Hospital Readmission Roullette

Hospital Readmission Roulette

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)Presented by:

Diane Buckley, BSN,RN RAC-CT Director of Quality & Performance

Improvement


Harmony Healthcare International, Inc. 3

Speaker Bio

Director of Quality and Performance Improvement for Harmony Healthcare International, Inc.Over 25 years in the healthcare industry

Nurse ManagerDirector of AdmissionsDirector Case ManagementManager of Quality & Risk ManagementTraining and development of training modules for

Critical CareHome CareLTCHAcute CareLong-Term Care and Case Management

Copyright © 2013 All Rights Reserved



Disclosure: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose:Planners:

Elisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTBeckie Dow, RN, RAC-MTKeri Hart, MS CCC, SLP, RAC-CT, Kristen Mastrangelo, OTR/L, MBA, MHA Christine Twombly, RNC, RAC-MT, LHRM

Presenter:Diane Buckley, BSN, RN, RAC-CT


Harmony Healthcare International, Inc.

Hospital Readmission RouletteDisclosure Speaker: Diane Buckley, BSN, RN, RAC-CT

The speaker has no relevant financial relationships to disclose

The speaker has no relevant nonfinancial relationships to disclose

Copyright © 2013 All Rights Reserved 5

Harmony Healthcare International, Inc.

Hospital Readmission RouletteCriteria for Successful Completion

Complete Sign-in and Sign-Out on Attendance FormAttendance for entire sessionCompletion and submission of speaker evaluation form

Copyright © 2013 All Rights Reserved 6

Hospital Readmission RouletteObjectives:

The learner will be able to summarize the CMS quality initiative for healthcare reform related to hospital readmissionsThe learner will be able to identify underlying causes and barriers related to readmissionsThe learner will be able to state current CMS research projects and pilot programsThe learner will be able to identify hospital and SNF strategies for collaboration Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7


Reducing Re-hospitalizations among Medicare beneficiaries has become a high priority for policymakers and the Center for Medicare & Medicaid Services (CMS)

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8


Hospital Readmissions are seen as an important indicator of care quality and account for billions of dollars in annual Medicare spending (MedPac, 2007)


Harmony Healthcare International, Inc. 10Copyright © 2013 All Rights Reserved


Hospitalizations and Rehospitalizations are symptomatic of multi process defect in the health care system due to lack of:

Timely or equitable access to careEffective handoffs and coordination of careSafe carePatient centered and appropriate end of life care



Five most common Medical condition for Readmission:

Heart FailurePneumoniaCOPDPsychosesGI problems



Five most common surgical procedures:

Cardiac stent placementMajor hip or knee surgeryVascular surgeryMajor bowel surgeryOther hip or femur surgery

Hospitalization of Nursing Home Residents CommonExpensiveOften Traumatic to resident and familyTense with many complications

DeliriumPolypharmacyFallsIncontinence and catheter useHospital acquired infectionsImmobility, De-conditioning, and Pressure Ulcers


Reducing Potentially Avoidable Hospitalization

Reducing Potentially Avoidable Hospitalization

Some Hospitalizations of NH Residents are Avoidable

As many as 45% of admissions of nursing home residents to acute hospitals may be inappropriate (Salibaet al, J AmerGeriatrSoc 48:154-163, 2000)

In 2004 in NY, Medicare spent close to $200 million on hospitalization of long-stay NH residents for “ambulatory care sensitive diagnosis”

Grabowski et al, Health Affairs 26: 1753-1761, 2007



Why do Re-admissions happen?



Discharge from Hospital is critical and requires adequate planning and preparations to avoid

Medication errorsPoor discharge planningInadequate arrangementsPoor communicationAdverse events

Why do Re-admissions happen?Medication Errors: The patient is discharged without prescriptions for the proper mix and doses of medication, or lacks instructions for taking them, or new prescriptions may interfere with existing medications.Poor Discharge Planning: There is little or no effort to plan follow up care, including scheduling necessary doctor’s appointments.



In half of all Medicare 30-day readmissions, patients had not seen their regular medical doctor or any health provider following discharge.Inadequate arrangements: Family members and other caregivers lack information or are unable to care for the patient after discharge.



