Quality/PI

Revenue Cycle

Customer Satisfaction

Survey Process

$urvivability

The Intersection of Clinical Services & Revenue Cycle 

Strategy to Reduce Readmissions

HomeTown Health

Spring Conference 2012

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Presentation Focus What is the problem?

Reduced reimbursement from Medicare, Medicaid, and commercial payers

Hospitals assuming more risk for discharged patients

What is the solution? Choosing a proven readmissions solution

model Choosing a solution team Choosing a solution tool

Where do we go from here? Next steps

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What is the Problem? Reduced reimbursements for avoidable

readmissions Medicare now Medicaid Commercial plans

Driven by employers to reduce costs

Hospitals assuming more risks for discharged patients. Examples: Medicare High Readmission Penalty Medicare Bundled Payments Medicare and Medicaid Accountable Care

programs

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Readmission Risks Over Time

Medicare Readmission Penalty Penalty Amount

Adjustments up to 1% will be imposed on hospitals in FY2013 (Oct 2012), related to higher than expected readmission rates

Penalty Basis Based on high readmission rates for fee for

service Medicare enrollees age 65 or older discharged from an acute care hospital with a principle diagnosis of Acute Myocardial Infarction (AMI) Heart Failure Pneumonia

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Future Medicare Readmission Penalties

More significant reductions in future years up to 2% in FY 2014 (Oct 2013) and

up to 3% in FY 2015 (Oct 2014)

Additional principle diagnosis conditions could be added such as: COPD Cardiovascular surgical procedures Vascular conditions

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Penalty Impact on Hospitals Hospitals in the bottom quartile

Hospitals in the bottom quartile on readmissions will suffer penalties in the hundreds of thousands

The measurement period has already begun.

Four HTH hospitals in bottom quartile CMS link -

http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Downloads/CCTP_FourthQuartileHospsbyState.pdf

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What if you are not on the CMS list? You could be on the next CMS list

Hospitals in the bottom quartile will work quickly to get off the list

Your readmission rates will be published on a public website (Hospital Compare)

Employers are selecting hospitals to reduce costs Workers and their families will be steered to

hospitals that can prove they deliver quality care. Providers would earn part of their fees for keeping patients as healthy as possible, similar to the "accountable care organizations" in the health care law.

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Effective Care Transition Barriers Practitioner Level Barriers

Practitioners often have not practiced in settings where they transfer patients

Sending practitioners may not communicate critical information to receiving practitioners

Practitioners may not know the patient and his or her preferences for care

Practitioners have no accountability Hospitals

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Effective Care Transition Barriers Patient Level Barriers

Patients assume that someone is in charge of coordinating care

Patients (and caregivers) are often the only common thread weaving between care sites

Yet they navigate the system with few tools or training to manage in this role

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Critical Success Factors Clinical professionals and care

coordinators must prepare patients and their caregivers to receive care in the next setting and actively involve them in decisions related to the formulation and execution of the transitional care plan

Bidirectional communication between clinical professionals, care coordinators, and patients is essential to ensuring high quality transition care

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Case Study 1 During a patient’s monthly follow-up

appointment with the cardiologist, he informed the doctor that he was having trouble with one of his medications. The doctor asked which one. The patient said “The patch, the nurse told me to put on a new one every day and now I’m running out of places to put it!” The physician had him undress and discovered that the man had over a two dozen patches on his body.

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Case Study 2 An older man with atrial fibrillation

who takes warfarin for stroke prophylaxis was hospitalized for pneumonia. His dose of warfarin was adjusted during the hospital stay and was not reduced to his usual dose prior to discharge. The new dose turned out to be double his usual dose and within two days he was re-hospitalized with uncontrollable bleeding.

