Track II 030612 AmyBoutwell Care Transitions · Six practical strategies ... OMB readmission reductions could save Medicare ... A 3% reduction in (re)admissions each year for the

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Reducing Rehospitalizations:

A quality effort at the heart of system redesign

Amy E. Boutwell, MD MPP

Collaborative Healthcare Strategies

co-Founder, STAAR Initiative

Why Are We Here Today?

88M with mild gait instability hospitalized for skin infection for 5 days, on IV antibiotics, discharged to home on oral antibiotics.

Lives at home with 88 yo wife, with mild mobility challenges; not home bound= no home health referral

Returns to hospital one day following discharge with >10 episodes diarrhea, weak, can’t manage at home

Caught in the System

87F recently hospitalized for an infected dialysis catheter returns to the hospital 8 days following discharge with shortness of breath.

61M with 8 hospitalizations this year for shortness of breath returns to the hospital 10 days after discharge with shortness of breath.

86M with cancer hospitalized for constipation and abdominal pain returns to the hospital 1 day after discharge with abdominal pain.

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Caught in the System

87F recently hospitalized for an infected dialysis catheter returns to the hospital 8 days following discharge with shortness of breath.

61M with 8 hospitalizations this year for shortness of breath returns to the hospital 10 days after discharge with shortness of breath.

86M recently hospitalized for constipation and abdominal pain returns to the hospital 1 day after discharge with abdominal pain.

Who is here today?

Which organizations? What settings? What roles? Who’s working on readmissions? Who is just getting started?

Who has a success story? Who has challenges?

Why are you here today?

What are you hoping to learn today? Do you have a personal reason for doing this work? Do you have a professional reason obligating or motivating you?

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Roadmap

Overview of readmissions: vital stats

National momentum: you’re in good company!

Reducing readmissions by working across settings

Six practical strategies

Discussion: How does this relate to your work?

Readmissions: Vital Stats

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“The Billion Dollar U‐Turn”

Frequent- 17.6% of all Medicare hospitalizations are 30d

rehospitalizations

Costly- Medicare 30-day readmissions est $17B annually

Performance highly variable– Rates vary 13-26% across states– Variation even greater intra-state

Actionable for improvement– 76% potentially avoidable

MedPAC Report to Congress, Promoting Greater Efficiency in Medicare. June 2007Mark Taylor, The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008Commonwealth Fund State Scorecard on Health System Performance. June 2009

Rehospitalizations are Frequent

2007 Medicare data analysis finds: 20% beneficiaries are re-hospitalized at 30 days 35% are re-hospitalized at 90 days 67% are re-hospitalized or deceased at 1 year

Among medical patients re-hospitalized at 30 days: 50% no bill for MD service between discharge and re-

hospitalization

Among surgical patients re-hospitalized at 30 days: 70% were re-hospitalized with a medical DRG

S. F. Jencks, M. V. Williams, and E. A. Coleman, “Rehospitalizations Among Patients in the Medicare Fee-for-Service Program,” New England Journal of Medicine, Apr. 2, 2009 360(14):1418–28.

Readmissions Among SNF/NH Elders

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Rehospitalizations are Costly

Medicare: $15-$18 Billion spent on 30-day rehospitalizations annually

OMB readmission reductions could save Medicare $26Billion over 10years

Massachusetts all-payer: 30day rehospitalizations accounted for 377,000 hospital days = $577Mannually

Pennsylvania: 57,800 readmissions costing $2.5 Billion in charges and 350,000 hospital bed days

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Variation in Readmission Rates

Dartmouth Atlas 2011

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81% of patients requiring assistance with basic functional needs failed to have a home-care referral

64% said no one at the hospital talked to them about managing their care at home

Opportunities for Improvement

Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices. Marblehead, MA: HCPro, Inc.; 2006.

What about California?

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CA rate: 17.1%Best state: 13%Best HRR: <10%CA rank: 20

CA rank: 23

What is the potential impact of improvement?

Potential Impact of Improvement

If California improved readmission rates to the level of the best performing state in the US…….