Poor Communication: Providers delay providing discharge instructions, or fail to provide them at all.Lack of discharge summaries to community physicians and post-acute care providers.Too many cases of community providers that have no reports, test results, or other history when seeing the patient at first post discharge visit. Patients may not have received information on how to have a successful recovery.

such as alerting them about symptoms that may need medical attention in an outpatient setting.




Research Recommendations:Interventions at time of DischargeReliable & prompt follow-up care by primary care physiciansAggressive Management of chronicle illness


Hospital Readmission RouletteSome Readmission to the hospital are plannedOther are avoidable and the result of

Poor quality of care/ uncoordinated care

Variation in readmission rates by hospitals and geographical regionsReadmissions rates can be reduced with application of evidenced based guidelines and enhanced care coordination



Medicare readmission rates for Skilled Nursing Facilities to hospitals increased 30% from 2000 to 2006




1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion



~ 10% - 25% of long stay NH residents are admitted to an acute hospital over a 5-month period




June 2007 & 2008 Medicare Payment Advisory Commission (MedPAC) Report to Congress highlighted avoidable Rehospitalizations as an area of high cost and low qualityPrompted leaders of healthcare systems across the country to focus on avoidable Rehospitalizations in anticipations of potential changes in the market

2009 Re-Admissions emerged as a Major Quality Initiative of Healthcare Reform.Reducing Re-hospitalization is an important element of President Obama’s February 2009 proposal for financing Health Care Reform.



12 million fee-for-service Medicare beneficiaries were analyzed per New England Journal of Medicine

20% who had been discharged were Re-hospitalized within 30 days ( 1 in 5 discharges)34% were Re-hospitalized within 90 days51% within 1 year13% of the readmissions - $12 billion worth – were “potentially avoidable,” (IPPS rule).




Hospital Readmission Roulette90% Re-hospitalizations within 30 days are unplanned75% of Readmissions preventable equating to $12 Billion a year to Medicare spending68.9% of patients discharged with a medical condition, were re-hospitalized or died within one year of discharge53% re-hospitalization of Discharges after a surgical procedure


.

Hospital Readmission Roulette50% of re-admissions within 30 days had no bill for a physician visit70% surgical patients were admitted for a medical condition such as pneumonia and UTI 19% of Medicare discharges are followed by an adverse advent with 30 days:

2/3 Drug Events that are preventable

Payers & Policymakers are targeting Readmissions to reduce healthcare expenditures & improve quality of care and patient outcomes Rehospitalization has become a focus for Medicare, other payers, and quality care organizations do to its Clinical and Financial impact.





The Affordable Care ActFrom a Policy perspective performance variation indicated lack of reliable attention to executing successful transition out of the hospital and into the next care settingSeveral provisions regarding improving Care Transition, Care Coordination and Reducing readmissions

HEALTHCARE POLICY PRIORITY

Affordable Care ActAccountable Care Organizations (ACO)Bundled PaymentsStrategic Partnership

Clinical & Financial Performance Data


Healthcare Policy PriorityBesides the penalties, the Obama administration is ramping up other efforts to reduce readmissions.

Giving out $500 million to help hospitals and other health-care providers improve the transitions of patients out of hospitals

And the administration has approved 154 “Accountable Care Organizations,” which are collaborations of hospitals, doctors and other health-care providers that receive financial incentives for preventing costly episodes such as readmissions


http://www.kaiserhealthnews.org/Stories/2011/January/13/ACO-accountable-care-organization-FAQ.aspx


CMS actively working to change payments to hospitals to incentivize readmission reductionHospitals with high rates of preventable readmission will have payments reduced



CMS has undertaken several initiatives to reduce readmissions among the Medicare fee- for- service (FFS) population



Initiatives:Reporting hospital readmission rates through Hospital CompareFunding hospital level improvements through partnership program Changing Payment Policies through the Hospital Readmission Reduction ProgramVarious Shared Savings Initiatives


Hospital Readmission Reduction Program


Section 3025 of The Affordable Care Act added section 1886(q) to the Social Security Act establishing the Readmission Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012




FY 2013 IPPS Final Rule finalized the following policies

Which hospitals are subject to the Hospital Readmission Reduction ProgramThe Methodology to calculate the hospital readmission payment adjustment factorWhat portion of the IPPS payment is used to calculate the readmission payment adjustment amountA process for hospitals to review their readmission information and submit correction to the information before the readmission rates are to be made public Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38



FY 2014 IPPS Final Rule finalized changes to the methodology to calculate the hospital readmission adjustment factor.

