The HOMERUN Collaborative – Understanding root causes of

TheHOMERUNCollaborative–Understandingrootcausesofreadmissions

AndrewDAuerbachMDMPHProfessorofMedicine- UCSFDepartmentofMedicine

DivisionofHospitalMedicine

Introduction

• TheHOMERUNOriginStory• Transitionsofcareinitiative

– Preventability– Patientperspective– MDperspective

• NextstepsforHOMERuN– Researchinitiatives– Buildingaresearchandimplementationcollaborative

Financialdisclosures

• Issuesbelowarenotrelevanttothetopicsbeingpresented:

• Honorarium– SocietyofHospitalMedicine(EditorofJHM)

• Royalties– UpToDate (EditorofHospitalMedicinesections)

• Researchfunding:– CDC,SamsungSemiconductor,PCORI

HOMERuN OriginStory

ThelandscapeforHOMERUN

• HOMERUNbeganinpartbasedontheobservationthatwehavelittleevidenceformostthingswedoinhealthsysteminnovation– Whatworks,when,how,andwhy?

WhatistherationaleforHOMERUN?

– Needadifferentplatformtodorigorousevaluationofhealthsystem innovation

• Infrastructure:– Notbenchspace

• Researchteamneeds:– HSR-like,butwithsociologistsandindustrialengineers

• Translationalmodels:– NotGCRC,moreexplicitlyfrontlineengaged

HospitalMedicineReengineeringNetwork(HOMERUN)

• LeveragetheroleofhospitalistsinthecareofgeneralmedicalpatientsinUShospitals– >60%ofMedicarepatientsgettingcarefromhospitalists

– <1,000inUSin1999,now>20,000

Whyhospitalists?

• AtUCSF,15hospitalistshaveassumedcarepreviouslyprovidedby>100physicians– Easiertogetfrontlineengagement,implementresearchprotocols

• Hospitalistsareakey‘lineitem’forhospitals– Hospitalistsviewsystemsreengineeringasakeyelementofprofessionalidentity

• Hospitalshavelotsofdata,withknownstrengthsandweaknesses

Theopportunity–Valuefocusedhealthsysteminnovation

• InvestmentinCER/HSIresearchcanprovidesubstantialROI:– HOMERUNcouldlowercostsfurtherANDprovideaplatformfor

translatingQIevidenceintopractice.– EmpiricallyevaluateQI‘mandates’atlowcostrelativetoongoing

costsbornebyhospitals• BacktranslationtoBench-to-Bedsideresearch

– ResourcesuchasHOMERUNcoulddefinenewtranslationalopportunitiesatlowcosts

Bench/Biomedical Research

Bench to bedside

translation

Clinical efficacy

knowledge

Comparative effectiveness

research

Comparative effectiveness knowledge

Implement practices effectively

Improved population health,

Improved healthcare value

Determine causal pathways

Clinical efficacy trials

Determine associations between treatments and

outcomesOutcomes and health services

research

Determine how patient, provider, and delivery system changes influence outcomes

- Health system redesign- Scaling and dissemination of delivery system changes

- Research in redesign and dissemination

QIandResearchActivities

More Research/empirical à

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HMO-RN

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UHC

ProjectImpact

NCDRNSQIP

HOMERUN

WhatistherationaleforHOMERUN?

– HOMERUN’sMission• Tousemeasuresthatmatter tohospitalistsandtheirpatientstoimprovecareinthehospitalandafterwards.

• Tolinksystemimprovementtorobustandtimelyevaluation ofimplementationefforts.

• Toacceleratethespreadofinnovations thatimprovethevalueofcare.

