provider implementation of pp rs 3m

3M Health Information Systems, Inc.

© 3M 2007. All rights reserved.

Provider Implementation of PPRs --

Florida Public Reporting of PPRs

Keith Mitchell PhD and Caroline Piselli, RN, MBA; 3M Health Information Systems

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Agenda

Pay for Performance and Potentially Preventable Readmissions (PPRs)

Florida Provider Proactive Approach to PPR Public Reporting

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Pay for Performance

Providers Payers

P4P

Consumers

QUALITYPAYMENT

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Readmissions beyond Florida

…situations in which patients return to the hospital within days or months of their initial hospitalization

Cause may be related to a patient’s treatment during the first hospitalization, or it may be the result of a secondary condition, suggesting possible quality problems in the hospital care receive during the initial visit or problematic transitions between hospital and the outpatient care setting

(Quality Matters: Hospital Readmissions: March/April 2008)

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Readmissions in the News beyond Florida

17.6% of Medicare patients were readmitted to the hospital within 30 days of discharge, accounting for $15 Billion in spending in 2005

(MedPac Report to Congress, Promoting Greater Efficiency in Medicare, June 2007)

Study of patients admitted to hospital with preventable admissions: 19.4% = at least 1 preventable readmission within 6 months

(Agency for Healthcare Research and Quality Study: B Friedman and J Basu (2004) The Rate and Cost of Hospital Readmissions for Preventable Conditions, Medical Care Research and Review 61, 225-240)

Commercial Population Example PacifiCare Health Systems Inc review in 2005-2006 Readmission rates at hospitals ranged from 0-44% (avg. 10%)(Quality Matters: Hospital Readmissions: March/April 2008)

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Potentially Preventable Hospital Readmission Rates (MedPAC 2007)

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Florida: 1st PPR Public Reporting!

Opportunity for collaborations/ partnerships to:Understand the data/ reports and impact

Determine potential reasons for PPRs

Drill down to root cause analyses

Create innovative approaches to improve outcomes together

Provide ‘lessons learned’ for the other 49 States…

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So, What Should Florida Hospitals Do Now?

Reports will be public soon…

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State Adoption Process/ Opportunity

Tracking/ReportingAwareness Education

Impact/ Gap Analysis

Implementation/Improvement

Speed and Momentum Vary with:

Public Reporting

Payment

Today

Soon1. Replicate Reports2. Understand

where you stand and potential opportunities.

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Recommended Provider Proactive Approach to PPR Public ReportingAppoint Interdisciplinary

Leaders- “Change Agents”

Educate OrganizationUnderstand Public Reports

(Peer Comparisons)

Analyze Impact/ Gaps

Communicate Offensively

Documentation/ Coding Service Lines Reasons PPRs

Internal Stakeholders

External Constituents

Initiate Focused Quality Improvement

Clinical Operations

Track, Monitor, Continue Focused Improvement Approach

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(Peer Comparisons)







Clinical Operations


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Include functional integration of Clinical Care Documentation & Coding Decision Support IT Operations Quality/ Case Management Discharge Planning FOCUS

Delegate responsibility and accountability for:

Coordination of organization-wide goals

Tracking and execution of control plan in conjunction w/ ancillary accountability

Gain insights into public perception of your hospital

Where does my hospital stand? How do I compare to others?

Emphasize internal and external importance/ implications

Clinical Quality Market Share

Focus upon opportunities for improvement and integration

Pre-admission and Discharge planning

Cross functional/ specialty coordination

Appoint Interdisciplinary Leads- “Change Agents”

Educate Organization Understand Public Reports

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(Peer Comparisons)







Clinical Operations


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Validate accurate documentation/coding within key areas

Implement improvement programs as needed

Emphasize – complete and accurate codified data provides the foundation from which public data is reported and improvement decisions are made

Consider a concurrent model


Documentation/ Coding

Analyze service lines and sub-service lines –e.g:

Rates Intervals #’s of chains PPRs % of discharges Top 10 Medical,

Surgical, other Top Reasons for

Readmits Severity Adjustments Linkage to financial

indicators (cost, charges)

