Central Valley/West Valley Care Coordination Coalitions ...

Central Valley/West Valley Care Coordination Coalitions Quarterly Community Meeting

Health Services Advisory GroupMarch 9, 2017

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Central Valley/West Valley Care Coordination Coalitions

Quarterly Community Meeting

Ettie Lande, MS, RN Associate Director, Care Coordination

Health Services Advisory Group (HSAG) March 9, 2017

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We Have “Gone Green”

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Benefits:

• Slides are sent in advance of the meeting by email.

• You can print a copy in advance if you prefer having a hard copy.

• Allows you to follow along electronically.



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Thank you!

Today’s breakfast sponsored by

ComForCare Senior Services

Thank you to Mark Redmond!

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If you would like to sponsor the breakfast for the September 26 meeting, please contact Cheryl Angotti at [email protected]

or call602.801.6916

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Introducing the HSAG Team

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Barb Averyt, Executive DirectorCheryl Angotti, Project Coordinator

Care Coordination and Adverse DrugEvents (ADEs)Ettie Lande—CV/WVCCCAssociate DirectorJenna Burke—EVCCCQuality Improvement Specialist

Behavioral HealthDennette Janus—Arizona and CaliforniaQuality Improvement Specialist

Nursing Home Quality Improvement and C. diffKeith ChartierAssociate DirectorElaine NelsonClinical Project ManagerBuffy LloydQuality Improvement Specialist—HAI

Antibiotic StewardshipKeith ChartierAssociate Director

mailto:[email protected]



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Your Meeting Feedback Is Important!

Please help us exceed the 85% target!

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79%

90%

73%

88%

50%55%60%65%70%75%80%85%90%95%

100%

March,2016

June, 2016 Sept, 2016 December,2016

2016 Evaluation Completion Rates

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Today’s Agenda

• Welcome and Introduction

• Readmission Rates, Targets, and Call to Action

• The Center for Transitional Care Clinic

• Adverse Drug Event Rates and Call to Action

• Anticoagulation Therapy in Acute Rehab

• Meeting Feedback and Evaluations

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Community Readmission Rates, Targets, and Call to Action

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WVCCC: Readmission Rates Q4 2013–Q2 2016

Oct 2013–Sep 2014

Jan 2014–Dec 2014

Apr 2014–Mar 2015

Jul 2014–Jun 2015

Oct 2014–Sep 2015

Jan 2015–Dec 2015

Apr 2015–Mar 2016

Jul 2015–Jun 2016

Target 15.6% 15.6% 15.6% 15.6% 15.6% 15.6% 15.6% 15.6%

Readmit Rate 17.00% 16.93% 16.93% 16.84% 16.85% 16.62% 16.32% 15.91%

17.00% 16.93% 16.93% 16.84% 16.85%16.62%

16.32%

15.91%

14.5%

15.0%

15.5%

16.0%

16.5%

17.0%

17.5%

Target Readmit Rate Desired Direction:Target: 20% RIR* by Q3 2018

Source: Medicare Fee for Service Claims Data. *RIR is Relative Improvement Rate, the percentage of improvement from baseline. The formula for Relative Improvement Rate (RIR) is (Baseline-Current)/Baseline.

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WVCCC: Readmission Relative Improvement Rates (RIR) Q4 2013–Q3 2016

Oct 2013–Sep 2014

Jan 2014–Dec 2014

Apr 2014–Mar 2015

Jul 2014–Jun 2015

Oct 2014–Sep 2015

Jan 2015–Dec 2015

Apr 2015–Mar 2016

Jul 2015–Jun 2016

Oct 2015–Sep 2016

Target 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0%

Actual RIR 2.01% 3.62% 4.17% 5.78% 6.76% 9.25% 12.18% 17.22% 19.45%

2.01%3.62% 4.17%

5.78%6.76%

9.25%

12.18%

17.22%19.45%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Target Actual RIR Desired Direction:Target: 20% RIR* by Q3 2018