UCSF– CoordinatingCenterMoffitt-LongHospital

SanFranciscoGeneralHospital

Baystate MedicalCenterCoordinatingCenter(TuftsCTSA)

BethIsraelDeaconnessBrighamandWomen’sHospital

MGH

UniversityofPennsylvaniaChristianaHospitals

NorthwesternUniversityUniversityofChicago

VanderbiltUniversity

UniversityofWashington

HOMERUNsites:13hospitals,9states

UniversityofMichigan

• SeedfundingfromAssociationofAmericanMedicalColleges(AAMC)2012– CatalyticroleinengagingDeans,CEO’sinmissiontoimprovehealthcarevalue

– Identifyingkeyopportunitiestorefineourstrategicgoals,shortandlongtermtactics

HOMERUNOriginstory(cont’d)

HOMERUN

– HOMERUNCareTransitionsProgram– Auditandfeedbackofcarepracticescriticaltoimprovingtransitionsfromhome-hospital-home

– Carepracticesforalldischargedpatients– Casereviewprocessforreadmittedpatients– Site-levelsurveyforcontextualfactorsimportantinachievingbenchmarks

ReadmissionStudyOverview

• Prospectivecohortstudyofgeneralmedicinepatientsreadmittedwithin30daysat13academicmedicalcentersbetweenAprilandDecember2012

• Goalsweretodetermine:1. Theproportionofreadmissionsthatare

potentiallypreventable2. Contributingfactors3. Potentialbenefitofdifferentinterventions

Methods

• 100randomlyselectedreadmittedpatients– Dischargedwithinthelast30daysfromageneralmedicineservice

– Readmittedtoanyservice,foranycause– ExcludedAMA&scheduledreadmissions

DataCollection

1. Trainedresearchassistantsinterviewed patientstounderstandperceptionsoftheircare

2. Surveys askingimpressionsofindexhospitalizationandreadmissionweresentto

• Previousinpatientphysician• Currentinpatientphysician• Primarycarephysician

DataCollection3. Chartreview collectedinformationaboutprocesses

ofcaresuchasmedicationreconciliation anddischargesummarycompletion

4. 2-physicianadjudicationofcasestodeterminepreventability,andunderlyingcauses

PatientInterview- Elements• Follow-upappointment• Communicationwithcaregiversinhospital• Understandingofdischargeinstructions• Knowledgeofredflags• Abilitytoperformself-careactivities• Socialsupport• Open-endedquestionsaboutanydifficulties

– Whatcouldhavekeptpatientoutofhospital?

PatientInterview

www.project-redcap.org

ConfidentialHOMERUN Patient Perspective

Page 1 of 3

Patient Perspectives Interview

Record ID __________________________________

Study ID __________________________________

"My name is _________ and I am working with a team which is trying to understand why patientscome back to the hospital after they go home. I'd like to ask you some questions about howthings went after your last hospitalization, and what ideas you have about how things mighthave gone better."

Who was interviewed? Patient CaregiverBoth

1. Did you have a follow-up visit scheduled for thetime before you came back to the hospital?

YES NO

2. Were you able to attend your scheduled visitbefore you came back to the hospital?

YES NO NO VISIT SCHEDULED

"Now, I would like to ask you some questions about your communication with the doctors andnurses who took care of you when you were getting ready to leave the hospital last time."

3. When you were getting ready to leave the hospital last time, how often did they use medical words that you didnot understand?

Always Often Sometimes Rarely Never Don't know or refused

4. How often did you feel confused about what was going on with your medical care because they did not explainthings well?


5. How often did they give you enough time to say what you thought was important?


6. How often did they listen carefully to what you had to say?


7. How often did you feel pressured by them to have a treatment you were not sure you wanted?


8. How often did they ask if you might have problems actually doing the recommended treatment (for example,taking the medication correctly)?


PhysicianSurvey- elements

• Whichfactorslikelycontributedtoreadmit?– Patientunderstanding,abilitytoself-manage– Continuityofcare,physiciancommunication– Socialsupport– Problemduringindexadmission(e.g.,misseddiagnosis,inadequatetreatment)

• Whatinterventionswouldhavehelpedpreventreadmission?

PhysicianSurvey


ConfidentialPage 1 of 3

Admitting Physician Survey

HOMERUN Admitting Physician Survey

Dear Reviewer,

Thank you for taking this survey and being a part of the HOMERUN study. Please refer to the email containing thelink to this survey to remind you of the patient to whom it refers. Feel free to talk about the case with your ownresidents or the discharging case coordinator or social worker. If you have any questions about the survey, please donot hesitate to email us.