Readmission Adjustment Factor:FY 2013, the higher of the Ratio or 0.99 (1% reduction)FY 2014, the higher of the Ratio or 0.98 (2% reduction)

Penalties will increase to a maximum of 2 percent for FY 2014 & 3% for FY 2015CMS considering similar payment reduction based on high readmission rates after joint replacement, stenting, heart bypass and stroke



As of October 1, 2012 a substantial number of hospitals began receiving reduced payments from Medicare due to high readmission rates within 30 days of dischargeApproximately 2,200 hospitals (2/3 of all hospitals) received a reduction in reimbursement for fiscal year 2013 (ranging up to the maximum 1%)



Significant number of hospitals have been working on innovative programs using a wide variety of approaches based on the Hospital Reduction Program



Major Points are emerging from current initiatives:

The reason for admissions aren't what people generally assumeClear communication during transition is keyHospital and health systems are forming collaborations with nursing homes and home care agencies, including monthly council meetings to look at problem cases together and explore the story behind the story



Major Points are emerging from current initiatives (continued):

Hospitals are developing innovative services to offer needed support to patients without necessarily admitting themHospitals and health systems are revamping transfer forms and educational materials to support smooth transitions and consistency between different settings



Major Points are emerging from current initiatives (continued):

Hospitalists in the post-acute setting play a valuable role in reducing readmissionsHospital and health systems boards need to develop a consistent strategy for post acute care


Hospital Readmission RouletteHospital Readmission Reduction Program

Post Acute Hospitalist Are Practicing In:

Skilled Nursing Facilities Post Acute RehabilitationPost Acute Psychiatric facilitiesCustodial nursing care Assisted LivingInpatient Hospice facilities



IPC The Hospitalist Company in CA is larger single-specialty group practice with over 1,200 full time Hospitalist nationwide and several hundred part time.

5 years ago accounted for 5% in post acuteToday increased to 20% of post acute



Barrier Faced by HospitalistMajor barrier to information flow between settings is a lack of compatibility between electronic records, even if the software is from the same companyThe standard hospital discharge form is designed as a succinct record of care the patient received while hospitalized, but is not designed as a road map for care the patient needs to receive after discharge Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47


Barrier Faced by Hospitalist (continued)

Privacy issues add another layer of complexity. Communication is horrible from hospital to the post acute care setting initiating let to dedicated post acute hospitalist practices. Patient are in the same practice and they meet weekly providing an effective handoff.



Hospital and other organizations have implemented additional strategies:

Enhanced patient educationIncreased post-discharge follow up careIncreased coordination with outpatient providers (Bradley et. al., 2012)


Hospital Readmission RouletteSeven Principles key to Reducing Readmissions

Seven Principles key to reducing readmissions from SNF with using “SNF-ist” of “Hospitalist” were developed by a Hospitalist Kevin Sundbye, MD from Stormont-Vail Healthcare in Topeka, KS



Fax needed medication to the pharmacy the day before discharge so medication are on hand when patient arrivesProvide written prescription for pain medication before the patient leaves the hospitalHave the doctor at the hospital contact the nursing home doctor who will be responsible for the patient.



Continued:Attempt to let the nursing home doctor know ahead of time that the patient is being discharged.Do not allow late-afternoon transfers. If you can’t have the patient at the nursing home by 4 pm, don’t send them.Anybody involved in the transfer process (doctor, nurses, social worker) can and should stop the discharge if they detect a problemUse a checklist to confirm that everything is ready and going to according to plan.

