PUTTING THE PIECES TOGETHER: REDUCING AVOIDABLE READMISSIONS

PUTTING THE PIECES TOGETHER:REDUCING AVOIDABLE READMISSIONS

The Medicare Quality Improvement Organization for Florida

Care Transitions Goals

Improve 30-day rehospitalization rates

• Improve AMI, PNE, and HF readmission rates

• Improve the number of physician follow-up visits among the patients who have been readmitted to the hospital

• Improve hospital performance of patient satisfaction (HCAHPS) for patients receiving information about discharge and medications


The Miami Opportunity

“Making the health care delivery system work reliably for very sick Medicare beneficiaries requires linking all clinical care providers and ensuring that transitions are thoroughly reliable. This work can only succeed when all of the community is engaged and working together, so the QIOs will serve to catalyze and coordinate the work across all care settings in the community.”

Barry M. Straube, M.D. Director & Chief Clinical Officer

Office of Clinical Standards & Quality for CMS

Community Readmission Rates

NOTE: Lower better. 30-day readmission rates are unadjusted, weighted averages and are based on a 6-month reporting period ending the specified quarter. Florida’s 30-day unadjusted readmission rate for the 6-month period ending May 2009 = 19.04%.

22.08% 22.03%21.65%

21.21% 21.48%21.13%

22.77% 22.96%

19.31%

15.00%

20.00%

25.00%

30.00%

35.00%

Oct-07 Jan-08 Apr-08 Jul-08 Oct-08 Jan-09 Apr-09 Jul-09 Oct-09 Jan-10 Apr-10

Discharge to ACH Rate Goal Baseline Contract Started Recruitment Started

Interventions Started Intervention Impact Remeasurement starts Remeasurement ends

6 months+

Disease-Specific Readmission Rates: AMI

NOTE: Lower better. AMI results are unadjusted, weighted averages and are based on a 3-month reporting period ending specified quarter. The AMI “unadjusted to risk-adjusted difference” at baseline = - 2.83%. Florida’s weighted, unadjusted AMI rate for the 6-month period ending May 2009 = 20.50%.

22.62% 22.26%22.08%

21.08%19.79% 19.43%19.25%

18.25% 17.79%

10.00%

15.00%

20.00%

25.00%

30.00%

Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10

AMI Estimated Risk-adjusted Risk-adjusted Goal

Disease-Specific Readmission Rates: CHF

NOTE: Lower better. CHF results are unadjusted, weighted averages and are based on a 3-month reporting period ending specified quarter. The CHF “unadjusted to risk-adjusted difference” at baseline = - 2.48%. Florida’s weighted, unadjusted CHF rate for the 6-month period ending May 2009 = 24.90%.

26.46%

25.43%24.98% 26.61%

23.98%

22.95% 22.50%24.13%

21.98%

15.00%

20.00%

25.00%

30.00%

35.00%


HF Estimated Risk-adjusted Risk-adjusted Goal

Disease-Specific Readmission Rates: PNE

NOTE: Lower better. PNE results are unadjusted, weighted averages and are based on a 3-month reporting period ending the specified quarter. The PNE “unadjusted to risk-adjusted difference” at baseline = - 2.71%. Florida’s weighted, unadjusted PNE rate for the 6-month period ending May 2009 = 17.80%.

20.94%19.88% 19.98%

19.90%

18.23% 17.17% 17.27% 17.19% 17.23%

10.00%

15.00%

20.00%

25.00%

30.00%


PNE Estimated Risk-adjusted Risk-adjusted Goal

Physician Follow-Up Visit

NOTE: Higher better. Results are unadjusted, weighted averages and are based on 6-month reporting periods ending the specified quarter.

36.85%

35.67%

40.43%

42.88%41.9%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09

Physician Follow-Up Prior to 30-Day Rehospitalization Goal

Improved Patient Satisfaction: Meds

NOTE: Results are unadjusted averages and are based on 12-month reporting periods ending the specified quarter. Based on number of HCAHPS questions answered “always or usually” to question # 16 (Before giving you any new medicine, how often did the hospital staff tell you what the medicine was for? And question # 17 (Before giving you any new medicine, how often did the hospital staff describe possible side effects in a way you could understand?)

