David G. SchulkeVice President, Research Health Research and Educational Trust dschulke@aha.org(202) 626-2319

October 18, 2011

Improving Transitions from Hospital to Community Care: Models that Work

The Health Research and Educational Trust The Health Research and Educational Trust (HRET)(HRET)

• HRET’s mission is to transform health care through research and education.

• AHRQ has retained HRET to support state-based Learning Networks with trainings for providers that wish to use AHRQ’s patient safety tools.

• Primary tools supported include Project RED (readmissions reduction), HCAHPS (patient satisfaction), VTE prevention, ED flow management.

Overview of PresentationOverview of Presentation

1. Review research behind new financial incentives to reduce readmissions in the Patient Protection and Affordable Care Act (ACA).

2. Examine the importance of patient centered care and the relationship between hospitals and other providers in the community.

3. Describe proven strategies hospitals use to improve care and protect against financial penalties, focusing on Project RED.

The Discharge Process and Post-hospital Care The Discharge Process and Post-hospital Care

Influence Rehospitalization RatesInfluence Rehospitalization Rates• 19% of Medicare inpatients are readmitted by

30 days.• Only half of the patients re-hospitalized within

30 days saw their doctor before their readmission.

• As many as 90% of rehospitalizations within 30 days appear to be unplanned.

• Cost to Medicare estimated at $17 Billion/year.

Source: Jencks et al N Engl J Med 2009;360:1418-28

How Many Readmissions Should be How Many Readmissions Should be Prevented?Prevented?

• What proportion of readmissions are truly “preventable,” with good care? No one knows.

• Evidence suggests many rehospitalizations result from poor practices and are preventable--• Many rehospitalized before seeing a physician• High inter-hospital and inter-state variation• Randomized clinical trials testing interventions

achieve 30+% reduction in readmissions

Business Case for Business Case for Hospital Action on ReadmissionsHospital Action on Readmissions• ALOS for rehospitalized patients is 0.6 day (13.2%) longer than the stay for patients in the same DRG who were not hospitalized in the previous 6 months

• Medicare payment for rehospitalizations is 4% lower than for index hospitalization

• For hospitals with excess readmissions: Penalty of 1% of all Medicare PPS payments in FY 13 (rising to 3% in FY15)

• Value-based purchasing penalty of 1% of all PPS payments (grows to 2% in future years)

• If your system has competitive pricing pressure: these are all inefficiencies others are driving out of their systems

Federal Penalties for Avoidable ReadmissionsFederal Penalties for Avoidable Readmissions

• Penalties on hospitals with readmissions above expected rates for targeted conditions (AMI, CAP, CHF), starting October 1, 2012

• Penalties will reduce hospital payments by at least $7 Billion over 10 years Exempt: Sole community hospitals, Medicare-

dependent rural hospitals, low volume conditions

• CMS proposes more conditions for 2014— Chronic Obstructive Lung Disease Coronary Artery Bypass Graft surgery Percutaneous Coronary Interventions Vascular Procedures

Laurens County Health System (76 acute, 14 SNF beds) and SCHA modeled potential annual effect of penalties:

Potential Financial Impact of Readmissions Penalty at a Small Community Hospital

Heart Attack Heart Failure Pneumonia

Patient Discharges

0 139 244

Readmissions w/in 30 Days

0 32 37

Risk-Adjusted Readmit Rate

0.0% 22.7% 15.3%

Medicare Payments at Risk

$0 -$278,900 -$478,900

Financial Incentives:Medicare Hospital Value Based Purchasing

• Medicare VBP program pays hospitals for actual performance on quality measures, not just reporting measures, beginning FY13

• The VBP program will apply to all acute-care PPS hospitals (VBP demonstration for CAHs)

• Funded by reducing all Medicare DRG payments by 1%, redistributed to best performers

• A hospital that meets or exceeds the performance standards will be eligible to earn back the initially withheld money (or more if others perform poorly)

Value Based Purchasing: Higher Scores with Value Based Purchasing: Higher Scores with Strong Discharge and Follow up Processes Strong Discharge and Follow up Processes

• H-CAHPS accounts for 30% of hospital VBP score

• Four patient perceptions measured by H-CAHPS are better predictors of readmissions than core clinical measures: “During this hospital stay, did doctors, nurses or other

hospital staff talk with you about whether you would have the help you needed when you left the hospital?” and

“During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”

“How do you rate the hospital overall?” “Would you recommend the hospital to friends and

family?”

