josh bennett, md mba the re-admissions problem- “tales from the road” october 17, 2014

Josh Bennett, MD MBA

The Re-Admissions Problem- “Tales from the Road”

October 17, 2014

2 PROPRIETARY & CONFIDENTIAL – © 2014 PREMIER, INC.

1. Introduction

2. The Problem1. 30 Day readmissions are financial issue for hospitals

2. Source of increased mortality/morbidity in those patients

3. Multifactorial causes of readmissions

3. Some Solutions1. PCP oriented

2. Hospital oriented

3. Community oriented

4. Next Steps

Agenda for Today


Premier Believes in “Lean” Travel


Even if you're on the right track, you'll get run over if you just sit there. - Will Rogers


The goal of the CIN is to establish mechanisms to monitor and control utilization of health care services that are designed to control costs and assure quality of care…the Triple Aim TM.

Success = improving Triple Aim™ population outcomes


Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program

• Requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012

• Defined readmission as an admission to a subsection(d) hospital within 30 days of a discharge from the same or another subsection(d) hospital

• Adopted readmission measures for the applicable conditions of Acute Myocardial Infarction (AMI), Heart Failure (HF) and Pneumonia (PN)

• Established a policy of using the risk adjustment methodology endorsed by the National Quality Forum (NQF) for the readmissions measures for AMI, HF and PN to calculate the excess readmission ratios, which includes adjustment for factors that are clinically relevant including patient demographic characteristics, comorbidities, and patient frailty.

• Established an applicable period of three years of discharge data and the use of a minimum of 25 cases to calculate a hospital’s excess readmission ratio of each applicable condition.

Background


Background

One in eight Medicare patients were readmitted to the hospital within 30 days of being released after surgery in 2010, while one in six patients returned to the hospital within a month of leaving the hospital after receiving medical care. Patients were not significantly less likely to be readmitted in 2010 than in 2008.

http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/02/interactive-map-the-revolving-door-syndrome.html

2 million Medicare patients return within a month each year• Costs Medicare $26 Billion• $17 Billion comes from potentially avoidable readmissions

2610 Hospitals were fined this year, totaling $428 million





0.75%0.1% 0.1%

1.0% 0.7%

TOTAL IMPACT

Value-Based Purchasing

30-day Readmissions Caps

Hospital-acquired conditionsMarket basket reductions

Multifactor Productivity Adjustment*Documentation and Coding Adjustment (DCA)**Sequestration ***

OCT2014

OCT2011

OCT2018

OCT2019

OCT2020

OCT2017

OCT2013

OCT2016

OCT2015

OCT2012

1.0% 1.25% 1.5% 1.75% 2.0%

3.0%

1.0%

0.3%

0.5% 0.4% 0.4%

1.9%4.9%

2.0%

5.7% 9.7% 10%6.0%

*The Multifactor Productivity Adjustment is an estimate generated by the CMS Office of the Actuary **DCA, also known as the behavioral offset. Estimates FY 2015-FY 2017 impact of the American Taxpayer Relief Act of 2012*** Sequestration (across the board cuts to reduce the federal budget deficit) will stay in place unless otherwise reversed by Congress

0.2%

7.1% 12.8% 9.5%10.7% 9.2% 8.5%8.7%

1.0% 2.0%

FFS Payment at risk or being cut

0.3%

0.8% 1.6% 3.6%2.4%

0.7% 0.7% 0.5%

Other Adjustments 0.2%

0.2%

0.4%


Projected Growth in Chronic Diseases

State of Healthcare 2010Source: USA Today

49.2

36.830.3

19.113.7 10.6

2.4

64.5

51.246.7

26.921.0

17.2

3.1

0

10

20

30

40

50

60

70

Pulmonary Conditions

Hypertension Mental Disorders

Heart Disease Diabetes Cancers Stroke

2003 Cases (Millions) 2023 Projected Total Cases (Millions)


How do we as care givers decrease the number of unplanned readmissions to our hospitals?•Financial problem•Social problem•Clinical problem•Multifactorial problem

The Problem faced by every Health System

Some Solutions to Consider


“Opportunity is missed by most people because it is dressed in overalls and looks like work.”

Thomas Edison

This is not going to be easy…..