(GovernanceInstitute.com; BoardRoom Press Dec 2012)



The Department of Health and Human Services (HHS) has included recommendations from the Medicare Payment Advisory Commission (MedPAC) to have skilled nursing facilities (SNFs) join hospitals in accountability for avoidable 30-day hospital readmissions. As part of the 2014 budget proposal, SNFs with high rates of Medicare rehospitalizations would have payments reduced by 3 percent beginning in 2017



The MedPAC analysis showed that approximately 14 percent of Medicare patients discharged to SNFs were rehospitalized. To avoid penalties and ensure quality care, this budget proposal challenges SNFs to provide

Better care so residents are physically ready for discharge, Provide better family education on subjects such a medication management and Form partnerships with high-quality community services.



Also on the table is MedPAC’s recommendation that bundled payment for post-acute care providers be implemented in 2018, including

Long-Term Care Hospitals SNFs Inpatient Rehabilitation Facilities Home Health Providers.



Medicare 9th Scope of WorkBegan investigating 30-day Re-Admissions.CMS’s Fiscal Intermediaries and state based QIOs began flagging 30-day readmissions to the same facility and for same diagnosis.

AMIHeart FailurePneumonia

QIOs contact hospitals and conducted reviews of discharge plans and other documentation to identify patterns of preventable readmissions.



CMS will monitor the success of this project by watching the rates at which patients in these communities return to the hospital. Re-admission rates for hospitals have been tracked by CMS for some time, and will be available to consumers through the Hospital Compare Web site at http://www.hospitalcompare.hhs.gov.


http://www.hospitalcompare.hhs.gov/


Hospital Readmission RouletteCMS included a Care Transition in its 9th Statement of work (started in 2008)

Quality Improvement Organizations (QIOs) in 14 communities are working to coordinate care and promote seamless transitions across settingsSpecifically focusing on reducing unnecessary readmissions to the hospital by improved transitions of care and greater coordination among providers



IHI (Institute for Healthcare Improvement) on May 1, 2009 launch the State Action on Avoidable Rehospitalizations (STAAR) Initiative

Grant support from the Commonwealth Fund.Initial phase, Two year Multi state project to reduce avoidable Rehospitalizations focusing on two components

STAAR Initiative

One of the First large-scale , multi-stakeholder effort to reduce readmissions and an early leader in encouraging the field to form state-level and local cross-setting partnership to address system issues in transitioning care across settings.


STAAR Initiative

Aims to reduce Rehospitalizations by working across organizational boundaries and by engaging:

PayersStakeholders at the State, Regional and National levelPatient and families and caregivers at multiple care sites and clinical interfaces


Hospital Readmission RouletteSTAAR Initiative

IHI partners with STAAR states to provide

Strategic guidance SupportTechnical assistance

To hospitals and cross-continuum teams to improve transitions in care and reduce avoidable rehospitalizations



Hospital Readmission RouletteSTAAR Initiative

IHI (Institute for Healthcare Improvement)

Focusing on Two components:A multi-state learning community to Improve Transition of CareTargeted Technical Assistance to address systemic barriers to reducing avoidable Re-hospitalizations

STAAR Initiative1. Improve Transition of Care by

cultivating a cross-continuum learning collaborative

Participants are required to engage partners from across the continuum of care to problem solve and co-design improvements in the day to day work of providersThe initiative supports the process improvement work in hospitals and cross continuum teams by creating robust learning community


STAAR Initiative

STAAR providesContent reviewsProcess recommendationsInventory Celebration of Best Practices and suggested measurement strategies


STAAR Initiative

2. Engage State-level leadership to understand and mitigate systemic barriers to change

Reducing rehospitalizations in a state or region requires not only front-line process improvement, but also identification and mitigation of barriers to system-wide improvements, policy & payment reforms that will reduce fragmentation and encourage coordination across the continuum of care


STAAR InitiativeReforms are necessary to address the shortcomings of the current volume-based incentives, and to place a premium on the quality of the patient’s experience across the continuumRehospitalization involves new behaviors, norms, relationships and partnerships to communicate and coordinate care between disciplines, settings and organizationsState-level leadership is essential to understand an act on the barriers that front line teams encounter in doing this workCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67