Source: Medicare Fee for Service Claims Data*The formula for Relative Improvement Rate (RIR) is (Baseline-Current)/Baseline. 9

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CVCCC: Readmission Rates Q2 2014–Q2 2016

Desired Direction:

Apr 2014-Mar 2015 Jul 2014-Jun 2015 Oct 2014-Sept 2015 Jan 2015-Dec 2015 Apr 2015-Mar 2016 Jul 2015-Jun 2016

Readmit Rate 17.42% 17.42% 17.44% 17.55% 17.68% 17.29%

17.42% 17.42% 17.44%17.55%

17.68%

17.29%

16.00%

16.50%

17.00%

17.50%

18.00%

18.50%




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CVCCC: Readmission RIR Q2 2014–Q3 2016

Apr 2014–Mar 2015

Jul 2014–Jun 2015

Oct 2014–Sep 2015

Jan 2015–Dec 2015

Apr 2015–Mar 2016

Jul 2015–Jun 2016

Oct 2015–Sep 2016

Target RIR 12.0% 12.0% 12.0% 12.0% 12.0% 12.0% 12.0%

Actual RIR 0.01% -0.26% -0.12% -1.47% -2.12% 1.48% 3.33%

0.01% -0.26% -0.12%-1.47% -2.12%

1.48%

3.33%

-4.0%

-2.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Target RIR Actual RIR Desired Direction RIR:Target: 12% RIR by Q3 2018


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CVCCC: 18-Month Challenge to Improve the Readmission RIR by 12% by Q3 2018

Q1 2017* Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Q3 2018

Readm/1,000* 36.9 36.4 35.8 35.3 34.7 34.2 33.6

Goal RIR 3.3% 4.8% 6.2% 7.7% 9.1% 10.6% 12.0%

36.9 36.435.8 35.3

34.7 34.233.6

3.3%4.8%

6.2%7.7%

9.1%10.6% 12.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

23.0

25.0

27.0

29.0

31.0

33.0

35.0

37.0

39.0

PER

1,0

00 B

ENEF

ICIA

RIE

S

Readm/1,000* Goal RIR

Desired Direction RIR:Readmit Count/1,000*:

*Readmission rates are based on the actual count of readmissions per 1,000 beneficiaries.**Q1 2017 data is actually Q3 2016 data that is being used as a proxy and projecting forward. The formula for Relative Improvement Rate (RIR) is (Baseline-Current)/Baseline. 12



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What Actions Can You Take Now?

• Convene an interdisciplinary readmission reduction team.

• Perform a gap analysis to identify areas of strengths and opportunity.

• Select an initial improvement project and clearly communicate the goals.

• Leverage partnerships, networks, and relationships.

• What else can you think of?

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Bruce Bethancourt, MD, FACP

CMO DIGNITY HEALTH MEDICAL GROUP

[email protected]



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urgent State of Health Care

Current State of Health Care

Understanding Upcoming Need to Change

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Large investment with low impact on care outcomes

Current State of Health Care

• Financially Unsustainable

• Increasingly Fragmented

• Poorly Coordinated

Organization for Economic Cooperationand Development (OECD)

Health at a Glance 2015

Top third performers.

Middle third performers.

Bottom third performers.

Indicator

Asthma

and COPD

hospital

admission

Diabetes

hospital

admission

Case-

fatality for

AMI

(admission-

based)

Case-

fatality for

ischemic

stroke

(admission-

based)

Cervical

cancer

survival

Breast

cancer

survival

Colorectal

cancer

survival

United States 25 24 5 3 21 2 9

Comparing 34 countries

Source: Health at a Glance 2015.

Table 1.4. Quality of care



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Why Population Health Now ?

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AGING POPULATION

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MEDICARE EFFORTS AT COST CONTAINMENT

• MEDICARE HOSPITAL READMISSION REDUCTION PROGRAM

• AFFORDABLE CARE ACT

• CMS ACO PROGRAMS

• RAC AUDITS

• OBSERVATION vs ADMISSION (TWO MIDNIGHT RULE)

• “VALUE BASED PAYMENT MODIFIER PROGRAM”

• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Merit-Based Incentive Payment System (MIPS)

Alternative Payment Model (APM).

