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Reducing Preventable Hospital Readmissions in Post Acute Care
Kim Barrows RN BSN
Session Objectives
At the end of the session the learner will be able to:
1. Discuss the history of hospital readmission and its impact on the industry.
2. Discuss and analyze the types of data necessary to appropriately measure hospital readmission rates.
3. Describe potential solutions within your facility that will positively affect clinical outcomes.
4. Describe how progress is measured after implementation.
5. Discuss measures to ensure continuous quality improvement.
The Affordable Care Act
This Act has brought about many challenges but at the same time it has opened opportunities for Skilled
Nursing Facilities to set themselves apart from their competitors.
Why The Focus
• The Patient Protection and Affordable Care Act (March 23, 2010) has several provisions to reduce hospital readmissions
• Medicare is offering financial incentives to reduce potentially avoidable hospital transfers through pay-for-performance, bundled payments, ACOs and other strategies
• CMS implemented financial penalties for hospitals with high 30 day readmission rates for the following diagnoses: CHF, Pneumonia, Acute Myocardial Infarction, COPD and elective Hip & Knee Replacements.
What is an ACO?
Groups of volunteer doctors, hospitals, nurses and other care providers who offer coordinated quality
care to a specific population of patients.
How are ACOs paid? Providing treatment in the most cost effective
environment.
ACOs Potential Impact on SNF Quality
American HealthTech www.healthtech.net
Bundled Payments
http://innovation.cms.gov/initiatives/map/index.html
Medicare Readmission Penalties by State
State
Total
Hospitals Eligible for
Penalty
# of
Hospitals Penalized
Average Penalty
for Eligible
Hospitals
Ohio 137 96 0.36%
Kentucky 65 57 0.66%
Indiana 89 42 0.32%
Michigan 95 55 0.39%
Pennsylvania 156 110 0.39%
West Virginia 30 27 0.46%
http://www.kaiserhealthnews.org/Stories/2013/August/02/readmission-penalties-
by-state-year-two.aspx
Readmission Penalties by Hospital
*Provided by Kaiser Health News; http://capsules.kaiserhealthnews.org/wp-content/uploads/2013/08/readmissions-year-2-data.pdf
How Did Medicare Decide On Penalties?
•Policy developed by CMS endorsed by the National Quality Forum (NQF) for heart attack, heart failure and pneumonia
•Three years of discharge data and minimum of 25 cases for each condition were used to develop these ratios
•Adjustment for factors that are clinically relevant including patient demographic characteristics, co- morbidities and patient frailty
*Provided by Kaiser Health News; http://www.kaiserhealthnews.org
30 Day, All-Condition Medicare Readmission Rates
http://cmsgovblog.files.wordpress.com/2013/12/30day.jpg
Post-Acute Care Reform
SNF Readmission Penalties
Oct 1st 2016-CMS will share with you how you are preforming as far as readmissions
Oct 1st 2017-Rates will be shared with the public on Nursing Home Compare
Oct 1st 2018-Rates will be cut 2%; based on your performance with readmissions you could get 98% of your rate or greater than 100%
http://waysandmeans.gov/uploadedfiles/pac_reform_fact_sheet.pdf
Potential Complications with Hospital Admissions
• Transfer Trauma
• Delirium
• Immobility/Deconditioning
• Falls
• Weight Loss
• Incontinence and Foley Catheters
• Hospital Acquired Infections
• Wounds
• Polypharmacy
Factors Influencing Hospital Readmissions
Hospitalizations
Geography
Demographics
Co-morbidities Patient/Family
Requests
Liability & Regulatory Concerns
Factors Influencing Higher Readmission Rates
Unsatisfactory Discharge Planning
Noncompliance
Family/Caregiver Competency
Clinical Condition
Medication Errors
Access to PCP
Strategies for Success
Success
Decrease Unnecessary Readmissions
Resident/Family Satisfaction
Advanced Directives
Quality Care
Preferred Provider
Communication & Collaboration
Advanced Data Collection Analysis Tracking Log
Tracking Log Considerations
Dis
char
ges
Physician/Staff Discharging
Time of discharge
Education
Advanced Directives
Palliative Care/Hospice
Interact Tools
Tracking Log Considerations
•Percentage of residents that are readmitted within the first 30 days for MI, Pneumonia or Heart Failure? Then include all diagnosis.
•Did we fully implement the cardiac program? Joint Replacement Program? Pulmonary Program?
•Who is referring to you? What type of residents are you admitting?
How to Measure Rehospitalization Rates
• Based on claims (hospital & SNF Part A)
• Does not include ER visits and observation stays
• Excludes Medicare Advantage and private insurance
%= numerator
denominator
%= # of persons sent to hospital
# of persons admitted to SNF
• Brown University: http://ltcfocus.org/
• SNF rehosp rates
Great Emphasis On Quality
Assuring and/or improving quality requires documenting valid metrics and proactively implementing & monitoring systems
How are we being graded?
• CMS Five Star Report
• Nursing Home Compare
• Quality Measures
• Facility Satisfaction Survey
• QIS/Traditional Surveys
• State - Resident Satisfaction Survey
• State - Family Satisfaction Survey
TriHealth Metrics
Metrics
Who’s Watching…
Hospitals
Survey Agencies
ACOs
MCOs
Humana SNF Scorecard Provider demographics and Services Available
Anthem Scorecard
Anthem-CareMore
Becoming the Preferred Provider
What is your niche or area of expertise?