STAAR Initiative

STAAR Hospital Teams focus on the implementation of four key recommended process level improvements that require extensive collaboration between the hospitals and their community partners to effectively co-design better processes


STAAR Initiative

Perform an Enhanced Assessment of Post-Hospital NeedsProvide Effective Teaching and Facilitate Enhanced LearningProvide Real-Time Handover- CommunicationsEnsure Timely Post-Hospital Care Follow-Up


STAAR Initiative

Perform an Enhanced Assessment of Post-Hospital Needs

Involve family caregivers and community providers as full partners in completing a needs assessment of patients’ home-going needsReconcile medications upon admission Create a customized discharge plan based on the assessment


STAAR Initiative

Provide Effective Teaching and Facilitate Enhanced Learning

Customize the patient education materials and processes for patients and caregiversIdentify all learners on admissionUse Teach Back regularly throughout the hospital stay to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71

STAAR InitiativeProvide Real-Time Handover- Communications

Reconcile medications at dischargeProvide customized, real time critical information to next clinical care provider(s)Give patients and family members a patient-friendly discharge planFor high risk patients, a clinician calls the individual listed as the patient’s emergency contact to discuss the patient’s status and plan of care


STAAR Initiative

Ensure Timely Post-Hospital Care Follow-Up

Identify each patient’s risk for readmissionPrior to discharge, schedule timely follow-up care and initiate clinical and social services based upon the risk assessment


STAAR InitiativeMeasurements of Outcomes and Process Measures

Outcome Measures: Readmissions30-Day All-cause Readmissions (% of discharges with readmission for any cause with 30 days)Readmission Count (Number of readmissions: Numerator for 30-day all cause readmissions measure)


STAAR Initiative

Outcome Measures: Patient Experience

HCAHPS Communication Questions: “During the hospital stay, how often did nurses explain things in a way you could understand?”“How often did doctors explain things in a way you could understand?”

HCAHPS Discharge Questions:“Did hospital staff talk with you about whether you would have the help you needed when you left the hospital?”“Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”


STAAR InitiativeOutcome Measures: Patient Experience

Care Transition Measures: The hospital staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left the hospital. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.When I left the hospital, I clearly understood the purpose for taking each of my medications


STAAR InitiativeProcess Measures:

Enhanced Admission Assessment for Post-Hospital Needs

Percent of admissions where patients and family caregivers are included in assessing post discharge needsPercent of admissions where community providers (e.g., home care providers, primary care providers and burses and staff in skilled nursing facilities) are included in assessing post discharge needs


STAAR Initiative

Process Measures (continued):Effective Teaching and Enhanced Learning

Percent of observations of nurses teaching patient or other identified learner where Teach Back is used to assess understandingPercent of observations of doctors teaching patient or other identified learner where Teach Back is used to assess understanding


STAAR InitiativeProcess Measures (continued):

Real-time Patient and Family-Centered Handoff Communication

Percent of Patients discharged who receive a customized care plan written in patient friendly language at the time of dischargePercent of time critical information is transmitted at the time of discharge to the next site of care (e.g., home health, long term care facility, rehab care, physician office) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 79

STAAR InitiativeProcess Measures (continued):

Post-Hospital Care Follow UpPercent of patients discharged who had a follow-up visit scheduled before being discharged in accordance with their risk assessment

Balancing MeasureObservation Admits

Number of Admission to observation status in the month


STAAR InitiativeFive Steps the STAAR initiative found to be effective:

Know your dataKnow your partners-with whom you share patientsForm operational alliances to share data and improve transition processes. Form a cross continuum teamPerform a review of five recently readmitted patients, and bring to the cross continuum team meetingIdentify shared process that span the transition from the hospital to other settings, and work together to improve those processes



The Affordable Care Act created a formal Community Based Care Transition Program (CCTP)

The program was to test models in for improving care transition and reduce readmissions for high risk Medicare beneficiariesCCTP is part of the Partnership for Patients (P4P) a nationwide partnership aimed to reduce preventable hospital errors by 40% and reduce hospital readmissions by 20%47 organizations are enrolled and budgeted to $500 million