MEDICARE ACCESS & CHIP REAUTHORIZATION ACT

MACRA

(CREATES TWO TRACKS FOR PROVIDERS)

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Merit-Based Incentive Payment System Alternative Payment Model

• Not in Advanced APM• In Advanced APM < 25%

associated With APM

• Shared Savings Program (Tracks 2 and 3)

• Next Generation ACO Model• Comprehensive ESRD Care

(CEC)• Comprehensive Primary Care

Plus (CPC+)• Oncology Care Model (OCM)



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MACRA

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Health Policy Brief: Medicare’s New Physician Payment System,” Health Affairs, April 21, 2016

Individual Physicians Responsibility

Resource Use = Total Cost

Pharmaceuticals

Post Acute Care

Specialist Referrals

Diagnostics

Hospital Readmissions

Ambulatory Sensitive Admissions

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MEDICARE HOSPITAL READMISSIONREDUCTION PROGRAM3% penalty for hospitals with “excess readmissions”

• Acute Myocardial Infarction (AMI)

• Heart Failure

• Pneumonia

• Chronic Obstructive Pulmonary Disease (COPD)

• Total Hip and/or Knee Arthroplasty

www.PresentationPro.com

Acute to Ambulatory Transition Failure Causes

Lack of Sufficient Follow Up

Medication issue

Health Care Literacy

Cognitive Dysfunction in the Elderly

Lack of Functionality

Lack of Family or Community Support



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How to Improve Care Transitions

F/U in 3 to 7 days shown to decrease readmissions

• Exceptions:

• Even with the best communication channels, chronically ill patients with multisystem

disease are oftentimes so vulnerable immediately following hospitalization that they

do not fare well in regular primary care office

• Most traditional primary care offices lack the care management resources needed by

high-risk patients, such as time, self-care education, and connections to community

resources

Transitions of Care Clinic

HospitalistTC sets up 1st F/U visit within 24-72

hours

1st TC visit & PRN X 30 days

Transition to Ambulatory Care

Readmission Index DX:• ≥ 7 Medications• ≥ 1 Readmit Past 12

Months• LOS > Predicted• No Primary Care• Multiple Co-Morbid

Conditions

• TC NP visits patient

in hospital to offer

program

• TC NP discuss case

with CM & SW

• Review chart

• Identify barriers to

care

• Physician calls PCP

to offer service

• Provider reviews

case with NP &

Patient

• Records Reviewed

• Medication

Reconciliation &

Educated by

Pharm D

• Needs Assessment

• Remote Care

Monitoring

• Summary of care

provided

• Medication

Reconciliation

• Phone call to

PCP

• Referral to new

PCP if needed



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Transitional Care System Oversight

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Individual Physicians Responsibility

Resource Use = Total Cost

Pharmaceuticals

Post Acute Care

Specialist Referrals

Diagnostics

Hospital Readmissions


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DHMG COMPENSATION MODEL 2016

•PRODUTIVITY (wRVUs) 80 %

•VALUE BASED 20%

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Patient Satisfaction

Stewardship

Quality Metrics

Access to Care


Readmissions

THANK YOU

"Everybody has accepted by now that change is unavoidable. But that

still implies that change is like death and taxes it should be postponed as

long as possible and no change would be vastly preferable. But in a

period of upheaval, such as the one we are living in, change is the

norm." --Peter F. Drucker

www.PresentationPro.com



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Reducing Adverse Drug Events (ADEs)

Ettie Lande, MS, RN

HSAG

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Readmissions and Medication Safety

• HSAG works with hospitals to reduce ADEs.

• ADEs contribute to readmissions and are the leading cause of preventable patient harm.1

• High priority medication targets for the National Action Plan for Adverse Drug Event Prevention2

(common, preventable, and measurable ADEs) are:

– Anticoagulants

– Diabetic agents

– Opioids

321. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107–16.2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention.Washington, DC: Author.