• Pick one or two specialties
• Develop a unique program
• Market the outcomes.
HCMG ‘s Collaborative Objectives
Reduce hospital readmissions
Improve patient outcomes with minimal cost
Improve the transition process from the hospital to SNF to home
Become the local hospital’s preferred provider
Cardiac Recovery Program
Cardiac
SBAR Charting
S= Situation
B= Background
A= Assessment
R= Recommendation
Improves the quality of information that is communicated to the physician resulting in an accurate diagnosis and treatment.
•http://interact2.net/docs/Communication%20Tools/SBAR%20updated%20February%202011.pdf
Evaluation of Resident’s Knowledge
Teach Back Method
• What is the name of the diuretic or water pill you take?
• What amount of weekly weight gain should you report to your doctor?
• Share with me what a low-sodium diet entails?
• Why is it important to take your water pill every day?
• How will you remember to check for symptoms of heart failure every day?
Stop & Watch Tool
• Guides frontline staff through brief review of early, often subtle indicators of change in condition
• Improves communication between frontline staff and the nurse in charge
•http://interact2.net/docs/Communication%20Tools/Early_Warning_Tool_(StopWatch)c.pdf
Electronic Medical Records
Electronic Medical Records (EMRs) with complete, accurate and solid data.
• Software integration with partners to round out EMRs, e.g., labs, pharmacies, EKG reports, etc.
• Specialization programs that focus on reducing length-of-stay and improve the quality of care.
• Outcomes reports showing positive trends for lowering costs, boosting quality and reducing readmissions.
YOUR RECOVERY The primary goal of your stay is for you to safely
recover from surgery, participate in therapy, and to put you on the road to recovery. If there is anything we can do to enhance your stay and rehabilitation, please feel
free to ask.
Orthopedic Programs
Knee Replacement
Hip Replacement
Wound Program
• Wound specialist of Greater Cincinnati
• Dr. Arti Masturzo
• Mist Therapy
• Negative Pressure Therapy
• Lymphedema Treatment
• Comprehensive Wound Care
The i-STAT System
An advanced handheld diagnostic tool that provides real-time, lab-quality results within minutes.
• Used for the Cardiac and Pulmonary Programs
• Comprehensive Point-of-Care Testing
• Diagnostic Testing (results ranging from 2 min to 17 min)
–Electrolytes and Hematology
–Blood Gas
–Chemistry
–Cardiac Markers
–Coagulation
•www.abbottpointofcare.com
LACE Scores & Readmissions
• Lace Index Scores
• L- Length of stay
• A- Acuity of the admission
• C- Co-morbidities
• E- Emergency department visits in the last 6 months
• Scores range from 1-19 and is helpful in predicting the 30 day readmission rate.
• http://www.iha.org/pdfs_documents/news_events/Breakout%20Session
%202B%20-%20Richard%20Fraioli,%20John%20Muir.pdf
Physician and NP/PA Expectations
• Required presence in facility
• Rounding with nursing staff
• Quarterly Meeting Involvement • Offer education and In-Services for staff/families
• New admissions seen in a timely manner
• Available for family conferences
• Facility leadership involvement
•Supportive of programs to reduce readmissions
Care Coordinator
Symptom Management Nurse Practitioner
Home Health Agency
How Often Home Health Patients had to be Admitted to the Hospital
Home Health Compare Website:
http://www.medicare.gov/homehealthcompare/search.html#
Unplanned Hospital Readmission
Average (%)
National Average 16%
Pennsylvania Average 17%
HCMG All Cause/All Payer 30 Day Readmission Rate
LTC Trend Tracker
Becoming the Preferred Provider
• Design Unique Programs that are appealing to your local hospital and document outcomes for marketing.
–SNF provider
• Invest in staff training and education
• Invest in equipment
• Implement a system for calculating data
•Identify a champion within your organization to train, monitor and evaluate programs.
• Collect valid data which will allow you to present measureable outcomes.
Becoming the Preferred Provider
•Collaborate
– Monitor your readmission rates and be prepared to present yourself as a solution to the hospital’s problem.
• Consider a Care Coordinator role within your organization and develop partnerships with like-minded companies to ensure a smooth transition of care.
Bridging Connections
• Local Hospitals
Marketing Points
– Improved medical care R/T early identification of change of conditions
– Capitalize on the program’s uniqueness
– Better nursing assessment skills
– Better clinical outcomes
– Reduction in rehospitalizations – Positive reputation among hospitals, MCOs and the community at large
– Improved Customer/Family Satisfaction
Everything Included…
Prepare Your Staff
“These materials and the intellectual property contained therein are Copyright 2012 and are the
exclusive property of The Health Care Management Group. Any use, reproduction, publication, transfer, display, distribution, copying, dissemination, display,
or adoption of these materials in other works without the express written permission of The Health Care Management Group is strictly prohibited and may give rise to criminal and civil penalties under the federal Copyright Act. All rights reserved by The
Health Care Management Group.”
