readmission management jacquelyn paynter, rn, mph, ccm executive director of care management
TRANSCRIPT
READMISSION MANAGEMENT
Jacquelyn Paynter, RN, MPH, CCMExecutive Director of Care Management
Burden of Readmissions
How big is the problem?
Fiscal Year FFY2013 FFY2014 FFY2015Targeted Conditions Heart Failure, AMI,
PneumoniaHeart Failure, AMI, Pneumonia
Heart Failure, AMI, Pneumonia COPD, CABG, PCI, Vascular Procedures
Aggregate payment withhold penalties Up to 1% Up to 2% up to 3%
The Top 15 DRG drivers of readmissions at Dekalb Medical are Heart Failure, Renal Failure, Psychosis, Sepsis, COPD, Pneumonia, Respiratory Failure, Red
Blood Cell Disorders, GIB, UTI,and Diabetes. These patient populations represent 33% (ND) and 48%(HD) of the overall readmission volume with an average
readmission rate of 15.5%.
According to an IHI sponsored demonstration project, the key drivers of unplanned readmissions were driven by health care delivery system failures in 4 key
areas:
• ENHANCED ADMISSION ASSESSMENT
• PATIENT AND FAMILY CAREGIVER EDUCATION
• HANDOVER COMMUNICATION
• DISCHARGE PLANNING
• COMMUNITY CONNECTION
Beginning October 1, 2012 (Federal Fiscal Year 2013), the Patient Protection and Affordable Care Act (PPACA) statute will penalize hospitals and integrated
delivery systems with higher than expected readmission rates.
Readmission Management Imperatives
Natl Avg Crude Rate
Eligible Discharges
Number of Readissions
Predicted Risk Adjusted Hospital Rate
Expected Risk Adjusted National Rate
Excess Readmission
Ratio
North DecaturAMI 19.2 109 25 22.1 21.6 1.0230HF 24.6 560 125 22.7 23.6 0.9636
CAP 18.5 494 79 16.6 17.6 0.9446Hillandale
AMI 19.2 23 3 20.3 21.1 0.9612HF 24.6 145 31 22.9 23.7 0.9645
CAP 18.5 95 25 19.0 16.6 1.1412
CMS Hospital Compare
FFY13 Pay for Performance Period: 7/1/08-6/30/11
Implemented heart failure focused care coordination
Structured systematic readmission risk assessment
Processes to identify ED and inpatient recidivist populations
Expanded ED social work coverage and scope
Bedside Rx delivery
Post-discharge phone calls
Diagnosis based ZONES discharge education
Readmission Achievement
Q2 FY 2009
Q3 FY 2009
Q4 FY 2009
Q1 FY 2010
Q2 FY 2010
Q3 FY 2010
Q4 FY 2010
Q1 FY 2011
Q2 FY 2011
Q3 FY 2011
Q4 FY 2011
Q1 FY 2012
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
30-day Readmissions to Same Hospital
Hospital Jurisdiction : 80th Percentile State : 80th Percentile National: 80th Percentile
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Medicare All Cause All Hospital Readmission TrendFFY12 Q1 PEPPER Report – North Decatur
Q2 FY 2009
Q3 FY 2009
Q4 FY 2009
Q1 FY 2010
Q2 FY 2010
Q3 FY 2010
Q4 FY 2010
Q1 FY 2011
Q2 FY 2011
Q3 FY 2011
Q4 FY 2011
Q1 FY 2012
0%
5%
10%
15%
20%
25%
30-day Readmissions to Same Hospital or Elsewhere
Hospital Jurisdiction : 80th Percentile State : 80th Percentile National: 80th Percentile
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Medicare All Cause All Hospital Readmission TrendFFY12 Q1 PEPPER Report – North Decatur
Q2 FY 2009
Q3 FY 2009
Q4 FY 2009
Q1 FY 2010
Q2 FY 2010
Q3 FY 2010
Q4 FY 2010
Q1 FY 2011
Q2 FY 2011
Q3 FY 2011
Q4 FY 2011
Q1 FY 2012
0%
5%
10%
15%
20%
25%
30-day Readmissions to Same Hospital
Hospital Jurisdiction : 80th Percentile State : 80th Percentile National: 80th Percentile
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Medicare All Cause All Hospital Readmission TrendFFY12 Q1 PEPPER Report - Hillandale
Q2 FY 2009
Q3 FY 2009
Q4 FY 2009
Q1 FY 2010
Q2 FY 2010
Q3 FY 2010
Q4 FY 2010
Q1 FY 2011
Q2 FY 2011
Q3 FY 2011
Q4 FY 2011
Q1 FY 2012
0%
5%
10%
15%
20%
25%
30%
30-day Readmissions to Same Hospital or Elsewhere
Hospital Jurisdiction : 80th Percentile State : 80th Percentile National: 80th Percentile
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Medicare All Cause All Hospital Readmission TrendFFY12 Q1 PEPPER Report - Hillandale
Multidisciplinary Collaborative Care Coordination Program
What did we do?