Solutions- Primary Care Provider Based


Patient Centered Medical Homes (PCMH’s) are becoming more prevalent nation-wide

Over 7000 practices have become recognized as a PCMH by NCQA

Some experts advocate that PCMH’s become the focus of care coordination for a health system’s population of patients

Included in this concept is using Care Managers/Coordinators embedded in the PCMH’s in an Accountable Care Organization (ACO)

Solutions- Primary Care Provider Based


A coordinated system of clinical care ensuring that the patient doesn’t get “lost” in the health care system

Care Managers, usually RN’s, coordinate the care for the “super utilizers”/high risk patients•Can be based in the PCP offices•Can be centralized

An entire structure needs to be created around this concept in the ACO setting

The following slides describe the concepts…..

Care Management


Population-Based Care Management Framework

Case Management

Disease Management

Prevention

Well & Low Risk Members

(Prevention)

Low Risk Members (Prevention and

Disease Management)

Moderate Risk Members (Disease

Management)

High Risk, Chronic, Multiple Disease

States (Episodic Case Management-

Inpatient Clinical Guidelines)

Complex Catastrophic Care

(Inpatient - LTC)

End of Life

Increasing Health Risk

Decreasing Health Risk

1 2 3 4 5

Source: Paul H. Keckley, Executive Director, Deloitte Center for Health Solutions, Washington DCPhD, 2007 National Predictive Modeling Summit: The Landscape for Predictive Models


Care Management Target Populations

Complex Individual Case Management (40% of cost)

Complex Disease Management –

Embedded/Primary Care

Disease Management – Virtual/Telephonic

Wellness/Prevention

2-3% of Population

5-7% of Population

20-25% of Population

100% of Population


CM is a systematic approach to handling care of a defined population.

Complex Care Management is a subset of CM, focused upon community based, coordinated interventions and management of a medically vulnerable group, through technology, data and evidence-based processes.

Chronic care/disease management is another subset of CM, focused upon community-based health care interventions and communications for populations with ongoing specific conditions. As patient self-care efforts are significant, conditions should be stratified according to disease severity and patient need.

Defining Care Management (CM)

Assessment

Tailoring

Planning

Delivery

Measurement

Evaluation

Activities Outcomes

Enhance Patient/Family Engagement

Ensure Continuity/Quality of Care

Eliminate Duplication

Promote Efficiency

Increase Patient/Family Satisfaction


This approach includes a combination of population health management assessment, high risk population management, chronic care/disease management and care transitions/post-acute care optimization strategies.

Managing the health of a population must take place and be integrated across the care continuum

Acute Care

PCMH

Post Acute/Outpt.

Chronic Care/ Disease Mgmt.

Transitions between providers/home

Transitions between sites of care/ home

Care Coordination within the site

Wellness/Risk Reduction

Complex Care Management

Transitions between sites of care /home

Care Coordination within the site

Supported by Information Systems, Evidence-Based Care & Analytics/Reporting


Legend

Comprehensive Care Management (CCM) process

High Risk population

Agencies/ Community Resources

Patient graduated from CM

Care Management Team PCPs/Specialists/

Providers/Care Managers/CM Assistant/Pharmacist/

Social Worker/Mental Health//Support Staff

Predictive analysis of population/

PCP identification high risk

Transition to PCP practice thru

collaboration by CM

Patient contact by PCP Follow through

by CMHigh risk assessment

Personal visit vs. phone

Patient and family

engagement

Initiate custom care plan (best practice), resource allocation

frequency & intensity of phone contact

Mobilization of community

resources and support staff

Decrease in risk transition to lower

stratification, reassessment of

plan

Evaluation of patient status and plan

modification

Modification of plan, frequency and

intensity of contact and resource

allocation

Disease Management Program

Medical clinic(s), behavioral health,

diabetes, wellness, smoking, medication management, social

resources

Preferred network of referral providers to be

established

CCM Process

Patient centric points of care

Secondary Source of Care


Coordinated CareCommunity Organizations (of Oregon Medicaid) reported this year that hospitalizations for:

• Congestive Heart Failure were down 32%• COPD were down 36%• Adult asthma was down 18%

All-cause readmissions dropped 1% from 12.3% to 11.3% but represented an 8% reduction in the readmission rate

These organizations used care management as one of the tools to decrease these admissions

How does Care Management help Re-admissions?