Discharge Process Must Address Breakdowns Discharge Process Must Address Breakdowns Leading to Avoidable Readmissions Leading to Avoidable Readmissions

Breakdowns include:

• Inadequate communication with primary care physicians

• Inadequate education of patient

• Drug therapy

• Poor coordination with other community providers

Process Breakdown: Poor Transfer of Information to Primary Care Physician

• 25% pts require additional outpt work-ups: 1/3 incomplete 25% pts require additional outpt work-ups: 1/3 incomplete (Source: Archives of Internal Medicine. 2007; 167: 1305-11)

• 41% inpatients discharged w/ pending test result41% inpatients discharged w/ pending test result 2/3 of physicians unaware of results 37% of tests actionable and 13% urgent

(Source: Annals of Internal Medicine. 2005; 143(2): 121-8)

• Discharge summary not readily availableDischarge summary not readily available: Only 12-34% at first post-discharge appt; 51-77% at 4 weeks

• Discharge summary lacking key componentsDischarge summary lacking key components: Hospital course (7-22%) Discharge medications (2-40%) Test results (33-63%) Pending tests (65%) Follow-up plans (2-43%)

(Source: JAMA 2007; 297(8): 831-41)

Process Breakdowns: Poor Pre-discharge Patient Education

• Poor transfer of information to patient: 37% able to state purpose of all medications 14% knew the common side effects 42% able to state their diagnosis

• Result: Poor patient understanding of how to use

medications after hospital discharge Patient doesn’t understand warning signs that

warrant an emergency call to their physician Lack of clarity on patient’s end of life care

preferences lead to unwanted rehospitalization

Source: Courtesy of Michael Paasche-Orlow, MD, Mayo Clinic Proceedings. August 2005; 80(8):991-994

Adverse Drug Events in the Transition from Hospital to Home

• Studied 400 consecutive hospital patients discharged home.

• 19% of patients had an adverse event (AE) within 3 weeks of discharge home.

• 66% of AEs were adverse drug events• Most ADEs were preventable or ameliorable,

unlike other Adverse Events.• Clinical process improvements suggested by

the authors: Identify unresolved problems at discharge Patient education re: treatment plan Post-discharge monitoring and follow up

(Source: Forster et al, Annals Int Medicine, Feb 2003)

Rates of Rehospitalization within 30 days Rates of Rehospitalization within 30 days after Hospital Dischargeafter Hospital Discharge

Source: Jencks SF, et al. N Engl J Med 2009;360:1418-1428

Hospital Admissions Vary for Ambulatory Hospital Admissions Vary for Ambulatory Sensitive ConditionsSensitive Conditions

2007 Medicare SAF data

Hospital Admissions of Short StayHospital Admissions of Short Stay Nursing Home ResidentsNursing Home Residents

2006 Medpar Data

Hospital Admissions of Home Health Hospital Admissions of Home Health PatientsPatients

OASIS data in 2008 AHRQ National Healthcare Quality Report

Implications

• Nursing home, home health agency, hospice, pharmacy, and physician practices influence your hospital admission rates

• Coordinating with these providers can help your hospital escape penalties for patient care breakdowns

• Reducing readmissions cannot be done as effectively with interventions only within the hospital’s walls

• Hospitals should improve their discharge process, but also talk with referral partners to see how to work better together

Help for Hospitals in Reducing Avoidable

Readmissions

Mathematica Study of Effective Care Coordination (March 2009)

• Most claims of high impact care coordination interventions are unproven

• Mathematica concluded 3 types of change packages are proven effective: Transitional care interventions (Naylor and

Coleman) Self-management education interventions

(Lorig and Wheeler) Coordinated care interventions (a few sites

from the Medicare Coordinated Care Demonstration)

Mathematica Study: Key Components of Mathematica Study: Key Components of Effective Transitional CareEffective Transitional Care

• Engage patients early in hospitalization

• Give patients comprehensive post-discharge instructions on medications, self-care, and symptom recognition and management

• Assist patients in setting up and keeping follow-up physician appointments

• Follow patients post-discharge

Reengineered Hospital Discharge Program (Annals of Internal Medicine, Feb. 2009)

Impact of Project RED on Hospital UseImpact of Project RED on Hospital Use

Impact of Project RED: Impact of Project RED: Reengineering the Hospital DischargeReengineering the Hospital Discharge

• RED reduced health spending vs. control group More patients reported seeing their PCP Inpatient and ED care reduced by 30% Net: Saved $412/patient (~$19/month)

• Three key components in Project RED: Discharge Advocate educates hospital patient Give “After Hospital Care Plan” to patient,

PCP Pharmacist calls patients 2-4 days post-

discharge (most hospitals struggle to arrange pharmacist calls)

RED 11-point ChecklistRED 11-point Checklist

RED has eleven mutually reinforcing components:1) Medication reconciliation

2) Patient education

3) Follow-up appointments

4) Outstanding tests

5) Post-discharge services

6) Reconcile discharge plan with national guidelines

7) What to do if problem arises

8) Written discharge plan

9) Assess patient understanding

10)Discharge summary sent to PCP

11)Telephone reinforcement

RED Component #1: RED Component #1: Reconcile the MedicationsReconcile the Medications

• Reconcile the patient’s home medication list upon admission to the hospital

• Review each medication; make sure that the patient knows why they take it

• Discuss new medications each day with medical team and with patient

RED Component #2: Educate the PatientRED Component #2: Educate the Patient

• Educate patient throughout the hospital stay

• The Project RED intervention starts within 24 hours of the patient’s admission to the hospital and continues daily until completion of the post-discharge telephone follow up call to the patient