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ADEs Contribute to Increased Costs and Negatively Impact Patient Care

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ADEs

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$3.5BILLION

Add an additional $3.5 billion in healthcare costs; of this, up to $5.6 million per U.S. hospital.3

Prolong hospital stays by 1.7 to 4.6 days.2

Account for 1/3 of adverse events encountered in hospitals.4

2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention. Washington, DC: Author.3. Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington, DC: The National Academies Press 2006.4. U.S. Department of Health and Human Services Office of Inspector General (OIG). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC. 2010 November. Report No.: OEI-06-09-00090.

National Rates: Emergency Department (ED) Visits for ADEs

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Associated with anticoagulants

17.6% of the visits, with

48.8% of cases resulting in hospitalization.5

Associated with diabetic agents


38.5% resulting in hospitalization.5

Associated with opioids


24.6% resulting in hospitalization.5

5. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi: 10.1001/jama.2016.16201.



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Engaging With Hospitals to Create and Implement ADE Interventions

• Data reveal that many facilities rank above the state average for high-risk readmission rates related to one or more of the three high-risk medication (HRM) classes:

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anticoagulants diabetic agents opioids

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• A hospital’s ADE rate is measured by counting the number of hospital admissions and ED visits related to an ADE from one of the three HRMs.

Arizona Medicare Readmissions Within 7 and 30 Days—2015

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25,176 Readmissions Within 30 Days

9,234 Readmissions Within 7 Days

1,735 7-Day Readmissions

Were on HRMs



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Arizona Medicare Readmissions Within 7 Days—2015

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Of the 9,234 Readmissions Within 7 Days,1,735 (18.7%) Readmissions Were for

Beneficiaries Who Were on HRMs

That is almost 1 out of every 5 readmissions!

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Medicare Fee-For-Service (FFS) Beneficiaries on HRMs in Arizona—2015

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Opioids are the most common drug type used, closely followed by diabetic agents. Fewer beneficiaries use anticoagulants.

Anticoagulants 4.49%

Diabetic Agents 6.02%

Opioids 7.14%Represents beneficiaries with at least 30-days supply of drug type. Patients may be included in more than one drug type category.



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ADE Rates Among Medicare FFS Beneficiaries Discharged on HRMs in Arizona—2015 (ADEs per 1,000 Discharges)

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Anticoagulant ADEs 54.39

Diabetic Agent ADEs 28.46

Opioid ADEs 6.01

Despite lower frequency of use, patients taking anticoagulants have the highest rate of ADEs per 1,000 discharges among Medicare beneficiaries on HRMs, followed by diabetic agents. Opioids have much lower ADE rates based on claims data.

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30-Day Readmissions Among Medicare FFS Beneficiaries on HRMs in Arizona—2015

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30-Day All-Cause Readmission Rate 16.0%

30-Day HRM Readmission Rate

19.4%

• Readmissions among beneficiaries on HRMs are much more frequent than the general population, suggesting ample opportunity for improvement.

• Percent of 30-day readmits with an anticoagulant or diabetes agent ADE are much higher than the percent of readmits with an opioid ADE.



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What Do ADEs Add Up to in Just 20 Minutes?

Remember, I said that ADEs add an additional $3.5 billion in healthcare costs.

• That’s $9.5M per day

• Almost $400K per hour, or $6,659 per minute

• Or, $133,181 healthcare costs added during this 20 minute presentation!

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It’s Not Just a Hospital Problem

• Most of a patient’s care occurs outside of the hospital in the community!

– Provider office and clinics

– Home health agencies—skilled and non-medical

– Nursing homes and long term care centers

– Acute rehab and acute long term care

– Community transitions of care providers

– Community paramedicine

– Hospice and palliative care providers

– Patients and caregivers (and their self-care practices)

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Factors That Contribute to ADEs

• Sub-optimal medication reconciliation

• Failure to confirm patient’s understanding of their medication regimen

• Inappropriate medication use by the patient and inappropriate prescribing

• Failure to monitor patient’s therapeutic lab values, drug treatment outcomes, and patient’s adherence

• Poor multidisciplinary communication and polypharmacy

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What Can You Do to Reduce ADEs?