Analyze reasons for PPRs Determine potential areas

of improvement Focus on measurable

indicators Track reasons over time “Repeaters”

Service Lines Reasons for PPRs

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FloridaHealthFinder.gov New PPR Reports soon

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General Guidelines for PPRs

PPR if related to complications of

prior surgery

PPR except conditions

clearly unrelatedSurgical

Not PPR unless initial medical

diagnosis clearly should have resulted

in surgery

PPR except if clearly unrelated acute

eventsMedical

SurgicalMedicalInitial Discharge

Readmission

PPR if related to complications of

prior surgery

PPR except conditions

clearly unrelatedSurgical

Not PPR unless initial medical

diagnosis clearly should have resulted

in surgery

PPR except if clearly unrelated acute

eventsMedical

SurgicalMedicalInitial Discharge

Readmission

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PPR Reason Codes: Medical Readmission

A Medical readmission is considered clinically related to the initial admission if the reason for the readmission falls into the following categories:

Medical readmission for1. Continuation or recurrence of the reason for the initial admission, or for a condition closely

related to the reason for the initial admission • e.g. a readmission for diabetes following an initial admission for diabetes

2. Acute decompensation of a chronic problem that was not the reason for the initial admission but was plausibly the result of inadequate care during the initial admission or inadequate outpatient follow-up care • e.g. a readmission for diabetes in a patient whose initial admission was for an acute

MI 3. Acute medical complication plausibly related to care during the initial admission. A

readmission for an acute medical problem was not considered clinically related unless it could have been a consequence of care provided in the initial admission. • e.g. Patient readmitted for a UTI infection ten days after a hernia repair, the

infection was likely related to the use of a foley catheter during the initial admission.

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PPR Reason Codes: Surgical Readmissions

A Surgical readmission is generally preventable unless they meet 1 of 2 criteria for a clinical relationship to the initial admission:

A readmission for a surgical procedure to address a:4. Continuation or a recurrence of the problem causing the initial

admission • e.g. a patient readmitted for an appendectomy following an

initial admission for abdominal pain and fever

5. Complication resulting from care during the initial admission • e.g. a readmission for drainage of a postoperative wound

abscess following an initial admission for a bowel resection

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Example: Surgical Initial Admission with Surgical PPR

Patient ID Hospital Admit Discharge LOS Status

Days Post Adm

PPR Type

IA APR DRG

RA APR DRG RA APR DRG Desc Pdx Pdx Desc Reason

Pat 1 A 16-Jan-06 21-Jan-06 5 01 0 IA 173 173 Other vascular procedures 44020 Atherosclerosis of native arteries of the extremities, unspecifiedPat 1 A 30-Jan-06 02-Feb-06 3 01 9 RA 173 791 O.R. procedure for other complications of treatment99832 Disruption of external operation wound 5Pat 1 B 27-Feb-06 28-Mar-06 29 06 25 OA 460 460 Renal failure 5845 Acute renal failure with lesion of tubular necrosis CR, but outside readmission window

Surgical Initial Admission for APR DRG 173 Other Vascular Procedures with a Surgical PPR

Only Admission- 25 days post admission:APR DRG 460- Renal FailureProcedure - Acute renal failure with lesion of tubular necrosis

Readmission- 9 days post admission:APR DRG 791- O.R. procedure for other complications of treatmentProcedure - Disruption of external operation wound

Initial Admission:APR DRG 173- Other Vascular ProceduresProcedure - Atherosclerosis of native arteries of the extremities, unspecified

Reason #5Complication resulting from

care during the initial

admissionReason Clinically

relevant but outside

readmission window

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Example: Medical Admission with Medical PPR

Patient ID Hospital Admit Discharge LOS Status

Days Post Adm

PPR Type

IA APR DRG


Pat 1 A 08-Oct-05 11-Oct-05 3 01 0 IA 194 194 Heart failure 4280 Congestive heart failurePat 1 A 21-Oct-05 26-Oct-05 5 01 10 RA 194 194 Heart failure 4280 Congestive heart failure 1Pat 1 B 17-Nov-05 23-Nov-05 6 06 22 OA 133 133 Pulmonary edema & respiratory failure 51881 Acute respiratory failure CR, but outside readmission window

