ASPIRE to Knockout Pneumonia Readmissions · 2019-08-30 · ASPIRE to Knockout Pneumonia...
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ASPIRE to Knockout Pneumonia Readmissions Webinar #1 Amy Boutwell, MD, MPP March 1, 2018
Transcript of ASPIRE to Knockout Pneumonia Readmissions · 2019-08-30 · ASPIRE to Knockout Pneumonia...
ASPIRE to Knockout Pneumonia ReadmissionsWebinar #1
Amy Boutwell, MD, MPPMarch 1, 2018
NCHAPneumoniaKnockoutTeam
KarenSouthardVP,Quality&[email protected]
TrishVanderseaProgramDirector,Quality&[email protected]
SarahRobertsLogisticsManager,Quality&[email protected]
DebbieHunterProgramDirector, Quality&Clinical [email protected]
LisaAlfonsoExecutiveAdministrativeAssistant,Quality&[email protected]
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
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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
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sion
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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
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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
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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
TrishVandersea,MPAProgramDirector
