ASPIRE to Knockout Pneumonia ReadmissionsWebinar #1

Amy Boutwell, MD, MPPMarch 1, 2018

NCHAPneumoniaKnockoutTeam

KarenSouthardVP,Quality&ClinicalPerformanceImprovementpne@ncha.org

TrishVanderseaProgramDirector,Quality&ClinicalPerformanceImprovementpne@ncha.org

SarahRobertsLogisticsManager,Quality&ClinicalPerformanceImprovementpne@ncha.org

ElizabethMizelleDirectorofMeasurementemizelle@ncha.org

DebbieHunterProgramDirector, Quality&Clinical PerformanceImprovementpne@ncha.org

LisaAlfonsoExecutiveAdministrativeAssistant,Quality&ClinicalPerformanceImprovementpne@ncha.org

ASPIREtoKnockoutPneumoniaReadmissionsDesigning&DeliveringWhole-PersonTransitionalCare

AmyE.Boutwell,MD,MPPNCHAKnockoutPneumoniaCampaign- Webinar1

March12018

KnockoutPneumoniaReadmissionsSeries

Monthly Webinars;allare2-3pm

March1

April5

May3

June7

August2

September6

October15-16in-personlearningsession

November1

December6

PurposeoftheKnockoutPneumoniaReadmissionsSeries

Thisseriesistosupportyourworktoreducepneumoniareadmissions

ØWewillfocusonconnectingconceptstoaction

ØWewillfocusonhigh-leveragestrategies toreducereadmissions

ØWewillfocusonimplementation coaching

Thebestuseofyourtimeistousethesehourstoactivelyadvanceyourpneumoniareadmissionwork

ØComewithquestions,challenges,cases,data,ideasforimprovement

ØInviteyourcross-continuumpartnerstoattend

ØEmailuswithquestionsorissuestodiscussonthenextwebinar

ObjectivesforthisSession

• Know yourdata

• Understandrootcausesofpneumoniareadmissions

Whatisyourhospital’scurrentallcause*readmissionrate?

Whatisyourhospital’scurrentpneumoniareadmissionrate?

*Allcause=adult,non-OB

Doyouknowtherootcausesofpneumoniareadmissions?

Howdoyouidentifyrootcauses?

Whatisyourhospital’sreadmissionreductiongoal?

Whatisyourhospital’spneumoniareadmissionreductiongoal?

WhatstrategiesareyoutestingtoreducePNAreadmissions?

Aretheytargetedstrategies?Dotheyaddressrootcauses?

Howmanypneumoniadischargesdidyouhavelastmonth?

Howmanypneumoniareadmissionsdidyouhavelastmonth?

Howmany(what%)pneumoniadischargesdidyou“serve*”?

*“serve” = serve differently because they are high risk of readmission

13customizabletools

https://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html

6-partwebinarseries

DesigningandDeliveringWhole-PersonTransitionalCare:TheASPIREGuide

ASPIREFramework

“Design”

“Deliver”

Reduce Pneumonia

Readmissions

Design

Deliver

ü .

HospitalswithHospital-WideResults

• Knowtheirdata–– Analyze,trend,track,display,share,post

• Broadconceptof“readmissionrisk”– Waybeyondcasefindingfordiagnoses

• Multifacetedstrategy– Improvestandardcare,collaborateacrosssettings,enhancedcare

• Usetechnologytomakethisbetter,quicker,automated– Automatednotifications,implementationtracking,dashboards

KNOWYOURDATA

NorthCarolinaanalyses;knowforyourownhospital

Discharges,PneumoniaDischarges,andReadmissions

All Pneumonia

Adult* discharges 723,698 18,281 2.5%discharges

Readmissions 108,345 2,920 2.7%readmissions

Readmissionrate 15% 16%

*adult,non-OB,NorthCarolina2016

Stats to know: • ~18k pneumonia discharges/ year• ~3k pneumonia readmissions/ year• ~2-3% of all discharges

NorthCarolinaAllPayerPneumoniaReadmissionRates

0.0% 2.0% 4.0% 6.0% 8.0%

10.0% 12.0% 14.0% 16.0% 18.0% 20.0%

Rea

dmis

sion

Rat

e

2016NorthCarolinaOverallandPNAReadmissionRate

Statewide Rate

PN rate

Linear (PN rate)

NorthCarolinaPNAreadmissionstrendedupwardby13%over2016

All-causerate:15%Pneumoniarate:16%

PneumoniaReadmissions,byPayer

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Rea

dmis

sion

Rat

e

2016NorthCarolinaPNReadmissionsTrend- byPayer

Medicare

Medicaid

Private/Commercial

Linear (Medicare)

Linear (Medicaid)

Linear (Private/Commercial)

AllpayersseeupwardtrendinPNAreadmissionrates

10DischargeDiagnoses*LeadingtotheMostReadmissions

Medicare Medicaid Private AllSepsis(n=4,501) Sepsis(n=768) Chemo Sepsis(n=6,413)

COPD(n=2,188) SickleCell(n=557) Sepsis COPD(n=2,997)

Acute KidneyFailure COPD(n=457) AcuteKidneyFailure AcuteKidneyFailure

Pneumonia(1,748) DKA(n=381) Pneumonia(278) Pneumonia(n=2,374)

Heart Failure(dias.) Chemo NSTEMI Chemo

Heart Failure(systolic) AcuteKidneyFailure MajorDepression HeartFailure(dias.)