The HOMERUN Transitions of Care Research Team

In your opinion, which of the following factors might have contributed to this readmission?(CHECK ALL THAT APPLY)

1) PATIENT UNDERSTANDING AND ABILITY TO SELF-MANAGE

Patient or caregiver lack of understanding of the post-discharge planPatient or caregiver inability to manage his/her medicationsPatient or caregiver inability to manage his/her symptomsPatient inability to otherwise care for him/herself or caregiver's inability to otherwise provide careInsufficient or ineffective patient or caregiver education

2) CONTINUITY OF CARE AND PROVIDER COMMUNICATION

Insufficient communication with post-acute care provider(s) re: post-discharge planDischarge summary unavailable in a timely mannerDischarge summary poorly written or with missing or erroneous informationFailure to obtain an appropriately timely follow-up appointment or follow-up studiesInability of the patient to keep the follow-up appointment or follow-up studiesInsufficient monitoring of the patient's condition(s) after discharge

3) SOCIAL SUPPORTS

Inappropriate choice of discharge destinationInadequate support for non-clinical issues (such as food, heat, transportation, or inability to affordmedications)Inadequate home services or equipment after discharge

4) PROBLEMS DURING INDEX (INITIAL) ADMISSION

Misdiagnosis made during the index admissionInappropriate/inadequate treatment of the patient during the index admissionDischarged from the hospital too soon after index admissionAbsent, erroneous, or incomplete medication reconciliationNo or inadequate end of life or goals of care planning

5) PROBLEMS WITH TRIAGE AFTER INDEX (INITIAL) DISCHARGE

Patient inappropriately went/sent to ED or inappropriately readmitted from ED



How probable do you think each of these potential types of interventions might have been inpreventing this readmission?

6) More complete communication of information (e.g. tests or appointments to be completed after discharge)

No probabilitySlightly probableSlightly less than 50-50Slightly more than 50-50Strongly probableNearly certain

7) Improved clarity, timeliness or availability of information provided at discharge


8) Improved self-management plan at discharge (e.g. patient-centered discharge instructions, transition coaches)


9) Provision of resources to manage care and symptoms after discharge (e.g. telephone monitoring of body weight)


10) Greater engagement of home and community supports (e.g. enlisting help of community agencies)


11) Improved discharge planning (e.g. appointments scheduled in advance)


ChartAbstraction- Elements

• Comorbidities,functionalimpairment• Languageproficiency,healthliteracy• Dischargeplanninganddocumentation

– Follow-uparrangements– Pendingtestresults– Advancecareplanning– Medicationreconciliation– Communicationwithoutpatientphysician

AdjudicationProcess

• Agroupprocesswhereby2-3MDsateachsitereviewtheentire‘packet’ofmaterialsonenrolledpatientsalongwithenoughofthemedicalrecordtomakeareasonableassessmentofthecase.

• Training:– Groupco-reviewofstandardizedde-identifiedcasesviawebex andconferencecall

AdjudicatorReview



Did the patient attend this visit?

YesNo, readmission occurred prior to scheduled appointmentNo, other reasonsUnsureN/A

Does the readmission med list match the discharge med list from the index admission? (ignore PRNs and completedcourses of therapy)

Yes No

If no, is there documentation to support that the changes were made by a physician/pharmacist?

YesNoUnable to determine

Any other important information regarding readmission:

READMISSION

Based on all the information from the medical record review and patient/caregiver/provider interviews, which of thefollowing may have contributed to this readmission? CHECK ALL THAT APPLY (i.e. evidence for causation more than50-50 but close call, strong evidence for causation, or virtually certain evidence for causation)

Monitoring and Managing Symptoms after Discharge

Inappropriate choice of discharge location (e.g. SNF vs. Home)Inappropriately long time between discharge and first follow-up with outpatient provider(s)Patient was not able to keep post-discharge appointmentsDischarge without needed procedureLack of disease monitoring (e.g. following daily weights, etc)

Social and Community Supports

Patient required additional or different home services than those included in discharge plansPatient was not able to access services at home (or turned them down after plans were made)Patient required additional help from patient's family, caregivers, friends that was not available or sufficientPatient required community programs (e.g. elder day programs, meals on wheels) not included in dischargeplansInpatient assessment of physical needs (e.g. commode, transportation) were incomplete or missed importantpatient requirements

Self-Management Instruction

Patient lacked awareness of who to contact, when to go (or not to go) to the EDPatient lacked awareness of follow-up appointments or other post-discharge plansPatient or family had difficulty managing symptoms at homePatient or family had difficulty managing other self-care activities at home