Partnership For Patients (P4P)


Partnership For Patients (P4P)



INTERACT(Interventions to Reduce Acute Care Transfers)

Joseph Ouslander, MD, Director of Boca Institute for Quality Aging at Boca Raton Community Hospital, created a program aimed at reducing the number of hospital admission from nursing homes

INTERACT

INTERACT was initially designed as “Toolkit” in 2007 Evolved into a full Quality Improvement Program that will assist nursing homes in meeting the federal requirement for QAPI program


INTERACTDesigned to improve the early identification, evaluation, management documentation and communication about acute changes in condition of residents in nursing homesThe goal is to improve care by reducing the frequency of potentially preventable transfers to the acute care hospital and related complications leading to increase health care expenditure


INTERACT

Program includes Evidenced Based and Expert recommended Tools Strategies to implement themRelated educational resources

The tools are to be integrated into everyday care and be incorporated into your facility’s quality improvement program


INTERACT

Tools:Quality Improvement ToolsCommunication ToolsDecision Support ToolsAdvance Care Planning Tools


INTERACTImplementation Elements

Advance Care Planning should begin at the time of or shortly after admission and continued through out the resident stay. The INTERACT Advanced Care Planning Tool aides in developing a person centered care planMedication Reconciliation Worksheet is designed to help with safe medication orders at the time of admission


INTERACT

Implementation Elements (continued)

Stop and Watch Tool to be used by CNAs to identify changes in resident and clearly communicate those changes to the licensed staff. The tool also can be used with staff who have direct contact with resident and may observe changes (Rehab, environmental services, dietary)


INTERACTImplementation Elements (continued)

Once a nurse is alerted to a change in condition the Care Paths and Change in Condition File Cards can be used as decision support tools to help with the recognition, management and reporting of specific symptoms and signs. Include criteria for notifying primary care clinician


INTERACT

Implementation Elements (continued)

SBAR Form and Acute Change in Condition Progress Note to enhance the evaluation of and documentation with acute changes and improve the communication utilizing a structure.Transfer Checklist and Transfer Forms used to communicate clearly and succinctly information that is critical for the ED and other hospital staff to care for the resident.


INTERACT

Quality Improvement ToolsThe Hospitalization Rate Tracking ToolQuality Improvement Tool

Both tools assist with:Tracking, trending, and benchmarking measuresConducting root cause analysis that identify areas for improvement


INTERACTFour Key Strategies for implementation essential for success

Make INTERACT an integral component of QAPI programIntegrate the INTERACT program and tools into everyday careTools are visible and accessible for everyday careCulture Change-change takes time and to be mindful of this


INTERACT

Commonwealth Fund Project Results

100 bed Nursing Home the average reduction of 0.69 hospitalizations/1000 resident days equates

25 fewer hospitalizations in a year$125,000 in savings to Medicare Part A (conservative)The Interventions as implemented as part of the project cost $7,700 per a facilityThe savings could aide the facility infrastructureCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96


Medicare Readmission Rates showed Meaningful decline in 2012 per a publication of the Center for Medicare & Medicaid Services, Office of Information Products & Data Analytics



Descriptive analysis of 30-day, all cause hospital readmission rate patterns from 2007-2012 .Population: Medicare FFS beneficiaries experiencing at least one acute inpatient hospital stay.



Method: Chronic Condition Data Warehouse claims, estimate unadjusted, monthly readmission rates for the nation, within the Dartmouth Hospital Referral Region (HRR), and compare participating and non-participating hospitals in the Partnership for Patients(P4P) program (overall and by number of inpatient beds at each facility)



Results:From 2007-2011 the national 30-day all cause hospital readmission rate averaged 19% 2012 readmission rate averaged 18.4%


Hospital Readmission RouletteCurrent Readmission Rates










CMS hopes to lower Hospital readmissions Rate by 20% by 2013 utilizing evidenced based interventions


The Affordable Care Act established the Hospital Readmission Reduction Program (HRRP) which ties payment to Performance on MeasuresHRRP begins October 1, 2012Lowers Medicare payment rate for hospitals with greater than expected readmission rates for specific conditions



Conditions beginning FY 2013Heart FailureAcute Myocardial InfarctionPneumonia

These three conditions made up approximately 10% of hospital discharges in 2009

(Avalere analysis of 2009 Medicare 100 Percent Standard Analytic files claims data from CMS.)