NSTEMI Pneumonia(n=234) COPD HeartFailure(systolic)

UTI HeartFailure Bipolar NSTEMI

HeartFailure (both) Schizoaffective MorbidObesity UTI

HF+CKD MajorDepression HeartFailure SickleCell

*adult,non-OB,NorthCarolina2016

PneumoniaReadmissions,byAge

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

18-44 45-64 65-84 85+

Pneumonia Readmissions and Discharges, by Age

Readmissions PNA Discharges

11%

15.9%

17.5%

15.1%

StatewideRArate: 16%

Rate65-84: 17.5%

Rate45-64: 15.9%

77%PNAreadmissionsage45-84

PneumoniaReadmissions,byPayer

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Medicare Medicaid Private/Commercial Other

Pneumonia Readmissions, by Payer

Readmissions Discharges

StatewideRArate: 16%

Medicare: 17.2%

Medicaid: 18.3%

77%PNAreadmissionsage45-84

PneumoniaReadmissions,byRace

0

2000

4000

6000

8000

10000

12000

14000

16000

White Black Asian Other Unknown Unavailable

Pneumonia Readmissions and Discharges, by Race

Readmissions PNA Discharges

15.5%

17.8%

10.8% 17.2% 11.9%14.2%

StatewideRArate: 16%

Ratebyrace,white: 15.5%

Ratebyrace,black: 17.8%

21%PNAdischargesblackrace

23%PNAreadmissionsblackrace

PneumoniaReadmissions,byDischargeDisposition

0

2,000

4,000

6,000

8,000

10,000

12,000

Home Home Health SNF Other

Pneumonia Readmissions and Discharges, by Discharge Disposition

Readmissions PNA Discharges

14% 20.2% 21.8% 11.3%

StatewideRArate: 16%

DischargedSNF: 21.8%

DischargedHH: 20.2%

61%PNAdischargestohome

53%PNAreadmissionstohome

16%PNAdischargestoHH

20%PNAreadmissionstoHH

15%ofPNAdischargestoSNF

20%ofPNAreadmissionstoSNF

ReadmissionRates,ifBehavioralHealthComorbidity

Source: Boutwell in collaboration with the Massachusetts Center for Health Information and Analysis 2016

Ø 40% of adult hospitalized patients had at least 1 behavioral health condition

Ø Patients with a BH condition had 77%higher readmission rates

Hospital-SpecificPneumoniaReadmissionRates

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100

103

106

Range of Hospital Specific PNA Readmission Rates

106NChospitals

Widerange5%to33%

Stateaverage:16%

NumberPNADischargesandReadmissionsperHospital

01002003004005006007008009001000

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101

105

PN_discharges

0

20

40

60

80

100

120

140

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101

105

PN_readmissions

106hospitals#PNAdischarges/year:3to877#PNAreadmissions/year:1to131

Mosthospitalshave100to400PNAdischarges- Divideyour#PNAdischargesby365- Compute#PNAdischarges/day- 300PNAdischarges/year=<1discharge/day- Wecanserve1patientperday!

InsightsFromDataAnalysisre:PneumoniaReadmissions

• Adult,Medicaid

• Age>45

• AfricanAmerican

• Dischargedtopost-acutecare

• Anybehavioralhealthcomorbidity

• ThereareamanageablenumberofPNAdischarges/daytoserveall

Askyourpatients“Why”Elicitthestorybehindthechiefcomplaint;identifyrootcauses

• 77F discharged following sepsis returns to the hospital 8 days later 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.

• 45F with HIV hospitalized for pneumonia discharged to home returns to the hospital 8 days later with cough.

Understandthe“storybehindthechiefcomplaint”

Chart reviews and administrative analyses will NOT reveal what you need toknow: you must talk to your patients, their families, care partners, providers

TheReadmissionInterview

77yearoldwomanwithESRD,HTN,HF,osteoporosis

Indexadmissionwastohavelineplacetoinitiatedialysis• Developedbacteremia,sepsis• ICUstay,onpressors,allhomemedsheld• Stabilized,transferredtofloor,BP“stableoffpressors”• Patienteagertogoafter2daysonfloor- “lipsticksign”• Married,highlyeducated,hasPCP,cardiologist,nephrologist

Readmitted8dayslaterwithshortnessofbreath• Scared,fearful;honestlyworriedthiswasthe“beginningoftheend”• Cracklesuptoherclavicles;3+peripheraledema

TheReadmissionInterview

“Tellmeaboutwhathappenedbetweenthedayyouwerefirstdischargedandtoday.Howdidyoufeelwhenyouwenthome?”