Evaluate Processes

• Conduct staff competency checks

• Evaluate each step of your medication reconciliation

• Review the discharge process and instructions provided to patients regarding medications

• Assess the post-discharge follow-up calls (did you fill your prescriptions, do you have questions about your medications?)

Conduct Gap Analysis

• Observe staff

• Audit at least 30 charts

• Interview staff performing the task

• Interview patients

• Interview caregivers

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Best Practices to Reduce the Risk of ADEs

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Best Practice Description

Pharmacist-led medication reconciliation and medication therapy review

Compares active medication orders to all of the current medications that the patient has been taking, identifies and addresses medication related problems (i.e., duplication of therapy, unnecessary medications, inappropriate dosing, drug-drug interactions)

Bedside delivery of medications prior to discharge

Prevents delay or interruption in medication therapy following discharge, verifies insurance coverage, manages prior authorizations or drug substitutions (i.e., therapeutic equivalent substitutions based on cost, availability, formulary, insurance)

Pharmacist-led discharge medication counseling

Provides information on proper medication administration, side effects, disease state education

Post-discharge follow up Reinforces the discharge plan, assesses patient retention of information, addresses patient questions and concerns, assesses medication therapy adherence

Medication Therapy Management (MTM)

Improves medication use, enhances health care professionals collaboration, enhances communication between patients and their health care team, encourages patient involvement

Comprehensive medication history

Assists with obtaining high quality, complete, and accurate medication history

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What Best Practices Have you Implemented?



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Anticoagulation Therapy in Acute Rehab: Pharmacist engagement to increase therapy effectiveness and

reduce gaps in care at discharge

Robert Kronenberg, Pharm.D.

Director of Pharmacy

HealthSouth Valley of the Sun Rehabilitation Hospital

[email protected]

HealthSouth Valley of the Sun Rehab Hospital

Acute Rehabilitation Hospital

~ 600 Medicare pts annually

Anticoagulation

A Fib

DVT

Prophylaxis

Treatment



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Warfarin

INR monitoring

Warfarin dosing

Patient education

Share information

Warfarin

H/H: 12/28/2016 9.3/27.5

INR Goal: 2-3

Ordering Physician: Dr. __________

Reason: A Fib Patient transferred with order for 4.5 mg and bridging w/Lovenox until INR > 2. Spoke with acute care pharmacist - pt fairly stable on 5 mg dose until treated with metronidazole. Since metronidazole completed they have been cautiously increasing the dose to return patient to therapeutic range. After 6 mg dose last night, INR 1.8 today

Plan: Give 6 mg dose tonight, monitor INR daily

Date Dec 29 Dec 30 Dec 31 Jan 1 Jan 2 Jan 3 Jan 4

INR --------- 1.7 1.8

Dose (mg) 4.5 6 6



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Parenteral

Enoxaparin (Lovenox®)

Fondaparinux (Arixtra®)

Heparin

Novel Oral Anticoagulants

Free 1st month (manufracturer)/Coupons

Rivaroxaban (Xarelto®)

Apixaban (Eliquis®)

Dabigatran (Pradaxa®)

Insurance coverage



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Bedside Delivery

Improve discharge safety

Improve patient satisfaction

Provide opportunity to communicate effectively

Concentrate on high-risk

Incorporate into admission reconciliation

Bedside Delivery



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QUESTIONS???

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CVCCC /WVCCC Monthly Community News

What is happening in the community between our quarterly meetings?