74.14%74.51% 75.31% 74.54%

76.21%

65.00%

67.00%

69.00%

71.00%

73.00%

75.00%

77.00%

79.00%


Expained Medications Goal

Improved Patient Satisfaction: D/C Info

NOTE: Results are unadjusted averages and are based on 12-month reporting periods ending the specified quarter. Answered “yes” to HCAHPS question # 19 (During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?)And question # 20 (During this hospital stay, did you get information in writing about what symptoms or heath problems to look out for after you left the hospital?)

74.93%

76.38%

76.45%

75.97%

76.93%

65.00%

67.00%

69.00%

71.00%

73.00%

75.00%

77.00%

79.00%


Discharge Information Goal


• Based on beneficiaries' claims 2007-2008

• Tests patient characteristics to determine non-diseased based disparities

• Tests the impact of:– Primary discharge diagnosis– Services utilized during hospital stay– Co-existing conditions defined during index hospitalization

Risk Modeling

NOTE: All diagnoses fields were classified using the CMS-HCC risk-adjustment model. Revenue & procedure codes were classified using utilization flags developed for the Healthcare Cost & Utilization Project (H-CUP), sponsored by the Agency for Healthcare Research & Quality (AHRQ).

–Age–Gender–Race/ethnicity

–Dual eligibility–ESRD–Length of stay


• Dual eligible

• ESRD

• Longer length of stays (>5.65)

• Males (slight)

• African American (slight)

Results: Patient Characteristics


• Congestive heart failure*

• Major psych disorders*

• Cardio-respiratory failure / shock*

• Metastatic cancer / acute leukemia#

• Chemotherapy / benign neoplasm#

• Artificial openings for feeding / elimination

* Impacts greatest number of patients# Greatest risk for readmission

Results: Primary Discharge Diagnosis


• Emergency department*

• EKG*

• Coronary care*

• Respiratory therapy*

• Ultrasound

• Renal Dialysis#

• Mental Health & Substance Abuse#

* Impacts greatest number of patients# Greatest risk for readmission

Results: Service Utilization


• Cardiac / Respiratory / Vascular*

• GI / GU

• Mental Health #

• Nutrition / Skin / Blood Disorders

• Cancer#

* Impacts greatest number of patients

Results: Co-existing Conditions


Community QI Activities


• Adapted Coleman’s Care Transitions InterventionSM (CTI)

• Addresses patient empowerment through Coleman’s 4 Pillars:– medication reconciliation, – physician follow-up, – disease management, – maintaining personal health record

• Framework’s greatest strength - it is an intervention that is standardized and replicable, but flexible enough to adapt to organizational and patient needs.

• CTI is not designed to be disease-specific, but it can easily be applied to patients with a variety of chronic illnesses, more specifically, those driving high readmission rates.

• Stresses patient empowerment by increasing the patient’s knowledge and self-care management skills

Project’s Conceptual Framework


Coaching


Provider-Specific Interventions


Collaboratives


• Fifth Pillar: QIO & Alliance for Aging Partnership (Area Agency on Aging for Miami-Dade and Monroe Counties)– The Community Living Program

• Sixth Pillar: QIO & Department of Elder Affairs (DOEA) Partnership– Nutritional support program

Additional Activities

The Medicare Quality Improvement Organization for FloridaThe Medicare Quality Improvement Organization for Florida

Contact:Contact:Susan Stone, MSN, RNProject Director – Care TransitionsDirect: 813.865.3526Fax: 813.865.3546Email: [email protected]

This material was prepared by FMQAI, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. FL2009T2F72T20611018

Documents

PUTTING THE PIECES TOGETHER: REDUCING AVOIDABLE READMISSIONS