ADMISSION ASSESSMENT
Readmission Risk AssessmentED Case Management*Medication Reconciliation*
PATIENT/FAMILY EDUCATION
Zone EducationWalgreens Bedside Rx Delivery and 72hr f/up callsVNHS Preferred Home Health Provider
HANDOVER COMMUNICATION
Hospitalists fax discharge summary and medication reconciliation to PCPCase Management provides an electronic discharge summary to post-acute providers (HHA,SNF,Dialysis)
DISCHARGE PLAN Walgreens Bedside Rx DeliveryMedication Reconciliation*Post Acute Services (HHA, DME, SNF, Dialysis, Hospice)
COMMUNITY CONNECTION
VNHS Preferred Home Health Provider48 hr Post-Discharge CallsPCP Follow-up Appointments*Post-Discharge Transition Clinic*
Implementation of the 5 Care Transition Pillarsat Dekalb Medical
CARE TRANSITION FOCUSDISCHARGE PROCESS
•
Implemented Walgreens Bedside Rx Delivery• ND Campus (May 2011)• Hillandale Campus(January 2012)
Key Functions• Ensures patient receives the medication upon discharge• Supports patient satisfaction with discharge experience• Pharmacy consultation provided, if needed• Caregiver included in consult• Reaffirms understanding of medication while patient still in healthcare
system• Immediate start of therapy on discharge• 15-30 minute turn-around time• Provides 30-day supply of medications• Ability to refill at any pharmacy of patients choice• Follow-up phone call from clinical pharmacist within 72 hours of discharge
Methods & Results
How well did we do it?
CARE TRANSITION FOCUSDISCHARGE PROCESS
•
Walgreens Bedside RX Delivery Results at Dekalb Medical
Volume Statistics North Decatur Hillandale
Discharges 455 1810
Non-Bedside Rx Discharges 370 1503
Bedside Rx Discharges 85 307
Penetration Rate 18.7% 17.0%
Dekalb Medical is among the highest volume
Bedside Delivery programs in the U.S.
Results
• Submitted study to Dekalb’s institutional review board (IRB)• Approved on April 25, 2012 (DM Protocol #040512) • Retrospective cohort • Census of all discharges (all payors)• Controls from
a. Hospital’s historic data (a type of retrospective cohort study)
b. Contemporaneous matches from non-participating facility
(i.e., Hillandale campus compared to North Decatur campus)• Multiple logistic regression, controlling for demographic and
clinical variables
Descriptive StatisticsVariableHistoric
Hillandale
Contemporaneous
Hillandale Historic
North DecaturContemporaneous
North Decatur
Bedside Delivery
North Decatur
n (count of qualifying admits) 4232 7024 13283 19089 1516
30-day readmit (%, n) 9.5% 400 10.8% 757 10.6% 1408 11.5% 2191 5.6% 85
LOS (mean ± SD) 4.3 5.1 4.3 9.6 5.5 6.4 5.1 240.7 4.0 4.2
age > 65 (%, n) 30.8% 1305 31.3% 2197 41.1% 5459 41.8% 7988 29.3% 444
age (mean ± SD) 54.9 18.0 55.0 18.4 59.5 17.7 59.5 18.0 55.7 15.3
HF_case (%, n) 3.5% 148 2.1% 146 1.7% 227 1.1% 207 0.3% 5
AMI_case (%, n) 1.3% 56 1.1% 74 1.0% 130 1.4% 271 1.6% 24
PN_case (%, n) 4.87 206 4.2 295 3.52 468 3.65 696 1.72 26
Medicaid (%, n) 12.0% 509 12.8% 902 9.9% 1312 10.6% 2028 9.3% 141
Race: Other (%, n) 2.1% 90 1.3% 93 5.0% 669 5.5% 1040 4.2% 64
Race: Black (%, n) 92.3% 3908 92.8% 6521 62.1% 8242 63.1% 12038 59.8% 907
Race: White (%, n) 5.5% 234 5.8% 410 32.9% 4372 31.5% 6011 36.0% 545
30 Readmission Rates are comparatively lower for Bedside Rx patients
Adjusted risk of readmission
Independent variables and covariates OR 95% CI Pr > ChiSqMale 0.954 0.896 1.014 0.1316Age 65 + 1.302 1.221 1.389 <.0001Medicaid 1.437 1.31 1.577 <.0001Race (Reference Group: White) 0 Black 1.243 1.153 1.339 <.0001 Other 0.896 0.757 1.061 0.2019Month 1.019 1.01 1.029 <.0001LOS 1.026 1.022 1.031 <.0001CMS Conditions (Reference: without condition) HF 1.554 1.267 1.905 <.0001 AMI 0.428 0.292 0.627 <.0001Interventional group comparison (Reference Group: Bedside Delivery) 0 Historic Hillandale 1.572 1.232 2.005 0.0003 Contemporaneous Hillandale 1.879 1.488 2.373 <.0001 Historic North Decatur 1.828 1.458 2.293 <.0001 Contemporaneous North Decatur 2.071 1.655 2.591 <.0001
The lower readmission rate for Bedside Rx patients is statistically significant
Facilitate PCP identification/referrals/appointments
Accurate medical history and medication reconciliation
Provide structured patient/family education
Establish nurse navigator/coach programs
Implement ED Case Management 7 day/wk 11a-11p
Provide transitional care clinic for P4P readmission discharges
Strengthen systematic handover communication between care providers
Further enhance use of Care Transition Home Health Visits and 30 day Post Discharge Medication
Management
Care Coordination Enhancement Opportunities
DISCUSSION