Track II 030612 AmyBoutwell Care Transitions · Six practical strategies ... OMB readmission...
Transcript of Track II 030612 AmyBoutwell Care Transitions · Six practical strategies ... OMB readmission...
3/19/2012
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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
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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?
©Collaborative Healthcare Strategies
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
©Collaborative Healthcare Strategies
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National Momentum
* 10 states with CMS Hospital Discharge Planning Model grant
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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
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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
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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
©Collaborative Healthcare Strategies
STAAR Cross Continuum Team OrganizationsHome Health Agencies, Office Practices, Nursing Homes, SNFs, etc
N>250
©Collaborative Healthcare Strategies
Multi‐Payer Medical Home Initiative
N=46
©Collaborative Healthcare Strategies
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INTERACT Nursing Homes/SNFs(INTErventions to Reduce Acute Care Transfers)
N>200
©Collaborative Healthcare Strategies
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
©Collaborative Healthcare Strategies
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Massachusetts Care Transitions Programs
N>300
©Collaborative Healthcare Strategies
• 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
Boutwell et al. An Early Look at a Four‐State Effort to Reduce Hospital Readmissions. Health Affairs. July 2011.
• 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?
Boutwell et al. An Early Look at a Four‐State Effort to Reduce Hospital Readmissions. Health Affairs. July 2011.
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