Continuity of Care

Team did not ensure that the patient had a PCPFollow-up appointments were not scheduled prior to dischargeFollow-up appointments were not sufficiently soon after dischargeTeam did not relay important information to PCP or other outpatient providers re: tests that requiredfollow-up, or important changes in care plan (e.g. transition to DNR status)Patient unable to be reached for post discharge care coordination (e.g. phone follow-up calls, calls to arrangeappointments)Test results ordered by initial team were not followed up appropriately



End of Life/Advanced Care Planning

Patient nearing end of life but still wants hospitalization and full treatment measuresPatient receiving palliative or hospice care, but unable to manage symptomsPatient with end-stage illness but palliative care not consultedPatient with end-stage illness and goals of care discussion not documented

Diagnostic or Therapeutic Problems

Missed diagnosis during the index admissionInadequate treatment of medical conditions during the index admission (other than Pain)Inadequate treatment of pain during index admissionPatient discharged too soon from index hospitalization

Decision-Making Concerning Readmission

Patient inappropriately sent from sub-acute facility to EDPatient inappropriately told to come to ED from homeED inappropriately decided to admit patient

Medication Problem or Adverse Drug Event

Errors in taking the preadmission medication history during the index admissionErrors in discharge ordersDrug-drug or drug-disease interactionPatient/caregiver misunderstanding of the discharge medication regimens (including changes frompreadmission regimen, indications, directions, and potential side-effects)Patient/caregiver inability to manage medications at home/inadequate drug level monitoringInadequate monitoring for side effects or non-adherenceInadequate steps to ensure patient could afford medications (e.g. non-formulary drug, no prior authorization)

Use this space to fill in up to 5 other potential contributing causes for the READMISSION (including social,psychological and medical reasons)

PREVENTION

In your assessment, was this readmission preventable? DEFINITION: A re-admission that could have been avoidedhad reasonable assessment, treatment, monitoring, access, and services been put in place and appropriate systemsbeen available to support the patient's care transition.

No evidence for preventabilitySlight evidence for perventabilityPreventability less than 50-50 but close callPreventability more than 50-50- but close callStrong evidence for preventabilityVirtually certain evidence for preventability

In your assessment, where would the intervention(s) to prevent the readmission have been most effective?

In the hospital prior to index dischargeHomeUsual provider's clinicEmergency DepartmentOther

If other, please specify: __________________________________

AdjudicatorReview

AdjudicationProcess

• Finaldecisionincludedfacetofaceagreementstep,wherebothreviewersagreedwiththeassessmentsmade.

• Inthecaseofdisagreementsoruncertainty,athirdphysician(forexample,thesitePI)resolveddifferences.

• 15-35”peradjudication

PreventabilityDetermination

• Standardforpreventability:– Areadmissionresultingfromanerrororsystemdesignflaw,oronethatcouldhavebeenavoidedwithareasonablepatientorphysicianaction.

– Donotassumeidealsociety(e.g.,nosubstanceabuseorhomelessness)

– Doassumeidealhealthcaresystem• Anyinterventiontopreventreadmissionsthatislikelytobecost-savingtosocietyshouldbeavailable

• Ifnotavailableanditsexistencewouldlikelyhavepreventedthereadmission,thenthereadmissionwaspreventable


• Factorsthatcouldmakeareadmissionpreventable:– Patientnon-adherencetomedications– Patientdidnotunderstandpost-dischargemedicationsorappointments

– Inadequatesymptomrecognition– Delayedormisseddiagnosis– Avoidablecomplication– Lackofappropriatefollow-up– Lackofcommunicationbetweenproviders

Audienceparticipation!

Case1• 63yo womandischargedafterprolongedhospitalizationforviralmeningitis,onprolongedoralacyclovirtherapy.

• Arrivesinprimarycaredoctor’soffice4daysafterdischargewith severeheadacheandlowgradetemperature(100.8inclinic).Shefeelsneitherareimproving.

• SenttoEDforevaluationandpossibleurgentLP,admittedtohospital.

Case1• SeenbysameIDconsultant,whopointstonotesfrompreviousadmissiondescribinghowthepatientshouldexpectcontinuedheadacheandlow-gradetemperatureformonths.