10,195 fewer Medicare readmissions per year $181,983,711 saved in readmissions for Medicare

$181 Million!

Commonwealth Fund State Scorecard on Health System Performance, 2009.

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Potential Impact of Improvement

Preventable (re)admissions in CA:

Cost $3.5 Billion annually

A 3% reduction in (re)admissions each year for the next 10 years could save more than $1 billion

California Office of Statewide Health Planning and Development, December 2010

$1 Billion!

Mobilizing Action

Within Settings and Across Communities

Hospital

“Home”

Skilled Nursing

AD

F

G

B

C

E

Landscape of complementary efforts

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A Portfolio of Complementary Approaches

Hospital

“Home”

Skilled Nursing

1. Hospital: RED, BOOST, STAAR, H2H

2. INTERACT

3. Medical home demonstrations and community supports (AoA, ADRC)

4. Enhanced services, such as coaching, transitional care

5. Improved communications, clarity on care preferences (MOLST)

©Collaborative Healthcare Strategies

Cross‐Continuum Efforts

Improving the discharge process: RED, BOOST, STAAR, H2H

Improving quality of NH and HH care: INTERACT, Advancing Excellence, VNSNYS

Transitional care between settings: Self-management coaching (Coleman), Transitional Care Model (Naylor)

Enhanced ongoing management for very high risk: Medical Home, PACE, Evercare, HF Clinics, POLST

Linkage to community-based supports and services Area Agencies on Aging, ADRC, BRIDGE

Hospital

Home

Skilled Nursing

State‐wide Data, Uniform Measurement

National , State, Local Leadership

Incentives for Change and Penalties for Inaction

Technology Enhancements

Patient, Caregiver and Public Engagement

Clarity on care

preferences

Quality Error‐Free

Inpatient Care

Beyond Setting‐Specific Approaches

Legal Issues

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Settings/Sectors Programs

Hospitals BOOST, RED, STAAR, H2H, CMS HEN

Community Teams QIO ICPC, STAAR, CCTP

Skilled Nursing Facilities, NH INTERACT

Home Health Agencies HHQIC BPIP, VNSNYS

Aging Services AoA grants, AAA, ADRC

Transitional Care Services TCM (Naylor), CTI (Coleman), BRIDGES

Health Information Technology ONC Beacon, ONC Challenge Grants, CAST

Public Engagement Aligning Forces for Quality, CMS

Multi-Sector Engagement AHRQ Chartered Value Exchange, HHS P4P

Person/ Caregiver Engagement UHF Next Step in Care, AHRQ guide, AARP

Housing with Services SASH

LTSS Providers LTQA Innovative Communities, CAST

What programs are out there?

Where are these programs active?


Program State/Setting

BOOST 26 states; 82 hospitals

RED >300 hospitals

H2H 50 states; 1141 hospitals

Care Transitions Intervention >36 states, >450 organizations

STAAR 4 states; 152 H; >600 xc partners

QIO Care Transitions Demo 14 communities; 682 xc partners

Aligning Forces for Quality 16 regions

ONC Beacon Communities 17 communities

AHRQ Chartered Value Exchanges 24 communities

Aging and Disability Resource Centers 50 states

CMS CCTP and QIO 10th SOW 50 states

INTERACT >400 sites

xc=cross-continuum

Program 2007 2009 2011

RED pilot dozens >300

BOOST pilot 25 82

STAAR pilot 62, >250 152, >500

H2H n/a launch 1141

QIO Theme n/a 14 communities 53 QIOs

Florida n/a 80 >100

Illinois n/a n/a ~200

New Jersey n/a n/a 46

N. California n/a n/a 40

Mobilization Over Short Time


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National Momentum

* 10 states with CMS Hospital Discharge Planning Model grant

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# 16 Aligning Forces for Quality

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14 QIO Care Transitions Theme Communities

7 CCTP Communities

+ 24 AHRQ Chartered Value Exchange

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† 16 states with 2010 ADRC Option D Care Transitions grant

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⌘ Regional Efforts (No.CA, NYC, Pittsburgh, Phila., Dallas)