Pat 1 B 13-Dec-05 22-Dec-05 9 06 20 IA 139 139 Other pneumonia 486 Pneumonia, organism unspecifiedPat 1 A 29-Dec-05 03-Jan-06 5 06 7 RA 139 194 Heart failure 4280 Congestive heart failure 2Pat 1 B 11-Jan-06 19-Jan-06 8 03 8 RA 139 133 Pulmonary edema & respiratory failure 51881 Acute respiratory failure 1Pat 1 B 15-Feb-06 20-Feb-06 5 06 27 OA 133 133 Pulmonary edema & respiratory failure 51881 Acute respiratory failure CR, but outside readmission window

Pat 1 B 10-Mar-06 03-Apr-06 24 03 18 IA 221 221 Major small & large bowel procedures 1538 Malignant neoplasm of other specified sites of large intestinePat 1 A 13-Apr-06 24-Apr-06 11 03 10 RA 221 460 Renal failure 5849 Acute renal failure, unspecified 3

Pat 2 E 13-Oct-05 15-Oct-05 2 01 0 IA 194 194 Heart failure 4280 Congestive heart failurePat 2 E 29-Oct-05 03-Nov-05 5 06 14 RA 194 194 Heart failure 4280 Congestive heart failure 1Pat 2 E 14-Nov-05 15-Nov-05 1 02 11 RT 194 194 Heart failure 4280 Congestive heart failure 1Pat 2 F 15-Nov-05 19-Nov-05 4 01 0 IA 175 175 Percutaneous cardiovascular procedures w/o AMI42731 Atrial fibrillationPat 2 E 27-Nov-05 29-Nov-05 2 51 8 RA 175 194 Heart failure 4280 Congestive heart failure 2Pat 2 E 29-Nov-05 03-Dec-05 4 51 0 RA 175 045 CVA & precerebral occlusion w infarct 43491 Cerebral artery occlusion, unspecified with cerebral infarction 2

Medical Initial Admission for APR DRG 194 Heart Failure with Medical PPR

Readmission 8 days post admission:APR DRG 133 Pulmonary edema & respiratory failure w/ acute respiratory failure

Reason #1Continuation or recurrence of the reason for the initial admission, or for a

condition closely related to the reason for the initial admission

Only Admission 27 days post admission:APR DRG 133 Pulmonary edema & respiratory failure w/ acute respiratory failure

Reason Clinically relevant but outside readmission

window

Initial Admission:APR DRG 194- Heart Failure w/ CHF followed by Readmission 10 days post admission:APR DRG 1940 Heart Failure w/ CHF

Reason #1Continuation or recurrence of the reason for the initial admission,

or for a condition closely related to the reason for the initial admission

Only Admission 22 days post admission:Pulmonary edema & respiratory failure w/ acute respiratory failure

Reason Clinically relevant but outside readmission

window

Initial Admission:APR DRG 139 Other pneumonia w/ pneumonia, organism unspecified followed byReadmission 7 days post admission:APR DRG 194 Heart failure w/ CHF

Reason #2Acute decompensation of a chronic problem that was not the reason for the initial admission but was plausibly the result of inadequate care during the

initial admission or inadequate outpatient follow-up care

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Example: Admission Procedure with Medical PPR

Admit Discharge LOS Status

Days Post Adm

PPR Type

IA APR DRG


12-Dec-05 14-Dec-05 2 01 0 IA 221 221 Major small & large bowel procedures 1540 Malignant neoplasm of rectosigmoid junction21-Dec-05 28-Dec-05 7 06 7 RA 221 221 Major small & large bowel procedures 9974 Digestive system complications, not elsewhere classified 130-Dec-05 31-Dec-05 1 01 2 RA 221 111 Vertigo & other labyrinth disorders 7804 Dizziness and giddiness ?15-Jan-06 19-Jan-06 4 01 15 RA 221 721 Post-operative, post-traumatic, other device infections 99859 Other postoperative infection 322-Feb-06 24-Feb-06 2 01 34 OA 223 223 Other small & large bowel procedures V552 Attention to ileostomy CR, but outside readmission window