Conditions Beginning FY 2015Chronic Obstructive Pulmonary DiseaseCoronary Bypass GraftPercutaneous Transluminal Coronary AngioplastyOther Vascular Conditions



Payment reduction is determined by an adjustment factor based on an assessment of excess readmissions



Hospitals with excessive readmission rates will have their Medicare payments reduced by up to

1% in fiscal year 2013 2% in 2014 3% by fiscal year 2015 and beyond




Hospitals with risk adjusted 30 day readmission performance in the lowest quartile will incur penalties against their total Medicare Payment beginning in fiscal year 2013 (starting October 1, 2012)CMS will evaluate prior year’s readmission data starting October 1, 2011



Preparing for Payment Penalties:Know your readmission metrics including original discharge disposition and origin of readmissionCalculate readmission rates by condition, physician performance and post acute care facilityIdentify opportunities based on patient demographics and common readmissionsScreen and target patients based on risk assessmentsCompare disease specific outcome measures to national and local competitor rates



Four stages of care that allow effective interventions

Preparation for discharge, a process starting on admission making staff aware of home environmentHand-off to the out patient physicianMedication reconciliation to make sure new prescriptions are filled and that patients are not falling back on their old medication routinesHome visits and/or phone call, daily or weekly for first 30 days



American Healthcare Association Goal:

Reduce Hospital Re-admissions within 30 days during a SNF stay by 15% by March 2015



Definition of Readmission 30 Day Readmission Measure

Readmission occurs when a patient is discharged from the applicable hospital to a non-acute setting and then is admitted to the same or another acute care hospital within 30 days for any reason



Definition of Readmission 30 Day Readmission Measure

Exclusion to Readmission Definition:

Transfers and planned readmissions are excluded

An exception for AMI for planned readmission for revascularization procedures (CABG PTCA)



1 in 5 Medicare FFS Beneficiaries are Readmitted to the hospital within 30 days


Hospital Discharge Condition

30-Day Rate for Re-hospitalization

AMI 19.8

Heart Failure 24.8

Pneumonia 18.4

Hospital Compare National Readmission Rate: http://www.medicare.gov/Download/DownloaddbInterim.asp. Jan 20, 2012

National Transitions of Care CoalitionMedicare Transitional Care Act of 2012

Improve transition of care for high risk Medicare beneficiaries at high risk for readmission as they move from the hospital setting to

HomeSkilled Nursing facilityNext point of care

The bill is step in improving patient outcomes and reducing unnecessary health-related expensesCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 118

National Transitions of Care Coalition

The Medicare Transitional Care Act puts in place an infrastructure to promote care transition interventions that have been proven successful

Seven key elements found in evidence-based care interventions


National Transitions of Care Coalition

Seven Essential Intervention Categories

Medication ManagementTransition PlanningPatient and Family Engagement/EducationInformation TransferFollow-Up CareHealthcare provider EngagementShared Accountability across Providers and Organizations



Nursing Home Value-Based Purchasing Demonstration Project

CMS initiative to improve Quality and Efficiency of care to Medicare beneficiariesFinancial incentives to nursing homes that meet certain conditions providing high quality of careDemonstration includes three states: Arizona, New York, and Wisconsin




Quality Performance Based on Four Domains:

Staffing Appropriate HospitalizationsMinimum Data Set (MDS) OutcomesSurvey Deficiencies

CMS will award points based on performance with each measure within the domainPoints will summed for an overall quality score




For each state Nursing home scores in the top 20 %Homes in the top 20% of improvement in their scores Eligible for a share of the State’s savings pool




Anticipate that potentially avoidable Hospitalizations may be reduced as a result of improvement of quality of careReduction in hospitalizations and subsequent skilled nursing stays result in Medicare savingsThe saving will fund the payment awards



Clinician and Hospital administrators are eager to find effective approaches to reduce Rehospitalizations.