• Discharged24hourslater

Case1• Casereview:

– Accuratemedrec– Dischargeinstructionsmentionedtakingmedsasinstructed,keepingappointments

– DischargesummaryhadbeencompletedbutfaxedtoPCPofficeondayofclinic

– Followup appointmentscheduledwithin7daysofdischarge

– PCPfeltthatshe‘hadto’readmitpatient– Patientfeltsheunderstoodplan,wasabletotakemeds,makeappointments,butdidn’tfeelshewasgettingbetterfastenough

Whatcausedthisreadmission?

• Patientinabilitytoselfmanage• Poorchoiceofpost-dischargesupports(e.g.SNFvs.Home)

• Poorcommunicationofdischargeplanbetweenproviders

• Dischargedtoosoon• Incompletedischargeinstructions• Errorsintriageattimeofre-presentation





Wasthisapreventablereadmission?

Preventability– Review

• Standardforpreventability:– Areadmissionresultingfromanerrororsystemdesignflaw,oronethatcouldhavebeenavoidedwithareasonablepatientorphysicianaction.

– Donotassumeidealsociety(e.g.,nosubstanceabuseorhomelessness)

– Doassumeidealhealthcaresystem


• Noprobability• Slightprobability• Lessthan50-50%butclosecall• Morethan50-50%butclosecall• Stronglyprobable• Nearlycertain

Case2• 55Mwithhistoryofadvancedpancreaticcanceradmittedwithpartialsmallbowelobstruction,vomitinganddehydration

• TreatedconservativelywithIVF,antiemetics withimprovementinsymptoms

• SeenAMofdischargebytreatingteam,dietadvancedandaftertoleratingdietwasdischargedhomethatevening.

• Readmittedin72hourswithrecurrentvomitingandnewAKI.


– Accuratemedrec– Dischargeinstructionsdescribenodietaryrestrictions– Dischargesummarycompleted– Followup appointmentscheduledwithin7daysofdischarge

– Readmittedbeforeseenbyanyambulatoryphysician


– Dischargingphysicianfeltthatthepatienthadadvancedtofulldietandwastoleratingwellatdischarge

– PCPdidnotknowaboutadmission– ReadmittingMDfeltpatienthadfailed’trialathome’– Patientfeltthathereallyhadn’teatenmuchbeforegoinghome,wasactuallyonlyabletotakeinhisjuiceandoatmealondayofdischarge.FeltOKabouttryingtogohomebutwasquiteworried.

– Afterarrivingathomehismedicationsdidn’tcontrolnauseaandhetriedto‘toughitout’for3daysbeforereturningtoED.











Case3• 74Mwithlowerextremitywoundsduetochronicstasis

ulcers.AdmittedforIVabx andfrequentinpatientdressingchanges.

• Livesathomewithson,whoworksfulltime.• Takes4medicationsandrequiresassistivedevicesforwalking

(cane)• Dischargedafter5daysIVantibiotics,placedonprolonged

oralcoursewithnewhomeservices(nursing,PT)arrangedtoassistwithdailydressingchanges

• Readmittedat10dayswith fever,malodorouswounds


– Accuratemedrec– Dischargeinstructionsdescribewoundcareclearly– Dischargereferralstocommunityservices– Followup appointmentscheduledwithin7daysofdischargebutpatient’ssonunabletoskipwork,sopatientmissedappt

– Nursingservicesabletoattendtopatientbutstatesthatpatientmaybemanipulatingdressingsduetoitch

– Notesbynursesaroundtimeofdischargethatpatientmaybesundowning


– Patientdidn’tseeaproblem– ‘Mylegsalwaysgetbad’– Physicians– patientunabletocareforself








• Dischargedtoosoon• Incompletedischargeinstructions• Errorsintriageattimeofre-presentation• ?Misseddiagnosis?



