2/25/2014

1

Improving Transitions atAllina Health

15th Annual International Summit on Improving Patient Care in the Office Practice and the Community

Steve Bergeson, MD

2

• Heart Failure

• HF, AMI and PN

• All cause

– Measured by PPR – i.e. clinically related

2

Improving Transitions

2/25/2014

2

3

Number of Days Between Discharge and a Potentially Preventable Readmission

• Between Jan. 1 and Aug. 31, 40% of potentially preventable readmissions across the system occurred within 7 days of discharge.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

50

100

150

200

250

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

% o

f To

tal

Po

ten

tia

lly

Pre

ven

tab

le R

ea

dm

issi

on

s

Days to Readmit

PPRs Count

Accumulated

Total PPRs %

4

Population Data by Discharge Status

Discharge Status PPRs Eligible

Discharges

PPR Rate Actual-to-

Expected Ratio

Self-Care 823 16,623 5.0% 0.96

Skilled Nursing Facility 340 3,947 8.6% 1.29

Home Health 189 2,179 8.7% 1.22

Other 50 626 8.0% 0.81

Grand Total 1,402 23,375 6.0% 1.05

2/25/2014

3

5

Improving Transitions: Preparing for the Transition Hospital

• Risk Stratification

• Transition Conferences for High and Moderate High Risk

• Interdisciplinary Planning Tool (IDPT)

• Clear communication to OP clinician what to do at the appointment (Recommendations for the OP provider: “ROP”)

• Use Ordersets to make a visit within 5 days and ROP a part of standard workflows

• Set up appointments before discharge

• Unresulted test results

5

6

Census Dashboard 2.18.2014 (10:23 AM)

6

2/25/2014

4

7

Transition Conference Performance in 2013 Across the System

• Generally better performance to expected Jan-Aug, 2013 for patients at high risk for a readmission with a transition conference than what is historically seen for that population.

0.00

0.50

1.00

1.50

2.00

2.50

Jan 2013 Feb 2013 Mar 2013 Apr 2013 May 2013 Jun 2013 Aug 2013

Act

ua

l-to

-Ex

pe

cte

d P

PR

(A

/E)

Ra

tio

Transition Conference Completed Historically Expected

8

Transition Conference Summary

• More than 1,900 Transition Conferences for High Risk since intervention started in April, 2012– 13% reduction in PPRs

– 10 Allina Health hospitals participated

• Impacts over 100 APR-DRGs

• More patients accepting post acute care– Ex. Home Health, SNF, Hospice, TCU

• 20% Reduction so far in Moderate-High

• Some hospital variation (not yet statistically significant)

8

2/25/2014

5

9

IDPT (Interdisciplinary DC Planning Tool)

9

10

IDPT (Interdisciplinary DC Planning Tool)

10

2/25/2014

6

11

Tools for Care Coordination at Allina Health

• Unresulted lab link

in DC summary

11

12

Tools for Care Coordination at Allina Health

AVS Redesign

• Patient friendly language

• Appointment before DC process based on 5d order

• ROP appears in the AVS

12

2/25/2014

7

13

• Call pts. to remind them of the appointment

• Early Follow-up (within 5d) -Hold appointments for Hospital Follow-up

• Accurate Medication Reconciliation

• Follow the ROP

• Self Management Support – Provide written instructions for all visits– What to do

– How to know the plan is not working

– Who to call

– When to Follow-up

13

Improving Transitions: OP Interventions

14

Current tools for care coordination at Allina Health

• FU within 5d orders

• ROP- Recommendations for the outpatient provider

2/25/2014

8

1515

Progress over time: FU within 5d, ROP

16 16

2/25/2014

9

17

Comparing Outcomes of Follow-up Appointments Completed within 5 Days and a Recommendation for the Outpatient Provider (ROP) to Those with Neither Completed for Medical Patients (System-Wide)

• Data is from Jan-Aug, 2013 for hospitalizations classified as medical.

0.86

1.08

0.00

0.20

0.40

0.60

0.80

1.00

1.20

Follow-up Appt within 5 Days at an Allina

Clinic and ROP Completed (4,700

Discharges)

No Follow-up Appt within 5 Days at an

Allina Clinic and No ROP Completed (1,468

Discharges)

Act

ua

l-to

-Ex

pe

cte

d P

PR

(A

/E)

Ra

tio

A/E Ratio

18

Comparing Outcomes of Follow-up Appointments Completed within 5 Days and a Recommendation for the Outpatient Provider (ROP) to Those with Neither Completed for Surgical Patients (System-Wide)

• Data is from Jan-Aug, 2013 for hospitalizations classified as surgical.

0.82

1.10

0.00

0.20

0.40

0.60

0.80

1.00

1.20

Follow-up Appt within 5 Days at an Allina

Clinic and ROP Completed (1,452

Discharges)

No Follow-up Appt within 5 Days at an

Allina Clinic and No ROP Completed (3,375

Discharges)

Act

ua

l-to

-Ex

pe

cte

d P

PR

(A

/E)

Ra

tio

A/E Ratio

2/25/2014

10

19

Advanced Care Teams (ACT)

• RN Care Coordinator

• Care Guide

• Pharmacist

• Social Worker

• Work with the highest risk patients

• Hand off from hospital Transition Conference to ACT.

19

20

Leadership

• TPOV Teachable Point of view

– Use data – Surgery conversation is going on now.

– Use stories – Clinicians hospitalized.

• Service Agreements

– Clinicians won’t automatically believe this is important to do or worry about being specific

• SNF transitions – work with SNF’s

– Initially one SNF had 0/10 requested elements consistently at transition.

20

2/25/2014

11

2121

Specialties are complexInpatient to Outpatient HF Process

2222

Results Minnesota R.A.R.E.

2/25/2014

12

23

Sept.-November (2009=1.00)

2013 A/E Goal: 0.89

2013 A/E Actual: 0.93

23

Results: Allina

Questions!