Solutions- Hospital Based


Discharge Planning and Instruction

Communication with the patient’s PCP office/Care Manager

Follow up appointments post hospitalization

Pharmacist involved in discharge medication reconciliation/understanding

Hospital Based Solutions


1. Discharge summary completed within 48 hours of discharge

2. Send completed discharge summary to post care provider/PCP within 48 hours of discharge

3. Follow up appt scheduled within 5 days post discharge with PCP and/or specialist

4. Discharge phone call by clinician within 48 hours

5. Involve pharmacy in medication reconciliation before discharge

6. Use Teach Back (or health literacy tool) to give discharge instructions

Discharge Planning


What’s driving readmissions

→ Poor preparation for discharge

→ Patients' low health literacy and comprehension

→ Failure or inability of patients to see physicians for follow-up after discharge

→ Lack of communication between inpatient and outpatient providers

→ Lack of hospital follow-up

“78% of patients discharged from the ER did not understand their diagnosis, their ER treatment, home care instructions, or warning signs of when to return to the hospital.” Source: The Annals of Emergency Medicine (June, 2000)


Automating post discharge follow-up

Automation for 100% of discharged patients

Engage Patients

Identify Care Gaps

Stratify Risks

Alert Care Team

Reduce Readmissions

Improve Satisfaction

Automated & Ongoing:

Data Integration

Analysis

Reporting

Communications


How it Works

Patients contacted within 24-72 hours of discharge

Patient Discharged

Patient receives a call to identify

risk factors

Alerts are routed back to the nurse or case manager


Example of Output of Phone Call Results


Seems to be reasonable that sending patients home without adequate instructions MAY be reason for the readmission

Many hospitals use nurses primarily to do the medication D/C counseling, with the thought that the community pharmacist will also counsel on any new medications

Evidence in the literature that many patients are not clear about all their medications when home.

Handwritten discharge medications lists may be hard to read and written in abbreviations, not layman's terms.

EHR printed discharge instructions may also be confusing

Hospital now adding pharmacists to the team to counsel high risk patients on discharge.

Medications and the relationship to readmission


Physicians• Medication reconciliation is “busy work”, “ I just check off boxes.” • On-Line medication lists are often inaccurate.

Nurses• If a patient goes to a private physician, then the medications will

not be in the system.• Medication Reconciliation is really the physician responsibility, but

the paperwork is important.

Pharmacists• Most likely to look at the “Value” of the process in determining

what the patient is actually taking, not just what is on the list.• More likely to question the Electronic medication list

• Medication reconciliation: A qualitative analysis of clinicians' perceptions, Research in Social and Administrative Pharmac published online 22 October 2012.

Perceptions of clinicians


Nester TM, LaDonna SH (Am J Health-Syst Pharm. 2002;59:2221-5)

Reeder TA., Mutnick A. (Am J Health-Syst Pharm. 2008; 65:857-60)

Medication ReconciliationPharmacists vs. Other Professionals

Variable RN(n=50)

RPh(n=50)

p Value

Patients receiving at least one clinical intervention (%)

16 34 <0.001

Patients identified as taking at least one herbal preparation (%) 6 22 <0.001Patients identified as taking at least one nonprescription medication (%) 68 98 <0.001Patients identified taking at least one herbal or nonprescription medication (%) 70 98 <0.001Patients whose medication histories were clarified with their community pharmacies (%) 4 24 <0.001Mean ± S.D. time between admission and entry of allergy information (min) 156 ± 123 68 ± 30 <0.005

• Pharmacists vs. Nurses

• Pharmacists vs. Physicians

Variable RPh MD p Value

Medications identified 614 556 <0.001

Documented doses and dosing schedules 614/614 446/404 <0.001

Identified discrepancies 353 295


Pharmacist and trained pharmacy technician's have shown to provide a “more comprehensive” medication history

• Emphasis on what the patient is actually taking prior to admission

Provide enough time for the assigned staff member to do an accurate history

• ( average 20-25 minutes per patient from literature sources)

For Electronic Medication History do not allow “reviewed all” as an option

• Too easy to use that option without speaking to the patient.

Consider adding medication to the inpatient formulary to help the MD’s with both admission and discharge reconciliation

Medication Reconciliation Pearls


Impacting Readmission Rates & Patient Satisfaction: Results of a Discharge Pharmacist Pilot Program (Wilkinson et al)

Objective• Assess the impact of pharmacist participation as a part of the

BOOST program (Better Outcomes for Older adults through Safe Transitions) on the discharge process by evaluating patient readmission rates, pharmacist interventions, & patient satisfaction.