Statisticalmethods

• Simplestatisticstocharacterizesitesandpatientdata

• Bivariable comparisonsofpreventableandnon-preventablereadmissions

• Correlationstatisticstodetermineunderlyingrelationshipsamongrelatedconcepts

Statisticalmethods

• Multivariablemodelingtodeterminefactorsassociatedwithpreventability

• Population-attributablerisk– Potential‘bangforthebuck’:Highestpriorityareasbasedonprevalenceofriskfactorandassociatedrisk

Transitionsofcare- Results

• Overview– Sitesurveys– Preventabilityassessments– Patientqualitativedata– Physicianperspectivedata

Team/servicestructures

• HospitalistGroups– Careformorethan50%ofpatientsat2/3ofHOMERUNsites

– 1/3ofsiteshavenonteachingservices,carefor<33%ofpatientsingeneral

• Service/wardstructure– 1/3ofsiteshavegeographicallylocalizedservices– 50%haveaunitco-leadership/medicaldirectormodel– 100%haveinterdisciplinaryrounds

EHR’sandcommunication

• 83%haveEMRwithCPOE– Ofthese,inpatientandambulatoryEMRarelinkedin80%.

• CommunicationwithPCP’s– 50%hadwrittenexpectationforcommunicationwithPCP

Standardexpectationsatdischargeplanning

• Commonitems(>75%ofsites)– Provisionofdiagnosisdata– Medicationteaching,including– Selfcareandwarningsigns– Followup instructions

• Uncommonitems(<50%ofsites)– Identificationofhighriskpatients:– Teachback– Toolsforliteracy– Pending

Summary

• Itisfeasibletogenerateaprioritizedlistoftransitionsofcareimprovementtargetsusinga‘360-degree’viewofreadmissions

• Targetsrepresentopportunitiestoimproveinpatientcaresystems(dischargetoosoon)aswellascoordinationwith/accesstoprimarycare

Limitations

• ‘Lookingunderthestreetlamp’– Wemayhavefoundthingsbecausewewerelookingforthem

– Ourtoolshadaveryextensive/comprehensivelistofpotentialriskfactors

• LimitedPCPresponserate(40%)vs.otherMD’s(65%)mayhavelimitedabilitytounderstandlongitudinalviewpoint

Twofollow-onstudies

• Qualitativeanalysisof– Openendedoptionstoexistingquestionsinourpatientinterviews

– Openended’anythingelse’question(1)• ComparisonofMD(PCP,inpatientMD)perceptionsofreadmission(2)

1– Greysen et.alBMJ20152– Herzig et.al.JAMA-IMInpress2016

FactorsContributingtoReadmissionFactorcontributing toreadmission

PCP%

Discharging%

Readmitting%

Patientunderstandingandability toself-manage

55 52 55

Continuityofcareandprovidercommunication

37 25 27

Problemswiththeindex admission 27 13 19

Socialsupports 22 14 16

Problemswithtriage afterindexdischarge 5 7 6

Agreement

• Agreementbetweenthe3physiciansastowhichspecificfactorsappliedtoindividualreadmissioneventswaspoor– Averagekappa0.16– Maximumkappa0.30

PotentialwaystopreventreadmissionPCP(%) Discharging

(%)Readmittin

g(%)

Improvedself-managementplanatdischarge

60 53 52

Greaterengagementofhomeandcommunitysupports

58 45 44

Provisionofresourcestomanagecareandsymptomsafterdischarge

58 47 47

Improveddischargeplanning 46 31 34Improvedcoordinationofcarebetweeninpatientandoutpatientproviders

41 33 37

Morecompletecommunicationofinformation

37 26 30

Improvedattentiontomedicationsafety 34 21 23Improvedclarity,timeliness,oravailabilityofinformationprovidedatdischarge

32 22 24

Agreement

• Underlyingfactors– Averagekappa0.16– Maximumkappa0.30

• Areasforimprovement– Averagekappa0.13– Maximumkappa0.28

Conclusions• Patientperspectives:

– Qualitativedataconfirmopportunitiesforpatientengagementandsupportivestrategies

– Patientsareveryforgivingofproblemsthehealthsystemmayberesponsiblefor.

• Understandingandplansformanagingdiseaseprogressionorexacerbations

• Are‘unexpected’eventsforpatientsunexpectedbyMD’s?• Physicians

– Tendtoseethesamegroupsofissuesasbeingrelevanttoreadmissionsoverall

• Reinforceafocusonmultidisciplinaryprograms– Agreeverypoorlyaboutwhatcontributedtoanindividual

readmission• Potentiallyimportantissue– arereadmissionsprograms‘doctordriven’orpatienttailored?

