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22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 www.mpro.org
Save Your Census:Strategies to Prevent
Re-hospitalization
March 30, 2010Joint Provider/Surveyor Training
9SOW-MI-7.2-09-60
Background:Hospitalization of Nursing Home Residents are:
• Common
• Often disruptive for the resident and family
• Fraught with many complications
• Costly
• Sometimes an inappropriate and avoidable use of the Emergency Room
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SNF Admissions/Readmissions:
• 40% of Medicare beneficiaries are discharged to a post acute setting. (SNF, Home Care, Hospice)
• 50% of these enter a nursing home for rehabilitation or long term care
• The rate of SNF 30 day rehospitalizations grew 29% between 2000 and 2006 from 18.2% to 23.5%
• The total cost for these re-admissions: $4.34 Billion
Source: The Revolving Door of Rehospitalization From Skilled Nursing Facilities, 1.2010 /29:1 Health affairs
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Michigan Data for 2006:
• 65,477 skilled nursing home episodes
• 25.8% were re-hospitalized within 30 days of the initial hospitalization
• Total re-hospitalization payments:$175.35 Million
Source: The Revolving Door of Rehospitalization From Skilled Nursing Facilities, 1.2010/ 29:1 Health affairs
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Top 5 Re-admissions from SNF:
• Heart Failure
• Respiratory Infection
• Urinary Tract Infection
• Sepsis
• Electrolyte Imbalance
Source: Medicare Payment Advisory Commission, Washington D.C., 2006
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These Re-admissions:
• Are potentially avoidable
• Account for 78% of all thirty-day SNF Re-hospitalizations
• Cost Medicare $3.39 Billion in 2006
Source: Medicare Payment Advisory Commission, Washington D.C., 2006
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Other Costs of Re-hospitalizations:
• Negative outcomes associated with medical errors
• Stress for patients and caregivers
• Duplication of tests or procedures
• Functional decline of patients
• Loss of SNF revenue due to empty beds
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Why do Re-hospitalizations Occur?
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• Transfer of information to the next care setting is often incomplete
• Receiving practitioners often do not know the patient and his or her preferences for care
• Practitioners have no accountability once a patient leaves their care
• Patients and caregivers have few tools to navigate all the settings
The Care Transitions Project:
• Three year Initiative ending July 31, 2011
• Focused in the Greater Lansing Area
• Goals of project: ■ Reduce hospital readmissions of Medicare
Beneficiaries■ Improve collaboration across care settings
►Acute care, LTAC, SNF, HHC/Hospice/ Physicians
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Skilled Nursing Facilities’ Role:
• Used INTERACT Toolkit to identify drivers of readmissions
• Implemented evidence-based interventions from INTERACT Toolkit to decrease the likelihood of readmissions
• Implemented Care Transition Coaching
• Joined Cross Setting Work group to reduce heart failure re-admissions
• Send PCP a discharge summary prior to rehab patient discharges
• Increased utilization of home care upon discharge
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Burcham Hills Improvement Journey:
• Improving communication through patient-centered care■ Welcoming program■ 3 day care conferences■ Inclusion of patient and family in discharge planning
• Improving communication across the continuum■ Adding a new staff position:
► Improved communication between residential community, hospital, and healthcare center
►Risk assessments
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Ingham County Medical Care Facility's Improvement Journey:
• Admission Assessments
• RN Gate keeper
• Staff Education
• Monitoring Results
• Cross Setting Collaboration through the heart failure workgroup
• Care transitions coaching
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How Does a SNF get started?
• Obtain data:■ Monthly hospital readmission numbers■ Monthly emergency department visits
• Determine potential drivers of readmissions■ Use INTERACT “Review of Acute Care Transfers” audit
tool
• Initiate or Join a cross-setting Collaborative to improve communication across settings.
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Use Interact Tools for:
• Reducing avoidable acute care transfers
• Early identification of a change in resident status
• To guide nursing home staff through a comprehensive resident assessment when a change is noted
• Improve documentation
• Enhance Communication
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Find the INTERACT II toolkit at:
•http://interact.geriu.org
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MPRO’s Care Transitions Team:
Donna Beebe, Project Manager
dbeebe@mpro.org or 248-465-7354
Sandra Soronen, Project Coordinator
ssoronen@mpro.org or 248-465-7347
Barbara J. Smith, Project Manager
bsmith@mpro.org or 248-465-1310
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22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 www.mpro.org
MPRO’s Mission:Improving quality, safety and efficiency
across the healthcare continuum.
This material was prepared by MPRO, the Medicare Quality Improvement Organization for Michigan, 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.
9SOW-9MI-7.2-10-83
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