CMS National Conference on Care Transitions

December 3, 2010

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How Project RED and the Care Transitions Project

Reduced Readmissions in South Texas

Robin Jones, RNQuality Care Coordinator

Valley Baptist Medical Center-Brownsville

Jennifer Markley, RN, BSNSenior Director, Medicare Quality

ImprovementTMF Health Quality Institute

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CMS Care Transitions Project• Project began in August of 2008 • Data analysis was based on 2007

Medicare claims data • 14 communities in the U.S • Reduce hospital readmissions

through improved quality of patient transitions

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CMS Care Transitions Project• Goal is minimum 2% reduction

30-day rehospitalization rate by 28th month of the project (November 2010)

• A comprehensive community-wide, cross-setting effort

• Yield sustainable and replicable strategies

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CMS Care Transitions Project

This map shows the 14 states where Care Transitions projects are located.

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Baseline MeasurementsTABLE 1: Hospital Disposition After Inpatient

Hospitalization Quarter 1, 2008 based on Medicare Claims Data

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Region and Provider Setting

Number of Discharges

Percentage of All Discharges

Discharges with a 30-day Readmit

Percent of Discharges with a 30-day Readmit

Home Health Agency (HHA) 1,109 22.6% 173 15.6%

Home 2,736 55.7% 648 23.7%

Inpatient Rehabilitation Facility (IRF) 281 5.7% 45 16.0%

Long-Term Acute Care (LTAC) 180 3.7% 29 16.1%

Skilled Nursing Facility (SNF) 604 12.3% 189 31.3%

All 4,910 100.0% 1,084 22.1%

VBMC-B Home Health Agency (HHA) 162 22.7% 22 13.6%

Home 387 54.3% 104 26.9%

Inpatient Rehabilitation Facility (IRF) 44 6.2% 4 9.1%

Long-Term Acute Care (LTAC) 41 5.8% 10 24.4%

Skilled Nursing Facility (SNF) 79 11.1% 26 32.9%

All 713 100.0% 166 23.3%

Harlingen Region

Valley Baptist Medical Center-Brownsville

• A faith based 280 bed licensed, not-for-profit acute care hospital, including a 37 bed off-campus Psych facility

• Level 3 designated trauma center• JC accredited for hospital & lab and

stroke-certified• Located on the southernmost tip of

Texas, on the border with Mexico

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Baseline Measurements –VBMC-B

• CT Project hospital baseline rate of 23.3% all cause 30-day readmission rate (Q1 2008)

• 28.1% Hospital Compare heart failure readmission rate–Data for discharges between July 01,

2006 and June 30, 2009– (http://www.hospitalcompare.hhs.gov)

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Solutions• Implementation of Project RED

−Initial focus on HF patients, Telemetry Unit

−May 2010, expanded to all diagnoses, Telemetry Unit

• Community-wide partnership with downstream providers−Use of EHR to improve hand-off

communication−Active involvement in Regional

Workgroup meetings9

Solutions• Education of medical staff including

physicians–Medication reconciliation–Health literacy and patient safety–Chronic kidney disease

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Implementation• All components of Project RED were

implemented and monitored in facility’s 30 bed Telemetry floor−Team approach to administering all

eleven components−Nursing, Care Management,

Pharmacy and Core Measures Team all contributed to process

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Teamwork• Nursing & Care Management– Educate the patient about his or her

diagnosis throughout the hospital stay –Discuss with the patient any tests or

studies that have been completed in the hospital and discuss who will be responsible for following up on the results

–Review the appropriate steps for what to do if a problem arises

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Teamwork• Nursing– Provide follow-up telephone

reinforcement–Assess degree of understanding

(teach-back)– Provide patient with a written

discharge plan–Make appointments for clinician

follow-up and post-discharge testing

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Teamwork• Care Management–Organize the post-discharge services– Expedite transmission of the

Discharge Resume to the physicians and other services accepting responsibility for the patient’s care after discharge

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Teamwork

• Nursing, Pharmacy & Care Management–Confirm the Medication Plan

• Nursing/Core Measures–Reconcile discharge plan with

national guidelines

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Monitoring for Effectiveness• Patients were asked a total of nine brief yes or no questions

about their perceptions. Surveys were available in English and Spanish.

– I was taught about my diagnosis during my hospital stay.

– I have follow-up appointments with my physicians.

– I have been told about test results or studies that have not been completed before I go home.

– If I need home health care, medical equipment or other help or services after I go home, it has been arranged.

– I understand what to do and who to call if a problem arises after I am home.

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Monitoring for Effectiveness• Survey Questions continued:

– I have received a written discharge plan that is easy to read and understand.

– I have received a written discharge plan that has the information I need to take care of myself at home.

– I have a written list of my discharge medications and know which medications are new or changed.

– When the nurses were teaching me, they asked me to explain what I had learned in my own words.

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Administering Patient Surveys

• Case Management (CM) runner sends out daily Length of Stay (LOS) report to identify patients going home with no services to Case Managers, Tele Supervisor/Charge Nurse, and Quality Assurance

• Floor staff is responsible for completing all components of RED prior to discharge

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Administering Patient Surveys

• CM runner delivers and retrieves patient survey and forwards completed surveys to Quality

• CM updates the LOS report daily to reflect D/C plan and submit to CM runner and Quality

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Patient Survey ResultsData Averages based on 273 completed surveys

between January and September 2010• 93% of patients surveyed said that they had received education

about their diagnoses

• 94% of patients surveyed said that they had a follow-up appointment. 88% had a follow-up appointment scheduled within one week post-discharge

• 99% of patients surveyed said that their written discharge plan had the information needed for self care and that it was easy to read and understand

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CT Project ResultsTABLE 2: Hospital Disposition After Inpatient

Hospitalization Quarter 1, 2010 based on Medicare Claims Data

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CT Project Results for Harlingen HRR

FIGURE 1: Percent of Discharges with a 30-day Readmission for HHRR• Hospital Disposition After Inpatient Hospitalization

• Baseline compared to Quarter 1, 2010 based on Medicare Claims Data

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CT Project Results for VBMC-B

FIGURE 2: Percent of Discharges with a 30-day Readmission for VBMC-B

• Hospital Disposition After Inpatient Hospitalization • Baseline compared to Quarter 1, 2010 based on Medicare Claims Data

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CT Project Outcome Measures for VBMC-B

FIGURE 3: Percent of Hospital Readmission Within 30 Days

• Semi-annual rate ending in Quarter 1 2010 • A 3.6% decrease in all cause 30-day readmissions

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CT Project Outcome Measures for VBMC-B

FIGURE 4: O-1a: HCAHPS Medication Management• 4-quarter rolling rate ending in the listed quarter

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CT Project Outcome Measures for VBMC-B

FIGURE 5: O-1b: HCAHPS Discharge Planning• 4-quarter rolling rate ending in the listed quarter

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CT Project Outcome Measures for VBMC-B

FIGURE 6: O-2: Percent of Patients Seen by a Physician Between DC and Readmission

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For more information about Project RED, contact

• For more information about Project RED research:https://www.bu.edu/fammed/projectred/index.html  • For additional information about dissemination:http://www.engineeredcare.com  • For commercial inquiries:info@engineeredcare.com

For more information, contact:Jennifer Markley, RN, BSN,

Senior Director, Medicare Quality Improvement

TMF Health Quality Institute

Phone: 512-334-1663

E-mail: jmarkley@txqio.sdps.org

Care Transitions Web Site: http://CareTransitions.tmf.org

This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, 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-TX-CT-10-67

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