• Sharing

– Trainings

– Webinars

– Toolkits

– Program updates

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Obtain the Best Medication History Possible

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• Available at hsag.com

• View online or download

• No charge

• Community driven

• Reduce medication errors and adverse drug events

• Evidence-based and Innovative

• Reduce variability and Increase reliability

• Integrate into training

• Checklists and resources

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The Medication History Toolkit is Online

Two ways to get to the Medication History Toolkit online:

• 1. Medication History Toolkit shortcut: http://www.hsag.com/medication-history-toolkit

• 2. Follow clicks to www.hsag.com > For Medicare Providers > Arizona > No Place Like Home/Care Coordination > No Place Like Home Tools & Resources (right-hand nav) > Medication Management

Choose from the download in the top descriptor, or scroll down and choose “View Resource”

To learn more, contact Ettie Lande at [email protected]

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http://www.hsag.com/medication-history-toolkit

http://www.hsag.com/



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Using Teach-Back Takes Training and Practice

• Research shows that patients remember and understand only half of what clinicians explain to them.

• Teach-back is a way to confirm that you have explained to the patient what they need to know in a manner that the patient understands.

• HSAG staff members can provide no charge on-site training for your staff.

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Teach-Back Training

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Want to share this training with your staff? Schedule a training now! Contact Jenna Burke at:

[email protected] or 602.801.6652



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Finding Resources Can Be Overwhelming

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• Providers unaware of existing community resources

• Patients who struggle with socio-economic challenges often readmit when these needs remain unmet

• A community workgroup developed the—

“Community Resource Guide of Guides”

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Community Resource Guide Training

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Want to share this training with your staff? Schedule a training now! Contact Jenna Burke at:

[email protected] or 602.801.6652



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Behavioral Health Webinar Series

Past sessions are recorded and available at:

hsag.com/events

Go to the calendar date to find the recorded link

Session 1: Behavioral Health BasicsFriday, January 13, 2017

Session 2: Understanding Common DisordersFriday, March 3, 2017

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Behavioral Health Webinar Series

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SESSION 3: De-escalation Techniques Friday, May 5, 2017 • 9–10 a.m.SESSION 4: Community and Behavioral Health Resources Friday, July 14, 2017 • 9–10 a.m.SESSION 5: Voluntary vs. Involuntary TreatmentFriday, September 8, 2017 • 9–10 a.m.SESSION 6: Medication and Medical Issues

Friday, November 3, 2017 • 9–10 a.m.

Save the Dates

For more information, Contact Dennette Janus at [email protected]



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Quick Recap of Other HSAG Initiatives

• Arizona Nursing Home Quality Care Collaborative Learning Sessions

– May 2: Camp Verde

• Outpatient Antibiotic Stewardship Initiative

– Get no-cost assistance implementing the Centers for Disease Control and Prevention (CDC) Core Elements

– https://www.youtube.com/watch?v=dkhu2gOY_gI

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For more information, Contact Keith Chartier at [email protected]

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CVCCC / WVCCC Quarterly Community2017 Meeting Schedule

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Meeting Date and Time Where Registration Required

ThursdayMarch 9, 2017

8:30-11:45 a.m.

Health Services Advisory Group3133 East Camelback Road

Phoenix, AZ 85016

ThursdayJune 13, 2017

8:30–11:45 a.m.

Mayo Clinic Hospital Waugh Auditorium

5777 East Mayo Blvd.Phoenix, AZ 85054

http://www.cvent.com/d/cvqthx

ThursdaySeptember 26, 2017

8:30–11:45 a.m.Location to be Determined http://www.cvent.com/d/pvqh7g

TuesdayNovember 7, 2017

8:30–11:45 a.m.

Mayo Clinic Hospital Waugh Auditorium

5777 East Mayo Blvd.Phoenix, AZ 85054

Registration Coming Soon!

https://www.youtube.com/watch?v=dkhu2gOY_gI

http://www.cvent.com/d/cvqthx

http://www.cvent.com/d/pvqh7g



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Your Meeting Evaluation Feedback Is Needed

• Target: At least 85% of you will complete a meeting evaluation form.

• Please complete the evaluation before you leave today. (Fold in half and leave on the table).

• Your feedback is very important and highly valued.

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Thank you!Ettie Lande, MS, [email protected]



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This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS),

an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-11SOW-C.3-03012017-01

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