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Collaborative Approach to Improving Care and Reducing Readmissions
Edna Clifton, MBA, BSN, RNAssociate Director, Care Coordination
Health Services Advisory Group (HSAG)
March 14, 2017
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Presentation Objectives
Define the focus of Quality Innovation Network’s (QIN’s) work.
Recognize where Florida’s readmission rates rank with the nation’s rates.
Identify the Centers for Medicare & Medicaid Services (CMS) strategy goals.
Examine the goals of community coalitions.
Identify projects that have successfully reduced readmission rates.
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CMS Quality Strategy GoalsBetter Care, Healthier People, Healthier Communities, Smarter Spending
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-Strategy-Goal-Card.pdf
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Health and Human Services’ (HHS) Efforts to Improve Healthcare
4Source: Burwell, Sylvia M. Setting Value-Based Payment Goals- HHS Efforts to Improve US Healthcare, New England Journal of Medicine, January 26, 2015.
30%
50%
85%
90%
Tying payment to value through alternative payment modelsof all Medicare fee-for-service (FFS) payments tied to quality or value by 2016
through alternative payment models by the end of 2016
of all FFS payments tiedto quality or value by 2018
through alternative payment models by the end of 2018
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Policy Development
Comprehensive Care for Joint Replacement, Coronary Bypass Grafts, Acute Myocardial Infarction, and Cardiac Rehabilitation
Proposed Rule for Discharge Planning
Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) and Value-Based Purchasing (VBP) for Skilled Nursing Facilities (SNFs)
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Medicare’s Call for Action to Communities
Build and sustain community coalitions focused on improving coordination of care between settings.
Strengthen communication with community coalition partners in an open, non-competitive forum.
Reduce hospital readmission rates for Medicare FFS patients by 20% by 2019.
Improve medication safety to prevent adverse drug events that contribute to significant patient harm.
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QIN-QIO Areas of Focus
Cardiac Health
Disparities in Diabetes
Support of Clinicians in the Quality Payment
Programs
Antibiotic Stewardship in Communities
Coordination of Care
Value-Based Purchasing
Program
Healthcare Acquired
Conditions in Nursing Homes
Patient is at the center of care
What are the Readmission Rates?
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Readmission Definition
“We define a readmission as a subsequent inpatient admission to any acute-care facility which occurs within 30 days of the discharge
date of an eligible index admission.”
Source: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/downloads/MMSHospital-WideAll-ConditionReadmissionRate.pdf
Florida State 30-Day Readmissions RankingJanuary 1–December 31, 2015
Source: This material prepared by Telligen, the Quality Innovation Network National Coordinating Center, 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. (11SOW-QINNC-00794-05/13/16)
We are here
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Why All the Talk About Readmissions?
• Poor care coordination and use of evidence-based approaches
• Large number of readmissions are preventable
Quality
• Institute of Medicine (IOM) reports made clear the consequences of poor transitions management
Safety
• Centers for Medicare & Medicaid Services (CMS) indicate $13B* in savings or $25B across all U.S. payers
Cost
*MedPac 2007 Report to Congress; Promoting Greater Efficiency in Medicare; Chapter 5: Payment Policy for Inpatient Readmissions Source: Riddle, S. M.. What Works for Preventing Hospital Readmissions? [PowerPoint]. http://www.wapatientsafety.org/downloads/Riddle_Readmissions_Programs_WPSC_2012-Final.pdf
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How Can We Reduce Readmissions?
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The Care Coordination SolutionDefine the Problem
Discharge Process
Mapping
Cause & Effect
Diagram (Fishbone)
Data Driven Root-Cause
Analysis
Evidenced-Based
SolutionsCost-Benefit
Analysis
Action Plan for
Improvement
Measure Intervention
Results
Sustain or Modify the
PlanHospice
Home Health
Skilled Nursing
Hospitals
Physicians
Patients
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Care Coordination Coalitions
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The Building Blocks of a Community Coalition
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Community Essentials
Developed around collaborative care delivery
Shared vision
Shared mission
Shared resources
Shared decision making
Environment of trust
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Care CoordinationEstablish coalitions to bring providers together to coordinate efforts to support the CMS call to action measuresAssist coalitions to identify the root cause of their readmissionsAnalyze processes to identify gaps which cause the failure to achieve a smooth transition from one level of care to the otherDevelop interventions to correct the issues
Measure effectiveness of the intervention
Modify processes Re-measure
Best Practices
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Best Practices: Program to Enhance Communication to Avoid Readmissions
Osceola Community
Issue:
Patients were being sent from the skilled nursing facility (SNF) to the emergency department (ED) for an issue and it was not clearly communicated to the ED why the patient was sent there.
Dilemma: With incomplete information, the ED treated the patient based on diagnosis and emergency medical services (EMS) information.
Solution: The SNF community collaborated with local ED physicians to identify critical information needed to appropriately treat the patient for that episode.
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SNF to ED Transfer Communication Sheet
Best Practices: Programs to Divert Readmissions to Appropriate Providers
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Jacksonville Community
Issue: Dialysis patients were presenting in the ED with fluid overload because of missed treatments.
Dilemma: Hospitals cannot dialyze patients on an outpatient basis.
Solution: The hospital reached out to a nearby dialysis center to negotiate chair times for these patients and averting a readmission.
Best Practices: Programs to Divert Readmissions to Appropriate Providers (cont.)
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Brevard Community
Issue: Patients discharged to home often become overwhelmed with changes in treatments and medications and tend to return to the ED for assistance.
Dilemma: The patients are often readmitted because of adverse drug events and/or changes in their condition due to failure to follow treatment plans.
Solution:
Patients who had been transported by emergency medical services (EMS) to the hospital for their initial admission had follow-up visits from EMS within 8–24 hours of their discharge. Treatment and medications were reviewed and the patients’ living conditions were assessed for community services. Providing this support reduced hospital readmission.
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Top 10 Evidence-Based Interventions
1. Enhanced admission assessment– Begin discharge planning on admission
2. Formal assessment of risk of readmission– Align interventions to patient’s needs
3. Accurate medication reconciliation at: – Admission – Any change of level of care– Discharge
4. Patient education – Assess health literacy
Source: www.hret-hen.org/topics/readmissions/13-14/2014-READSChecklist.pdf
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Top 10 Evidence-Based Interventions (cont.)
5. Identify primary caregiver6. Use teach-back to validate understanding7. Send discharge summary within 24–48 hours8. Collaborate with post-acute care and community9. Schedule follow-up appointments before discharge10.Conduct post-discharge follow-up calls within 48
hours of discharge
Source: www.hret-hen.org/topics/readmissions/13-14/2014-READSChecklist.pdf
Coming together is a beginning.Keeping together is progress.Working together is success.
–Henry Ford
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Florida, 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. Publication No. FL-11SOW-C.3-02282017-01
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