIAL HOSPITAL

30-Day Medicare Readmissions

Lowest Rates



GARFIELD MEMORIAL HOSPITAL



SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ



LINCOLN COUNTY MEDICAL CENTER



Most Improvement



SUTTER DAVIS HOSPITAL

SUTTER LAKESIDE HOSPITALSUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ



ESPANOLA HOSPITAL

LDS HOSPITAL


30-Day Heart Failure Readmissions

Lowest Rates

LDS HOSPITAL

ALTA VIEW HOSPITAL

SUTTER LAKESIDE HOSPITAL

SUTTER DAVIS HOSPITAL


SEVIER VALLEY MEDICAL CENTER

ESPANOLA HOSPITAL




SDM as Infrastructure for Enterprise Level Patient Engagement

November 2014

Andrew Masica, MD, MSCI

14

What is Shared Decision Making (SDM)?

• A collaborative process between patient and clinician that engages the patient in decision making by

– Helping them understand that a decision needs to be made (decision point),

– clarifying all acceptable options and ensure that patients are well-informed regarding the best available medical evidence, and

– choosing a course of action consistent with the patients’ needs, preferences, and values.

• SDM is part of delivering patient centered care.

Patient Engagement

Hibbard et al., Health Affairs 2012

PatientEngagement

SDM

Relationship Between Patient Engagement and SDM

17

Program Implementation

• Challenges– Workflow in clinics– Survey Administration Tool– Health Coach Turnover– SDM must start very early in the process, not when the patient

has already decided to have surgery or once they are in the hospital

– Relative perceived value in fee-for service reimbursement

• Successes– Socialization of SDM as a “best practice”– SDM Training transitioned to on-site program

18

CMMI Progress: Ortho

• September 2013-September 2014– Enrollment (embedded health coach model)

• Hip 36• Knee 81• Spinal Stenosis 5• Herniated Disk 2

• Referral process, access to single on-site health coach, “pre-determination,” physician acceptance, equivocal patient interest all acted as barriers that impacted accrual

19

Revision in Strategy

Average annual CMS spend on beneficiaries with DM in BSWH-North Texas PHN(from spring 2014 HVHC report)

20

Leverage Points in Reducing Costs

Condition Case Volume Average CMS Spend Total

Orthopedic Surgeries 1,500 $20-45K $45MCHF 5,500 $42K $231MDiabetes 20,500 $20K $400M

• Orthopedic procedure utilization rate was slightly below the HVHC mean

• Numerous “touchpoints” for our patients with chronic disease

• SDM training was rolled out to personnel interfacing with these patient populations (primary care health coaches, hospital-based transitional care staff)

Extending SDM’s Reach in the BSWH North Division

22

Improved Accrual in Chronic Disease Patients

Is SDM Impacting Outcomes?

PCMH as an Ideal Site for SDM

24Miller, How to Create an Accountable Care Organization, 2009 www.CHQPR.org

25

Redesigning SDM Approach

• Successfully implementing SDM requires all parts of the healthcare team to play their part with a process fully integrated into the system’s culture and practice

• SDM is not an intervention that can be conducted at one point in time, it is part of the healthcare delivery and communication process– a whole systems approach

Transforming Population Health – Achieving accountable, high-quality, cost-effective care for the patients we serve

Scalability is the Key Challenge

26https://fortress.maptive.com/ver3/c9ee95d0ae96b4e648088aeee101e296

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The Future of SDM

• Training– PCMH- MA– System Level Care Coordination department

• Revising & Spreading training, integrating into system quality education program

• Development of leadership & physician training modules

• Allocation of operational budget to support this work

There is always a choice…..

© 2014 Sutter Health

Jennifer Pearce, MPAHealth Literacy Program ManagerSutter Center for Integrated Care

Health Literacy &Health Literate Care

29


How is “health literacy” different from “literacy”?

•Having the basic skills to read, write and compute without regard to context

Literacy

•Reading, writing, computing, communicating and understanding in the context of health care

Health literacy

30

Source: Weiss B. Epidemiology of Low Health Literacy. Understanding Health Literacy: Implications for Medicine and Public Health


Health literacy includes one’s ability to perform multiple tasks

Health literacy

Obtain

Document literacy

Process

Prose literacy

Understand

Quantitative literacy

Communicate: listen and speak

Numeric literacy

31

Source: IOM. 2004. Health Literacy: A Prescription to End ConfusionSource: Schwartzberg, J. 2005. Understanding Health Literacy: Implications for Medicine and Public Health


What’s for lunch?

Document literacy

Prose literacy

Quantitative literacy

Numeric literacy


Mismatch leads to harm

Source: Parker, R. and Ratzan, S. 2010. “Health Literacy: A Second Decade of Distinction for Americans', Journal of Health Communication” 15: S2, 20 — 33

Health literacy

Patient skills/ability

Health system demand/complexity


Patient skills: Prevalence of low health literacy

2003 National Assessment of Adult Literacy

Proficient12%

Below Basic14%

Intermediate52%

Basic22%

34

Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy


Adult health literacy by highest level of education

35Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy

Only 1/3 of those with a graduate degree have the skills to effectively manage a chronic illness

NAAL (2003)


Adult health literacy by age

36Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy

Only 3% of those age 65+ have the skills to effectively manage a chronic illness

NAAL (2003)


Best practice

Reading ability

Education level

Socio-

economic status

Universal Precaution Approach

37

Source: Smith, Sandra A. (2001). Patient Education and Literacy in Labus, A. & Lauber, A. (Eds.) Preventive Medicine and Patient Education. Philadelphia: WB Saunders, 266-290.


Evidence: Easy-to-read is preferred!

College educated readers’ response to health information written at 5th grade level:

Recall of key messages

Satisfaction

Source: Smith SA. Information giving: Effects on birth outcomes and patient satisfaction. Int Electronic J Health Educ 1998:;3:135-145.

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System resources

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One Patient – One Message Disease and condition management (stoplights)

Personal health record (electronic & paper)High risk medication tools

Acute

Ambulatory

Skilled &

Rehab

Home care,

Palliative & Hospice


Health literate stoplight tool with universal precaution approach applied

Center for Plain LanguageWashington, D.C.

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Medication and Route Dose Frequency Reason Instructions

Partnered with EMR to develop patient friendly medicine list

Font size increased to 14 pt


Health literacy impacts all six aims

Patient

Timely

Safe

Equitable

Patient centered

Efficient

Effective


Health.gov

http://www.health.gov/communication/interactiveHLCM/#resources

Please feel free to contact me

Jennifer Pearce, MPAHealth Literacy Program ManagerSutter Center for Integrated Carepearcej1@sutterhealth.orgwww.suttercenterforintegratedcare.org

For questions or additional information:

http://www.health.gov/communication/interactiveHLCM/

Documents

Intermountain-led CMS Hospital Engagement Network Readmissions November 4, 2014 Affinity Call Andrew Masica, MD, MSCI Baylor Scott & White Health Jennifer