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What’s the Solution? Key Goals

Identify issues and barriers to transitions across the continuum of care

Evaluate appropriate referral criteria between levels of care

Assess available technology, evidence based guidelines, medication reconciliation, and adherence gaps

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What’s the Solution cont’d? Focus on the root cause of readmissions

Patient non compliance With medications With physician follow-up With nutrition (meals) With physical therapy

Barriers to patient compliance Lack of transportation Lack of help at home Home environmental barriers

Heating and cooling Changing bed sheets Reducing fall related risks

Cultural, mental, and language barriers16

Solution Components Select a proven care transitions model

National models include Eric Coleman CTI model Mary Naylor model Project RED Boost Guided Care

Select care coordinators – options include: Hospital staff (legal review required) Local area agency on aging Home health agency FQHC Outsource to case management company

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Solution Components cont’d Engage patients and caregivers

Obtaining consent for participation Orientation and education

Engage care transition team members Patient Physicians Patient Pharmacists Skilled Nursing Facilities Home health care agencies Community resources

Area agency on aging United Way agencies Churches

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Solution Components cont’d Select Care Transitions Tool for:

Collecting hospital discharge data Conducting risk assessments Building transitions care plan Selecting and scheduling referrals

Medical Non medical

Tracking care plan compliance Capturing and analyzing results

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Care Transition System

 

 

Non Clinical Components

Support network engagement

Clinical Components

Disease Management

Mental/Dental/Specialty Care

Medication Management

Immunization Schedule

Transportation

Home environment

Food and Nutrition

Patient Management Action Plans

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Real Healthcare Reform

Hospitals

Local government agencies

Safety Net Clinics

Health Departments

ChurchesUnited Way

Agencies

Area Agency On Aging

Home HealthAgencies

My patient’s most pressing health issue was a broken carburetor

“Months later, before a pending well-child visit, I called the school to get an update on his development. I was shocked to learn that it had been weeks since he had last attended. When he and his mother came in for their appointment, I learned her car had broken down. She was saving money for a fix, but had no one to rely on for her son’s transportation and hadn’t known where to turn for help. . . .

This was a crystallizing moment for me. The long-term health and well being of a developmentally delayed child whom I had helped coax through recovery from prolonged hospitalizations and multiple complicated surgeries hinged not on the quality of my medical care but on a taxi voucher and a broken carburetor.”

Dr. Douglas Jutte, MD, UC Berkeley Medical Program - 12/7/2011

Gaps with EMR Technology “Today’s EMR technology was not developed to support role-based access to information for team care. Instead, it was developed to support a traditional fee-for-service, visit-based reimbursement model, with the focus on documentation requirements to support a billing function.

That technology is inadequate to the transformationalactivities required for new health care models. Anchoring the electronic health record (EMR) in the traditional visit-based care delivery model limits the potential of the medical home togenerate paradigm-shifting care delivery transformationand the positive outcomes it promises.”

Source: Cyberinfrastructure Patient-Centered Medical Home: Current andFuture Landscape - Zayas-Caban, Finkelstein ,Kothari, Quinn, Nace, 2011

Where do we go from here? The clock is ticking

Oct 2012 will be here soon Hospital Compare site already up

Act now to manage “forced” risk Engage with Home Town Health

E.g., CMS Community Care Transitions Grant Engage Home Town Health Partners

CivicHealth - Care Transitions Tool Other HTH partners as appropriate

Consultants Personal telemonitoring

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Questions and Answers

Richard Taylor CivicHealth rtaylor@civichealth.com   615 482 3600 

Lou Semrad HomeTown Health lsemrad@gmail.com   706 474 0434  

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Additional Slides

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Hospital (Discharge

Plan)

Care Coordinators

PatientPhysician

Family

Health advisors

and coaches

Provider and Social Services Network

Care Transitions Team Interactions

Patient community Database

Eligibility and Community Resources

Referral Coordination

Case Management/Disease

Management

Process Function Uses/Data

Outcomes Reporting/ Analytics

 

Patient Intake

Patient Eligibility

Patient Referrals

Patient Management

A Comprehensive Patient Management Solution

Patient assessments and demographics,medical history

Eligibility Rules (e.g.,CHIP,Medicaid); community resources database

Set up and schedule Referrals – social and Clinical (transportationmeals, home services)

Manage patientCompliance (goals, alertsFollow-up interventions)

Patient Management Applications Care Transitions

Managing patients after discharge ER Room Redirection

Reducing uncompensated care by redirecting uninsured patients to safety net clinics

Accountable Care Programs E.g., chronic Disease management

Community Health Improvement programs E.g., reducing community obesity

Prenatal and Maternal/Child health programs Coordinating care for pregnant mothers

Senior Citizen Health Management Coordinating programs for seniors

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