Conclusion

• HOMERuN isa‘practicebased’inpatientresearchnetwork– Healthsystem andpatient-basedparticipatoryresearchprograms

– Yieldedimportantresearchfindingswhichmayalsoleadtoasustainablecollaborativenetworkmodel

HOMERUNcollaborators• UCSF– MoffittLongHospital

– AndrewAuerbachMDMPH• Baystate/Tufts:

– PeterLindenauer MDMSc• MassachusettsGeneralHospital

• JoshuaMetlay MDPhD• UniversityofPennsylvania

– JenniferMyersMD• UCSF– SFGH

– JeffreyCritchfield MD• UniversityofWashington

– GrantFletcherMD– UniversityofMichigan

– ScottFlandersMD,SanjaySaintMDMPH

• ChristianaHospitalSystem– Edmondo RobinsonMDMBA

• BethIsraelDeaconness– Shani Herzig MDMPH,Michael

HowellMDMPH• BrighamandWomen’sHospital

– JeffreySchnipper MDMPH– VanderbiltUniversity

– SunilKripalani MDMSc,EduardVasilevskis MDMCE

• NorthwesternUniversity– MarkWilliamsMD

• UniversityofChicago– GregRuhnke MDMPH– DavidMeltzerMDPhD

WheredoesHOMERuN gofromhere?

HOMERUNclinicalresearchprograms

• Readinessfordischargeprogram• Palliativecare/criticalcommunicationstudy

– PotentialpartnershipwithPalliativeCareResearchCollaborative

• (Newlineofinquiry)– Valueofrepeatedlabtestinginpneumoniapatients

HOMERUNdatastrategies

• CurrentStatus– Shortterm:ContinuetocollectchartdataviaRedCap

– Mediumterm:• TransitiontomHealth platform(s)• Partnershipswithhealthsystems/existingnetworks

mHealth cohorts

• Healthe-HeartVirtual’Framinghamstudy’– https://www.health-eheartstudy.org

• CaringthroughAcuteIllnessandRecovery(CAIRE)Cohort– Reportsof14,30,and60dayfunction,sleep,fatigue– Readmissionexperience(usingHOMERuN TOCtools)– Prototypingmobileapp,webinterface,consentnow– Pilottestingrecruitmentandfollowup atUCSFMay-July2016

mHealth andPhysiciandata

• Transitionphysicianfax/emailsurveystodigitalform– Sitelevelsurveys(targetPI’s)– Crosssectionalsurveys(onetime)– ‘Ecologicalmomentaryassessments’

Potentialpartnerships

• UHC/Vizient/MedAssets– PotentialtolayerHOMERuN dataontoexistingadmindata

– OtherCDRN’s?

Usecaseforpartnershipswithdatavendors

What can we learn from the high and low performers? Can we translate best practices more effectively?Can we eliminate/de-translate ineffective ones? Who do we talk to when we want (or need) to do that?

DataHierarchyinHOMERuNSitelevelfactors•Sitesurveys

Physiciancrosssectionalsurveys

Ecologicalassessmentdata•Patients•Providers

Patientoutcomesdata•Administrative•Chartcollected

Collaboratives Networksbasedonadmin.data

Networksbasedonclinicaldata

TraditionalResearchNetworks

Examples IHI/BTS UHCPremier

VtOxfordNSQIP,ProjectImpactSTS

ARDSnetHMO-RN

Data QIcollectStoryboardLittlecentral

AutomatedUB-04Chargemaster

RNcollectModeratechangeovertime

GenerallyRNProjectspecific

Datauseincomparatororganizations

Infrastructureishardtobuildandsupport

– Howcanwebuildinfrastructurewhichisfaster,better,andcheaperthanthecurrentmodel?

– Whatarethetraditionalfunders?

– Whichinitiativesareofinteresttoourhealthsysem

– Usecasescritical

Thebusinessmodel• Twooptions

– Traditionalresearchsources(NIH/AHRQ/PCORI)– Subscriptionmodelforparticipation(NSIP,VtOx)

• Supportsbenchmarking/collaborativeinfrastructure• Paidforbyhospitals,payors,others• Butconcernaboutduplicationwithothersubscriptions

Fundingsustainableorganizations

More Grant drivenà

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NSQIP HOMERUN?