Primary endpoint: 30-day readmission rate

Secondary endpoints:• Number and type of interventions, cost avoidance, and patient

satisfaction

Method: prospective, cohort, nonrandomized trial• Patient Selection: >18yo, >10 maintenance meds or therapy with

high risk meds.• Pharmacists participated in patient discharge including one-on-

one counseling, medication reconciliation, and overall provide support during the discharge process.

Wilkinson TW, Pal A, Aroop P, Couldry RJ. Hosp Pharm 2011;46(11):876–883.


Impacting Readmission Rates & Patient Satisfaction: Results of a Discharge Pharmacist Pilot Program (Wilkinson et al)

Results:Outcome Measure Study (156) Control (81) p Value

Readmissions 36/229 (15.7%) 95/440 (21.6%) 0.04

Cost Avoidance $378,889

Interventions 313

• Average time per counseling session = 36.9 minutes

Conclusion: Pharmacist support in the discharge process facilitated increased communication on the multidisciplinary team and resulted in a lower unplanned readmission rate.

Satisfaction: 98% indicated that review of meds was helpful“Very Satisfied” (4.9)“More likely to return”


Four Critical Success Factors in Medication Reconcilliation

Kaboli and Fernandes summarize the four factors that they believe are critical success elements:

1. Preadmission medication lists are critical

2. Best-possible medication history requires a skilled interviewer.

3. Transitions of care are vulnerable moments for medication discrepancies to occur and propagate. Identifying these time points focuses effort.

4. Targeted interventions are probably the most cost-effective. Triaging high-risk patients to interventions is essential. However, such targeting needs to be balanced with the expectation for safe practices that can apply to all patients in any high reliability organization.

Mueller SK., et al. Hospital-based medication reconciliation practices. doi:10.1001/archinternmed.2012.2246. E1-13Kaboli P., Fernandes O. Medication reconciliation: Moving forward. doi:10.1001/archinternmed.2012.2246. E13-4.

Solutions- Community Based


PARTNERS

Hennepin County Human Services and Public Health Department

Hennepin County Medical Center

Metropolitan Health Plan

Northpoint Health and Wellness Center

PROGRAM OVERVIEW & OBJECTIVES

A county-based ACO that integrates medical, behavioral, and social services

Targets single, nondisabled adults, ages 21-64 with incomes at or below 75% of the FPL ($8,124/year) who qualify for Medicaid

Offers proactive, comprehensive, and integrated care

Case study: Partnering with a county public health department

Hennepin Health

Source: Agency for Healthcare Research and Quality. http://www.innovations.ahrq.gov/content.aspx?id=3835

http://www.innovations.ahrq.gov/content.aspx?id=3835



POPULATION SERVED

68% are of minority status

45% have some level of chemical dependency

42% have mental health needs

32% have an unstable housing situation

30% have more than one chronic disease

30% need chronic pain management

STRATEGIES

Patient-centered care approach based on the medical home model provides an integrated system of comprehensive care that includes primary care, outpatient services, behavioral health and substance abuse services, dental care, as well as public health and social services

Assigned care coordinators ensure that enrollees receive appropriate services based on their needs

Partners share data electronically to ensure all members of the care team have a complete view of patients’ needs

Partners jointly implement initiatives to improve care and promote appropriate utilization

Hennepin Health (continued)





EARLY RESULTS

Increase in primary care utilization – 5%

Decrease in ED visits – 39%

Decrease in admissions – 29%

Decrease in readmissions – 2%

Lower costs for high utilizers – 40%-95%

High enrollee satisfaction – 88%

Increase in housing stability – 10 members/month placed

Increasing enrollment – 4,884 enrollees to over 6,400

Hennepin Health (continued)





Research new and innovative methods that may work in your own market/health system

Get a champion

Keep using Continuous Quality Improvement to refine the solution

Use patients for input

Get physicians involved

Next Steps


You've got to be very careful if you don't know where you are going, because you might not get there.

-Yogi Berra

josh bennett, md mba the re-admissions problem- “tales from the road” october 17, 2014

Documents

excess readmissions

readmissions measures

medicare patients

day readmissions capshospital

coding adjustment dca

excess readmission ratios

defined readmission

risk adjustment methodology