QIO 10th Scope of Work ICPC Aim, CMS HEN

9 State‐wide FL, MA, MI, WA, OH, NJ, IL, MN, VT

17 Beacon & 4 Challenge Grants

Observations and Opportunities

Observations: This is a truly unique moment in time Heavy investment in hospital setting technical assistance Heavy investment in Medicare fee-for-service focus Strong focus on mobilizing communities

Opportunities in 2012: Take advantage of national momentum to engage

champions Explore newly available technical assistance resources Expand lens beyond Medicare and/or specific diagnoses Champion the consistent inclusion of person /caregiver

Incentives

Medicare: Readmission penalty October 2012 Medicare: New Programs

• Community-based Care Transitions Program (payment)• Bundled Payment (payment)

• Innovation Challenge Grant (grant 2012-2015)

Commercial Payers: P4P, align with existing resources Medicaid: some states exploring incentives, penalties

Medicare is on a path to paying for “transitional care” in about 5 years if cost-savings

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Affordable Care Act 3025: The “Penalty”

Performance improvement incentive FYI 2013 (October 1 2012) Hospitals with higher than expected CMS 30-day

rehospitalization rates subject to penalty Initially, 3 conditions (AMI, HF, PNA) Penalty of up to 1% of total Medicare charges Rapidly escalates to 2% in 2014 and 3% in 2015

Number of conditions will increase Hospital compare all-cause risk adjusted for AMI, PNA, CHF Under review: PCI (stents) In development: stroke, elective hip & knee Planned: CABG, COPD, other vascular

$500 M payment program to pay for improved care transitions after hospitalization

Explicitly partners hospital and “community based organizations” to improve care transitions based on a community based root cause analysis to identify process failures and target population

Affordable Care Act 3026: The “Incentive”Community Based Care Transitions Program

Take‐Aways

In past 2 years, rapid changes in concept of readmissions, and levers to improve care

Predominant focus is on multi-sector nature of improvement

Payment reform will be one of several key components

Payment reform by itself won’t “solve” readmissions

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The STAAR InitiativeState‐Action on Avoidable Rehospitalizations

Why “State‐Action?”

Two-part, concurrent strategy

Mobilize providers across the continuum to work on improving care transitions; provide quality improvement technical assistance; and

Recruit and engage state-level leadership to provide visibility and mobilize solutions to common systemic challenges

STAAR Strategy

Boutwell et al. An Early Look at a Four-State Effort to Reduce Hospital Readmissions. Health Affairs. July 2011.

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The STAAR Cross-Continuum Collaborative:Optimize the transition for all patients

STAAR InitiativeSTate Action on Avoidable Rehospitalizations

1. Measure all‐cause 30‐day readmission rates

2. Form a cross‐continuum team

3. Cross‐continuum team reviews the longitudinal experience of 5 recently readmitted patients

Available at: www.ihi.org/staar

STAAR Collaborative Recommendations

1. Enhanced Assessment of Patients:why does the patient/caregiver/SNF/outpatient provider think caused readmit?

2. Enhanced Teaching and Learning: change focus from what providers tell patients to what patients/caregivers learn

3. Real‐time Communication: timely, clinically meaning information exchange with opportunity for clarification

4. Timely Post Acute Care Follow‐Up: clinical contact (call, home health visit, office visit) within 48h or 5 days depending on risk

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STAAR CollaborativeRecommendedChanges

% Testing Description

Cross‐Continuum Team

100% Understanding mutual interdependencies, the hospital‐based teams co‐design care processes with their cross‐continuum partners to improve the transition out of the hospital

DiagnosticReview

100% Teams perform a diagnostic review of five recently readmitted patients to understand transitions from the perspective of the longitudinal patient experience and to identify opportunities for improvement

EnhancedTeaching

91% Utilizing health literacy principles, effectively teach patients about their conditions, medications, and self‐care

Enhanced Assessment

76% On admission, perform a comprehensive assessment of patients’ post‐discharge needs and initiate a customized discharge plan

Timely Follow‐up

76% Based on assessed risk of readmission, schedule post‐hospital care follow‐up prior to discharge