Expectationsforcommunicationatdischarge

18 of 25

33. Do any of the following describe your group’s/hospital’s expectations regarding communication with PCP’s at discharge? For purposes of this question, an expectation is a minimum care standard which your group feels should be followed the majority of the time. (select all that apply)

Response

PercentResponse

Count

Verbal discussion with PCP or covering attending

25.0% 3

Email or faxed letter written by accepting physician

8.3% 1

Written or verbal communication 25.0% 3

Email using standard communication template

16.7% 2

Page or SMS text message 0.0% 0

Fax or email of discharge summary or transitions materials

50.0% 6

Voice mail notification 8.3% 1

Other, please describe:

16.7% 2

answered question 12

skipped question 1

What’sinyour

dischargesummarytemplate?

17 of 25

32. If a template or automatic importation is used, what information does it include? (select all that apply)

Response

PercentResponse

Count

Date of admission 91.7% 11

Date of discharge 91.7% 11

Reason for admission 50.0% 6

Principal diagnosis at discharge 66.7% 8

Major procedures and tests 66.7% 8

Results from major procedures and tests

66.7% 8

Discharge medication list 100.0% 12

Changes in medications from preadmission medications

50.0% 6

Reasons for changes in medications

25.0% 3

Studies pending at discharge 41.7% 5

Follow-up appointments 91.7% 11

Patient instructions 75.0% 9

Advance directives 16.7% 2

Surrogate decision maker 0.0% 0

24/7 contact information for issues related to inpatient stay (NOT 911

or ER)16.7% 2


skipped question 1

50% require DC summary within 24 hours of discharge

ExpectationsforcommunicationwithPCPatadmission

9 of 25

19. Is PCP access to the inpatient EMR (vpn, secure web-based login) available to all PCPs?

Response

PercentResponse

Count

YES 36.4% 4

NO 63.6% 7


skipped question 2

20. Do any of the following describe your group’s/hospital’s expectations regarding communication with PCPs at admission? For purposes of this question, an expectation is a minimum care standard which your group feels should be followed the majority of the time. (select all that apply)

Response

PercentResponse

Count

Verbal discussion with PCP or covering attending

16.7% 2

Email communication 16.7% 2

Email using standard communication template

0.0% 0

Page or SMS text message 8.3% 1

Voice mail notification 0.0% 0

ANY communication to PCP (phone call, email, fax, page,

etc.)50.0% 6

Nothing 41.7% 5

Other, please describe:

8.3% 1


skipped question 1

Whocomestomultidisciplinaryrounds?

6 of 25

12. Which professions attend Interdisciplinary Rounds? (select all that apply)

Response

PercentResponse

Count

Physician 100.0% 12

Nurse 66.7% 8

Pharmacist 50.0% 6

Case Manager 83.3% 10

Social Worker 83.3% 10

Physical Therapist 25.0% 3

Utilization Review 16.7% 2

Chaplain 0.0% 0

Other, please specify

33.3% 4


skipped question 1

13. How often does it occur?

Response

PercentResponse

Count

Daily 83.3% 10

Weekly 0.0% 0

Other, please specify

16.7% 2


skipped question 1

• 83% of time the rounds are daily• Other people who attend: Unit medical director,

NP’s

Medicationreconciliation

• Admission– 33%relyonMDalone,33%relyoncombinationofMD/Pharmacist/Nurse

• Discharge:– Reconciliation=MD– Teaching=Nurse

• Mostusingelectronictools


• Ifunsureaboutpreventability,consider:– Consensus– Complexity– Comorbidity– Deviationfromnorms– Emergentsituations– Riskofadverseevents– Hindsight

Barrier4:IRB’s,DUA’sandsharing

• IRB’sinconsistentonhowtodealwithgridcomputingarchitecture,andQI– Aprojectwhichdoesbothismorechallenging– HOMERUN:UsingUCSFIRBasasteppingoffplace– BasedourDUAonthatusedforotherQI/benchmarkingcollaboratives(butseekapprovalafterIRBapproval).

Documents

The HOMERUN Collaborative – Understanding root causes of