06-Jul-06 12-Jul-06 6 01 0 IA 221 221 Major small & large bowel procedures 1541 Malignant neoplasm of rectum12-Jul-06 19-Jul-06 7 06 0 RA 221 721 Post-operative, post-traumatic, other device infections 99859 Other postoperative infection 326-Jul-06 30-Jul-06 4 06 7 RA 221 252 Malfunction, reaction & complication of GI device or procedure56962 Mechanical complication of colostomy and enterostomy 309-Aug-06 23-Aug-06 14 06 10 RA 221 221 Major small & large bowel procedures 9974 Digestive system complications, not elsewhere classified 1

09-Jan-06 13-Jan-06 4 01 0 OA 791 791 O.R. procedure for other complications of treatment 9986 Persistent postoperative fistula, not elsewhere classifiedFirst admission without a subsequent PPR within window

08-Feb-06 14-Feb-06 6 06 26 OA 226 226 Anal procedures 566 Abscess of anal and rectal regions CR, but outside readmission window

17-Apr-06 20-Apr-06 3 01 62 IA 221 221 Major small & large bowel procedures V553 Attention to colostomy30-Apr-06 05-May-06 5 06 10 RA 221 721 Post-operative, post-traumatic, other device infections 99859 Other postoperative infection 301-Jun-06 06-Jun-06 5 02 27 TA 248 248 Major gastrointestinal & peritoneal infections 56722 Peritoneal abscess07-Jun-06 10-Jun-06 3 01 1 OA 254 254 Other digestive system diagnoses 6191 Digestive-genital tract fistula, female Admission without a subsequent PPR within window

01-Jul-06 04-Jul-06 3 02 21 TA 721 721 Post-operative, post-traumatic, other device infections 99859 Other postoperative infection04-Jul-06 06-Jul-06 2 01 0 IA 813 813 Other complications of treatment 9986 Persistent postoperative fistula, not elsewhere classified20-Jul-06 29-Jul-06 9 06 14 RA 813 791 O.R. procedure for other complications of treatment 9986 Persistent postoperative fistula, not elsewhere classified 5

Admission for APR DRG 221 Maj Small & Large bowel Proc with a Medical PPR

Readmission 10 days post admissionAPR DRG 221 Major small & large bowel procedures w/ digestive system complications,

not elsewhere

Reason #1Continuation or recurrence of the reason for the initial admission,

or for a condition closely related to the reason for the initial admission

Patient 2- Hospital AInitial Admission:APR DRG 221- Major small & large bowel procedures w/ malignant neoplasm of rectum

followed byReadmission 0 days post admission: APR DRG 721 Post-operative, post-traumatic, other device infections w/ other

postoperative infection followed byReadmission 7 days post admission:APR DRG 252 Malfunction, reaction & complication of GI device or procedure w/

mechanical complication of colostomy and enterostomy

Reason #3Acute medical complication plausibly related to care during the initial admission. A readmission for an acute medical problem was not considered clinically related unless it could have been a consequence of care provided in the initial admission.

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Example: Medical Initial Admission with Surgical PPR

Hospital Patient ID Admit Discharge LOS Status

Days Post Adm

PPR Type

IA APR DRG


A Pat 1 14-Apr-06 18-Apr-06 4 01 0 OA 244 244 Diverticulitis & diverticulosis 56211 Diverticulitis of colon (without mention of hemorrhage)A Pat 1 12-Jun-06 15-Jun-06 3 01 55 IA 254 254 Other digestive system diagnoses 5641 Irritable Bowel SyndromeA Pat 1 28-Jun-06 02-Jul-06 4 01 13 RA 254 254 Other digestive system diagnoses 5641 Irritable Bowel SyndromeA Pat 1 06-Sep-06 11-Sep-06 5 01 66 IA 251 251 Abdominal pain 78904 Abdominal pain, left lower quadrantA Pat 1 20-Sep-06 05-Oct-06 15 03 9 RA 251 221 Major small & large bowel procedures56081 Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)