• Feltfine,gladtobegoinghome!• Day2-3-4postdischargetooktobed– hadbeenthroughanordeal• Day5triedtoresumeexpectedactivity,but“wipedout”• Day6notedwasgettingeasilywinded• Day7missedappointmentbecausedidn’tfeelwellenoughtogo• Finally,onday8knewshehadtocomein– couldn’tbreathe

”Let’sreviewyourmedications…..”• Findoutthatshewasnotinstructedtoresumeheranti-HTNandlasix on

discharge,soshehadnotbeentakingthem!!!

TheReadmissionInterview

Lessonsfromthisreadmissioninterview• Didn’tfeelrushedoutthedoor;noevidenceofprematured/c• Issue:instructionsregardingmedications,monitoringvolumestatus

Howcouldhaveavoidedthisreadmission?• Postdischargecontact(phonecall,homevisit,appointment)• Checkinonsymptoms– wouldhavecaughtit• Checkinonappointments– wouldhavecaughtit• Checkinonmedications– wouldhavecaughtit

• Interviewed 60 patients who returned to ED <9days of visit• Average age 43 (19-75)• Majority had a PCP,• Preferred the ED: more tests, quicker answers, ED more likely to treat symptoms • Most reported no problem filling medications• 19//60 thought they didn’t get prescribed the medications they needed (pain)• 24/60 expressed concerns about clinical evaluation and diagnosis

• Primary reason: fear and uncertainty about their condition• Patients need more reassurance during and after episodes of care• Patients need access to advice between visits

Annals of Emergency Medicine

ReadmissionInterview:ExampleScript

“I see you were discharged a [few days, weeks] ago. Can I ask you* to remember back

to the day you were discharged? How did you feel when you left the hospital? Tell me

about how thing went [over the next few days]. Did you have any problems or

questions or challenges with anything? Did you have any interaction with any health

care providers, or anyone who checked in on you? At what point did you – or someone

else – decide you needed to return to the hospital? We’re glad you’re here with us now,

and we’re going to take good care of you, but looking back over the past [few days,

weeks], is there anything that you think could have been done to help you after you

left the hospital the first time?”

*You=patientand/orcarepartner.Engageanyinformantwhowasinvolvedinthecarefollowingthefirstdischarge

ASPIRETool2

Purpose:• Tounderstandpatientperspective

• Tounderstandrootcauses

• Tounderstandtherearemultiplefactors

• Toidentifyopportunitiesforimprovement

• Todevelopabetterplanforthepatient

• Todevelopbetterservicestooffer

Recommendation:

• Conductatleast5thismonth!

• Bestpractice:doforallreadmissions

Boutwell,ASPIRETool2athttps://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html

Basedonyourreadmissioninterviews,whatfactorscontributetoreadmissions?

TakeaData-InformedApproach

1. Whatisouraim?

2. Whatdoesourdatashow?

3. Whoshouldwefocuson?

4. Whatservicesshouldwedeliver?

Manyteamsstartinthereverseorder!

ü Ensureyouknow thefollowing:• Yourhospital’s*overallreadmissionrate• Yourhospital’spneumoniareadmissionrate• The#ofpneumoniadischargesperday• Thedischargedispositionofpneumoniadischarges(eg withwhomyouneedtocollaborate)

ü Conduct“readmissioninterviews”forallofyourpneumoniareadmissions• Haveasysteminplacetoidentifyyourreadmittedpatientsonadailybasis(dailylist)• DelegatesomeonetoconductreadmissioninterviewforallpneumoniapatientsinMarch• Collectanddiscussfindingsasagroup– andsharewithusforournextwebinarinApril!

ü Starttoidentifyservicesandsupportstoreducepneumoniareadmissions• Basedondatainsights(eg stratifyeffortsbasedondischargedispo)• Basedonrootcauses(eg somepatientsneedmedicationmanagement,othersneednavigationsupport)

ü CometoAprilandfuturewebinarswithquestions!• Letusknowwhatyouareworkingonandwhatchallengesyouface– youarenotalone!

Recommendations

*Ifyouareleadingasystemeffort,pleaseevaluateeachhospital’sdataseparately

Thankyouforyourcommitmenttoreducingreadmissions

AmyE.Boutwell,MD,MPPPresident,CollaborativeHealthcareStrategiesAdvisor,NCHAPneumoniaKnockoutCampaignAmy@CollaborativeHealthcareStrategies.com

617-710-5785

ContactUs

KarenSouthard,RN,MHAVicePresident,QualityandClinicalPerformance

ksouthard@ncha.org

TrishVandersea,MPAProgramDirector

tvandersea@ncha.org