Communication 66% Provide customized, real‐time critical information to the next care provider(s); Provide the patient and his or her family caregiver with written self‐care instructions

Cross Continuum Teams

• The most transformational recommendation in STAAR

• Reinforces that readmissions are not solely a hospital problem

• Considered the training ground to develop competency for evolving to integrated care delivery models (e.g. bundled payment models, ACOs)

• Greatly enhances uptake of QI action in a multiplier effect

Readmission Diagnostic Interviews

• Teams complete comprehensive review of the last five readmissions every 6 months (chart review and interviews)

• Members from the cross continuum team hear first‐hand about the transitional care problems “through the patients’ eyes”

• Engages the “hearts and minds” of clinicians and catalyzes action toward problem‐solving

• Opportunities for learning from reviewing a small sampling of patient experiences abound

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Enhanced Assessment of Post‐Hospital Needs

• Most teams think that they are already doing this ‐‐ but have gained new insights from completing the Readmission Diagnostic Reviews

• Family caregivers and community providers are an important source of information about home‐going needs of patients

• Many are embedding questions from the Readmission Review into all assessments of recently readmitted patients

Effective Teaching and Learning

• Clinicians readily embrace Teach Back techniques to enhance patient and family caregiver education

Most successful process improvement change; spread not only from unit to hospital, but through continuum

• There is value in planning multiple teaching sessions with patients and family caregivers

• Providers share teach‐back key messages and materials across settings

Real‐Time Communication

• Communicate clinically relevant information that the receiving provider needs to manage the patient

“warm handoff; opportunity for clarification

• Cross‐continuum teams readily see value in updated standardized transition forms (universal transfer form)

• Written care plans for patients and family caregivers should use clear, user‐friendly formats for describing care at home

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Ensure Post‐Hospital Follow‐Up

• High risk patients need clinical contact within 48 h

• Does not need to be an MD office visit

• Most challenging process improvement is to schedule MD visits

Successes occur when MD practices are part of cross continuum effort

• Use follow up phone calls to reinforce same plan of care, teaching messages

Examples from the Field

Baystate Medical Center, MAOutcome Improvements

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Baystate Medical Center, MAOutcome Improvements

<+) <

0)'''''' ' ' ' ' '''

UCSF Heart Failure Pilot

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Percentage of Patients readmitted within 30 days

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

New Value P&S HF 20.3 34.0 27.5 21.3 25.3 32.1 29.3 32.6 14.8 13.2 22.0 20.0 18.2 15.1 14.0 20.4 27.5 14.0 17.0 18.9 21.2 17.4

30 Day Readmissions for HF Pilot Nursing Units: Any Dx of HF

Goal: 16% (30% reduction)

Average for past 12 Months = 17.9%

UCSF Number (v %) of Readmissions

Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb. Mar April

Series1 11 14 19 12 17 15 17 15 9 6 7 10 8 9 9 9

0

2

4

6

8

10

12

14

16

18

20

Number of patient readmissions cut in half

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USCF Unexpected 90‐day Impact

Jan -March

09

Feb -April 09

March - May

09

April -June 09

May -July 09

June -Aug 09

July -Sept 09

Aug -Oct 09

Sept -Nov 09

Oct -Dec 09

Nov -Jan 10

Dec-Feb 10

Jan-Mar 10

Feb -April 10

March - May

10

April -June 10

May -July 10

June -Aug 09

New Values 43.3 45.6 43.9 38.6 40.9 43.3 39.4 35 35.5 40.3 39.3 38.1 31.2 29.6 29.9 32 33.1 26

20

25

30

35

40

45

50

90 day Readmissions for HF patients

Goal : 31% (30% reduction)

St Luke’s Hospital 3 years focus on HF

Massachusetts State‐Action: A Portfolio of Complementary Efforts

• Care Transitions Forum

• State Strategic Plan on Care Transitions

• Division of Health Care Finance and Policy PPR Committee, providing hospitals state wide rehospitalization reports

• HCQCC Expert Panel on Performance Measurement

• Quality inspectors trained in elements of a good transition

• Vetted standard transfer forms between all settings of care

• Hospital requirement to form patient/family advisory councils

• MOLST (Medical Orders for Life Sustaining Treatment)

• INTERACT (Interventions to Reduce Acute Care Transfers)

• Medical home demonstrations; new applications coordinate training on principles of optimal transitions with STAAR

• ASAPs join cross continuum teams

• State‐wide education and outreach for CMS CCTP

• ONC Challenge grant to create electronic universal transfer forms

Boutwell et al. An Early Look at a Four‐State Effort to Reduce Hospital Readmissions. Health Affairs. July 2011.