RED Component #3: Reconcile Discharge RED Component #3: Reconcile Discharge Plan with National GuidelinesPlan with National Guidelines

• Example: Discharge medication orders for ACEIs/ARBs for Heart Failure patients

• Communicate with medical team each day about the discharge plan

• Recommend actions that should be taken for each patient under a given diagnosis

• Schedule PCP appointment for the patient, to occur within 2 weeks after discharge

• Review, with the patient, the provider’s location, transportation and plan to get to appointment

• Consult with patient regarding best day and time for appointments

• Discuss, with the patient, the reasons for and importance of all follow-up appointments and testing

RED Component #4: Make appointments for RED Component #4: Make appointments for clinician follow-up and post-discharge testingclinician follow-up and post-discharge testing

RED Component #5: Discuss with Patient RED Component #5: Discuss with Patient Pending Tests/studies and Who will Follow upPending Tests/studies and Who will Follow up

• Explain tests and studies done while in the hospital and tell the patient which clinician is responsible for reviewing the results

• Encourage the patient to discuss tests his/her PCP

• Let the patient know that this information will be listed on the AHCP

RED Component #6: RED Component #6: Organize Post-discharge ServicesOrganize Post-discharge Services

• Collaborate with case manager and social worker about patient needs and post-discharge services

• Provide patient with contact information for these services (phone number, name of company, etc.)

RED Component #7: Give the Patient a Written RED Component #7: Give the Patient a Written Discharge Plan Before Discharge Discharge Plan Before Discharge

The After Hospital Care Plan (AHCP) should include, in plain language understandable to the patient:

1) Principal discharge diagnosis

2) Discharge medication instructions

3) Follow-up appointments with contact

information

4) Pending test results

5) Tests that require follow up

RED Component #8: Review with the Patient RED Component #8: Review with the Patient Steps to Take if a Problem Arises Steps to Take if a Problem Arises Review with the patient—•What’s an emergency vs. a common problem

•What to do if a question or a problem arises

•Where in After Hospital Care Plan to find contact information for the discharge advocate and PCP to answer questions after dischargeHCAHPS questions about the discharge process: • Q 19: “During this hospital stay, did doctors, nurses or

other hospital staff talk with you about whether you would have the help you needed when you left the hospital?”

• Q 20: “During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”

RED Component #9: Teach the Patient the AHCP, RED Component #9: Teach the Patient the AHCP, and ask the Patient to Tell You the Details of the Planand ask the Patient to Tell You the Details of the Plan

• Explain post hospital care and post-discharge medications in a way the patient understands, including how to take the meds and how and where prescription can be filled 

• Communicate this information to the accepting physician

• Deliver information to reach those with a low health literacy level

• Include caregivers when appropriate• Utilize professional interpreters as needed

RED Component #10: Expedite Transmission RED Component #10: Expedite Transmission of the Discharge Summary to the PCP of the Discharge Summary to the PCP

• Fax the discharge summary and AHCP to PCP within 24 hours after discharge

• National Quality Forum Safe Practice SP-15: “Reliable information from the primary care

physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods”

“A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.”

RED Component #11: Telephone Reinforcement RED Component #11: Telephone Reinforcement of the After Hospital Care Plan after Dischargeof the After Hospital Care Plan after Discharge

• RED intervention calls for a pharmacist to call the patient within 72 hours after discharge If pharmacist unavailable, have pharmacist help

with “script” and available for back up Why? Because most patients leave with drug

therapy, most post-discharge adverse events are drug problems, and 2/3 of adverse drug events are preventable or ameliorable

• Assess patient status• Review medication plan• Review follow-up appointments• Take appropriate actions to resolve problems

Compare Your Discharge Process with RED Compare Your Discharge Process with RED Checklist to find Improvement OpportunitiesChecklist to find Improvement Opportunities

AHRQ’s Consumer Version of the Project RED “After Hospital Care Plan"

• Project RED research team created this tool to help-- • Keep track of

medications• Patients talk with

hospital staff and primary care doctor

• Family assist patients

• Get it free from AHRQ: http://www.ahrq.gov/qual/goinghomeguide.pdf

Health Care Leader Action GuideHealth Care Leader Action Guide

Provides strategies for you to– Examine your hospital’s current rate of readmissionsAssess and prioritize your improvement opportunitiesDevelop an action plan of strategies to implement Monitor your hospital’s progress

Get it free at www.hret.org/resources

Other AHRQ and CMS-funded Tools to Help Reduce Avoidable Readmissions (continued)• TeamSTEPPS, a method for improving team

communication and patient safety culture among hospital staff

• Care Transitions Toolkit–free resources at QIO site: http://www.cfmc.org/integratingcare/

• QIO program Home Health Quality Improvement project’s patient risk assessment tool for Home Health Agencies: http://www.homehealthquality.org/hh/ed_resources/interventionpackages/hra.aspx

• QIO program originated toolkit for nursing homes: Interact2.net

Thank you!Thank you!

Your Questions and Your Questions and Comments are Welcome!Comments are Welcome!

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