Medical Initial Admission for APR DRG 251 Abdominal Pain with a Surgical PPR

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Report #1: Overall Rates of Potentially Preventable Readmission ( PPRs )

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Report #2: PPRs Admissions by Service Line

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Report #3: Admission Reasons by Service Line

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Report #4: PPRs Admissions by Service Line

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Report #5: PPRs Patient-level Details

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(Peer Comparisons)







Clinical Operations


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How Will You Proactively Understand PPRs?…eventually prevent PPRs?

http://student.bmj.com/issues/99/11/education/images/oliver_howes.gif

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Carefully examine areas in need of improvement

Pre-admit process details (e.g. elective admits)

Clinical Practice Discharge & Post-discharge

• Multi-faceted

Implement ‘readmission mitigation’ strategies for key areas

Include multi-disciplinary clinical team Focus and build Avoid ‘boiling the ocean’


Clinical

Collect data once and repurpose it many times

Prioritize most important – focused operational improvements

Cost/benefit analysis

Operations

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Example: NQF National Priorities Survey- January 2008

Top 3 Conditions-Lead to most sizeable gains in improvement

-- Diabetes-- Healthcare Acquired Infections-- End of Life Care

NQF Survey : National Priorities Partners Survey Council Data, Jan 10, 2008; Karen Adams, PhDCouncils representing Consumers, Health Plans, Health Professionals, Provider Organizations, Public/Community Health Agencies, Purchasers, QMRI, Supplier,Industry &Other

Top 3 Cross-Cutting Strategies:-- Care Coordination-- Health Information Technology-- Medication Reconciliation

Top Recommendations:Stakeholders: Broad range across the continuumImplementation: Concrete goals within a roadmapBurden: Include administrative/ documentationSystems Approach: Process/Outcomes coupled w/ human capacityIT: EHRs w/ registries, interoperability, reportingHealth Lifestyle/Prevention: Value/reward for early detection/ preventionEpisodes of Care: measure acrossEfficiency: Incorporate w/ effectiveness

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P4P- A Provider Proactive Approach (Hypothesis)

Success in payment reform …will require unprecedented levels of collaboration across

the entire system of care. “Hospitals and physicians have a substantial obligation… to knock down barriers to improving quality and

effectiveness.

Modern Healthcare, 3/3/08 issue: “A Quality incentive at a crossroads- P4P summit features debate on limits, potential of bonus pay for meeting

benchmarks- quote from Tom Priselac, president and CEO of Cedars-Sinai Medical Center, LA, CAL

Key Tools: Risk Adjustment, Preventable Com

plications,

Readmissions, Continuum

of Care Outcomes

Autocoding/And/ or working DRG

Ope

ratio

nal Q

ualit

y S

yste

m

OperationalPractice

Improvement

Quality (Process/ Outcomes)/

Financial Metrics

IntegratedDecisionSupport

Clinical Practice Improvement

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Example: The Virtuous Circle of Hospital Admissions

“Shifting the focus of servicesTackling some typical scenarios

Authorities can find themselves trapped in 'vicious circles' of providing crisis-driven services which are neither effective for the service users and carers concerned nor an effective use of their resources.

In these circumstances, authorities have to identify how they can inject a different dynamic into the system of care to turn 'vicious' into 'virtuous' circles of activity. “

Source: Improvement and Development Agency: makingendsmeet.idea.gov.uk/idk/aio/5221438, makingendsmeet.idea.gov.uk/idk/core/page.do?p...

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Some Additional Challenges

**Used with Permission by George Isham, Health Partners

Hypothesis:Improvement of Outcomes

Measures may positively impact performance across hospitals, physicians, health plans, states, etc……

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(Peer Comparisons)







Clinical Operations


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Continually educate and update key stakeholders

Gain insights



Communicate hospital accomplishments and expertise

Multi-venue Integrated approach


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(Peer Comparisons)







Clinical Operations


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Establish baseline information, reports, data Continually track and communicate to interdisciplinary teams Understand outcomes data and potential relationships Focus and continue learning…


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Questions?

provider implementation of pp rs 3m

Technology

appoint interdisciplinary

large bowel

considered

inadequate

condition

acute medical

ppr reason

health plans