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STAAR Hospitals

N=50


STAAR Cross Continuum Team OrganizationsHome Health Agencies, Office Practices, Nursing Homes, SNFs, etc

N>250


Multi‐Payer Medical Home Initiative

N=46


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INTERACT Nursing Homes/SNFs(INTErventions to Reduce Acute Care Transfers)

N>200


Aging Service Access Points

N=116 trained care transition coaches

MOLST Pilot & IMPACT Pilot (Medical Orders for Life Sustaining Treatment)

(Improving Post Acute Care Transitions)

Worcester “Galaxy” Meeting with STAAR, MOLST, IMPACT, INTERACT


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Massachusetts Care Transitions Programs

N>300


• Multi‐stakeholder public private sector steering committee

• Inventory and coordinate complementary initiatives

• Decrease any sense of competition between programs; participate in the momentum through any of a number of ways

• Address common barriers, such as state‐wide data

• Mobilize and support quality improvement efforts for hospital‐based cross continuum teams

State‐Action Model


• State rehospitalization data

• The financial impact of reducing readmissions on hospitals

• Aligning payers and incentives

• Health information exchange

• End of life care preference documentation

• Outdated regulation

• Practice norms and culture

• Patient and public engagement

Systemic Barriers to Reducing Readmissions in States/Regions

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State‐Level Priorities

1. Leadershipmobilization; Shared Framing of Approach

Specifically promote work to reduce rehospitalizations as a “cross‐continuum” team challenge

2. Data

None of the states had access to state‐wide data on rehospitalization

3. Financial Impact

Hospitals had not assessed the current or future impact of readmissions on hospital finances

4. Alignment

Among provider organizations: promoting “system‐ness”

With complementary programs; finding synergy in education, recruitment

With payers; What are they? Can they be aligned?


State‐Action Results to Date

1. Leadershipmobilization/ Shared Framing of Approach

Steering committees: essential guide, align, mobilize and sustain

“Cross continuum” concept took hold: >148 hospitals with >500 partners

2. Data All 3 original states arrived at local solutions to accessing “best‐available”

state‐wide rehospitalizations data reports

3. Financial Impact

Financial impact “roadmap” developed; 1,100 attendees on webinar

4. Alignment

Among providers: cross‐continuum teams

With complementary programs: STAAR + INTERACT + AAA/ADRC + medical home + MOLST

With payers: WA (Medicaid); MI (BCBS); MA (BCBS, Health NewEngland)

STAAR Financial Impact Analysis Roadmap

1. Calculate the all-cause 30 day readmission rate for the hospital and the percentage of the average daily census due to readmitted patients.

2. Partner Financial Lead with Clinical Lead and review the personal, clinical, and financial story of one (or more) recently readmitted patient(s). - Calculate revenue, expenses, and margin.- Analyze clinical/operational insights from this story.

3. Conduct a financial analysis on a sample set of readmissions for a select time period (1 month, 12 months, etc). - Analyze characteristics of this sample set (payer mix, LOS, conditions, outliers, etc)- What is the average direct and total margin per readmitted patient in this sample?

4. What financial variables does your hospital consider when examining the impact of readmissions? - Revenue, expenses, direct costs, indirect costs, variable costs, fixed costs, etc.- How does your organization define direct, indirect, fixed and variable costs?- How does your organization allocate indirect costs?

5. How do readmissions to your hospital, today, influence your hospital’s bottom line?

6. If you were to successfully reduce readmissions by 10%, 30%, 50%, which costs would be influenced and which costs would remain fixed?