As Payers, Policy makers and Purchasers are eager to develop incentives to improve practice.



Transition in CareA

Culture Change


SNF Culture Change

WHY A Culture Change? Needed in order to be successful!

The Affordable Care Act mandates that each facility have a Quality Assurance and Performance Improvement Program (QAPI)Improving Management of acute changes in condition and reducing unnecessary hospital transfers is one potential focus to meet QAPI requirements


SNF Culture Change

Corporate Compliance program in place and supported by the organizationSupport and buy- in from senior leadership down front line staffQAPI program

Make readmission an initiative

An organization ready for changeCross the continuum collaboration


SNF Culture Change

Know your DataPartner with Hospitals, physician offices, Home care, Hospice, Assisted Living, Acute RehabBe part of Pilot programs or initiativesImplement INTERACTTrain and Educate all employees from top down


SNF Culture Change


Admission ProcessReceive complete and accurate admission informationManage Admissions times and daysCustomer ServiceEstablish protocols and procedures

Handoff communication

Transition meeting scheduled with 72 hours of AdmissionINTERACT Advanced Care Planning


SNF Culture Change

Customer Services: Making a Good Impression

Providing pre-admission contact with patient/familyStaff and room are ready to receive patientImplement a room readiness checklist

A warm home like atmosphereA welcome gift


SNF Culture ChangeTransition Planning Meeting

Scheduled with 72 hours of AdmissionInterdisciplinaryCommunicationGoal:

Ease transition into and out of the facilityLength of StayIndividualized to each patients situation and conditionReduce readmissions to the hospital



SNF Culture Change (continued)Education Patient and Family through out careAccountability/Communication

Effective Hand Off of Care

Medication ManagementMultidisciplinary approachDischarge planning that starts on admission



SNF Structural SupportMD/PA/NP availability-“SNF-ist” or HospitalistPharmacy support 24/7 and responsivenessRespiratory Therapist and Respiratory vendor support

Training and competency

Infusion Therapy RN Support Training and competency24/7 availabilityCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 134


Questions & Answers




References & Resources

Healthcare Leader Action Guide to reduce Avoidable Readmissions, 2010 Health Research & Educational TrustReport on Medicare Compliance, “CMS Targets Readmission Through Payment, Audits; “Coaching” Model Reduces Rates.” Volume 17,Number 24. June 30, 2008Reducing Hospital-SNF 30-Day Readmission. Case Management Monthly. January 2010.




Improving Care Transition and Reducing Hospital Readmission. The Remington Report. January/February, 2010 Care Transitions. Re-hospitalizations Among Patients in the Medicare Fee for Service Program. New England Journal of Medicine, April 2, 2009.Institute For healthcare Improvement: Effective Interventions to reduce Rehospitalizations, March, 2009.



Hospital Collaborate with SNFs, Home Care, Hospice, to Reduce Readmission by Elaine Zablocki, National Research Corporation, December 2012 BoardRoom PressMedicare & Medicaid Research Review 2013: Volume 3, Number 2, Medicare Readmission Rates Showed Meaningful Decline 2012, Gerhardt, G., Yemane, A. Hickman, P., Oelschlaeger,A., Rollins, E., Brennan,N.Readmission Reduction Program. CMS. Gov, www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/AcuteinpatientPPS/Readmission-Reduction-Program.html



State Action on Avoidable Rehospitalizations. www.ihi.org


Questions/Answers

Harmony Healthcare International1 (800) 530 – [email protected]

Harmony Healthcare International, Inc. 141141Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

Harmony Healthcare InternationalHave you Considered a Customized Complimentary

HARMONY(HHI) MEDICARE PROGRAM EVALUATION

or CASE MIX ANALYSIS

for your Facility?Perhaps your facility has potential for additional

revenue Assess your facility against key indicators and national

norms

Email us at for more [email protected]

Analysis is cost & obligation freeHarmony Healthcare International, Inc. 142Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

mailto:[email protected]

Health & Medicine

Hospital Readmission Roullette