7. What is your hospital’s ability to influence (reduce) fixed costs? In the near and long term?

8. Is there latent demand in your hospital service area? Would you expect to keep volume stable if readmissions decreased? What would happen to ED visits? Observation stays?

9. What there anything that surprised you about this analysis?

10. Is there anything that your hospital will do differently as a result of this analysis?

© Institute for Healthcare Improvement 2010

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6 Practical Strategies

Specific recommendations for your work in 2012

6 Practical Strategies

1. Know your data (perform a root cause analysis)

2. Know your partners (meet them and work together)

3. Know your high risk patients (identify and manage)

4. Know what’s going on (align within and across orgs)

5. Move to action (“don’t build a cathedral”)

6. Mobilize available resources (while they last)

“Community‐based” Root Cause Analysis

A requirement of CCTP (Section 3026) applications Approach not specifically outlined in BOOST, RED, STAAR Variety of tools gathered at CFMC ICPC website

Consists of: 1. Data analytics (hospital, SNF, HH)2. “Cross-continuum team” / community focus groups3. Patient, caregiver interviews

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Example Insights of CB‐RCA

6,478 Medicare FFS admissions among 4,732 people 6,148 Medicare FFS alive discharges (some exclusions) 908 30-day readmissions; 14% all cause readmission rate 50% 30-day readmissions <10 days of d/c; 25% <96h Top 10 RA dx: HF, RF, UTI, sepsis, GIB, arrythmia, COPD,

syncope, gastritis/esophagitis, PNA/respiratory infection 369 people (8%) hospitalized >3 times; used 1339 H (22%)

• Among high utilizers, 495 30-d RA; rate 38%• Among high utilizers, 55% d/c to home with no services (N=716)• Top 10 dx: same HF, RF, UTI, COPD, GIB, sepsis, esophagitis

Example Insights of CB‐RCA

Patient/ Family interviews• Did not understand d/c instructions; felt rushed• Did not understand doctor

• Felt “lost” when returned to home• No time to fill new medications

Provider interviews• MD: Did not know patient was in hospital• MD: Did not have any information from hospital re: tx/rx• HH: Called MD, directed patient back to ED

• SNF: Change in clinical status, no MD to evaluate

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Identify and Manage High Utilizers

Identify based on hospital data Collaborate among hospitals in a community HIPPA: request permission Pilot proactive outreach and optimize resources If focus on 369 patients with 1339 hospitalizations,

• A 20% reduction in hospitalizations= 268 H! • Reduce cycle of hospitalizations by 0.7 per person• take each person from average 3.6 H/y to 2.9 H/y• Saves Medicare $2,680,000• Improve quality of life for individuals in cycle of

repeated rehospitalizations

Hospital

“Home”

“Skilled Nursing”

Transitional CareTransitional Care

Mobilize and Align Efforts

Hospital: RED

SNF/NH: INTERACTHH: BPIP

Medical Home: CM

Aging ServicesSocial Services

ED: Avoid admit

Shared care plan

Shared care plan

Summary

Rehospitalizations are frequent, costly, and actionable for improvement

Working to reduce rehospitalizations focuses on improved communication over time and partnership across settings

Working to reduce rehospitalizations is part of a comprehensive strategy to transform the healthcare delivery system

2012 is about implementing! Apply the concepts in a locally-relevant way to leverage your natural partners and strengths.

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New ResourcesQIO Aim: Integrating Care for Populations and Communities

Toolkit http://www.cfmc.org/integratingcare/toolkit.htm

Resources for Patientshttp://www.cfmc.org/integratingcare/patient_resources.htm

Actual Tools from Teams across US:http://www.cfmc.org/integratingcare/toolkit_interventions.htm

Thank you

Amy E. Boutwell, MD, MPPCo-Founder, STAAR Initiative

Collaborative Healthcare Strategies, Lexington, MAInstructor in Medicine, Harvard Medical School

[email protected]

Documents

Track II 030612 AmyBoutwell Care Transitions · Six practical strategies ... OMB readmission reductions could save Medicare ... A 3% reduction in (re)admissions each year for the