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HOME IS THE HUBAn Initiative to Accelerate Progress to Reduce Readmissions in Virginia
WELCOME AND OVERVIEW
Abraham Segres VHHAVice President, Quality & Patient Safety
[email protected] (804) 965-1214
VIRGINIA HOSPITAL & HEALTHCARE ASSOCIATION
An association of 30 member health systems representing 107 community, psychiatric, rehabilitation and specialty hospitals throughout Virginia.
VisionThrough the power of collaboration, the association will be the recognized driving force
behind making Virginia the healthiest state in the nation by 2020.
MissionWorking with our members and other stakeholders, the association will transform Virginia’s health care system to achieve top-tier performance in safety, quality, value, service and population health. The association’s leadership is focused on: principled, innovative and effective advocacy; promoting initiatives that improve health care safety, quality, value
and service; and aligning forces among health care and business entities to advance health and economic opportunity for all Virginians.
VHHA 2015-2020 IMPROVEMENT PRIORITIES
1. Hospital readmissions1a. Hospital-wide1b. Post-acute transfers1c. Total hip/Total knee Replacement 30-day readmissions
2. Clostridium difficile – Healthcare-acquired Infections3. Patient Experience – HCAHPS 4. Serious Safety Events
OBJECTIVES
1. Understand the need to accelerate progress to reduce readmissions in Virginia
2. Have one “ah-ha” moment / new lesson learned
3. Identify one action to take in follow up to this presentation
4. Understand how the data-informed, high-leverage focus areas build on the “portfolio” of strategies at your hospital
HOUSEKEEPING
• Slides were sent this morning• Webinar is being recorded• Please use the “telephone” option
• Audio pin prompt• All participants are muted• Raise your hand • Ask a question• Warm up
DATA-INFORMED STRATEGY & HIGH LEVERAGE OPPORTUNITIES
Amy Boutwell, MD, MPP Collaborative Healthcare Strategies
(617) 710-5785
OVERVIEW• Case for accelerating progress
• Review of data
• Data-informed, strategic focus areas
• Review of best practices
• Planned activities to support statewide learning and action
• Discussion
THE CASE FOR ACCELERATING PROGRESS
Slipping performance relative to national average; climbing penalties
READMISSIONS IN VIRGINIA• Virginia ranked #46 in US for average readmission penalties in 2015
• 67 of 79 hospitals received a readmission penalty
• $16,664,900 in total readmission penalties• Average penalty: $211,000• Maximum penalty: $1, 230,800
• Expansion of penalty conditions to COPD, THR/TKR substantially increased impact of penalties for VA hospitals
READMISSIONS MEASURE TREND ANALYSIS – STATE RANK
Rate of Readmission for Heart Attack Patients 30 of 51 38 of 51 ▲ 38 of 51 40 of 51 ▲ 46 of 51 ▲
Rate of Readmission for Heart Failure Patients
32 of 51 29 of 51 ▼ 32 of 51 ▲ 34 of 51 ▲ 38 of 51 ▲
Rate of Readmission for Pneumonia Patients 40 of 51 40 of 51 42 of 51 ▲ 45 of 51 ▲ 46 of 51 ▲
Rate of Readmission After Hip/Knee Surgery 34 of 51 43 of 51 ▲ 49 of 51 ▲
Rate of Readmission for Chronic Obstructive Pulmonary Disease Patients
41 of 51 42 of 51 ▲
Rate of Readmission After Coronary Artery Bypass Graft Surgery
38 of 51
July 1, 2011 - June 30, 2014
June 2011July 1, 2010 - June
30, 2013
State Rank
No Data
June 2012July 1, 2008 - June
30, 2011July 1, 2007 - June
30, 2010
No Data
No Data
Dec. 2013 * Dec. 2014 June 2015July 1, 2009 - June
30, 2012
Rank
s
THE CASE FOR ACCELERATING PROGRESS: VIRGINIA’S NATIONAL RANK ON READMISSIONS
* CMS modified its calculation of readmission rates to better account for planned readmissions. As a result, it is likely that rates will be lower than previous publications. Readmission rates are normally updated around June of each year.
68 of 89 hospitals in VA received
readmission penalties this year, totaling over$21million
HIP/KNEE REPLACEMENT READMISSION RATES & PENALTIES
State Rank State Rate
1 Vermont 4.195%
2 Nebraska 4.212%
3 North Dakota 4.337%
4 California 4.380%
5 Hawaii 4.419%
25 Wisconsin 4.681%
49 Virginia 5.170%
50 Alaska 5.261%
51 D.C. 5.403%
Condition
FFY 2016 Program Penalty
DollarsFacilities
Penalized
Heart Attack 2,285,000$ 31
Heart Failure 2,482,000$ 42
Pnumonia 2,148,000$ 48
Total Hip & Knee 11,938,000$ 41
COPD 2,231,000$ 41
Total Penalties 21,084,000$ 68
Total facilites being measured - 89
GOAL
In response to these readmission statistics, the VHHA Board has set a goal:
Reduce all-payer readmissions by 20% by 2020
Key elements of this goal:• All-payer: preparing hospitals by looking forward to the future market realities• All-condition: forward-looking to risk-based contracting and alternative payments• Dedicated focus areas: THR/TKR, post-acute, and hospital-wide readmissions
A CLOSE LOOK AT THE DATA
Using data to re-examine prior assumptions, develop data-informed strategy
READMISSIONS OCCUR ACROSS ALL AGES
Source: VA Medicare FFS data, courtesy of VHQC
TKR/THR READMISSIONS OCCUR ACROSS ALL AGES
Readmissions by Age Category
18 - 39 40 - 64 65 - 74 75 - 84 85+ 18 - 39 40 - 64 65 - 74 75 - 84 85+0K
5K
10K
15K
20K
Num
11,097
3,575
7,493
680472
18,176
16,626
7,813
1,014159
Total Hip Replacement ADMISSIONS Total Knee Replacements ADMISSIONS
Total Hip Replacement 30-Day Readmissions in Virginia Total Knee Replacement 30-Day Readmissions in Virginia
18 - 39 40 - 64 65 - 74 75 - 84 85+ 18 - 39 40 - 64 65 - 74 75 - 84 85+0
200
400
600
Num
289
219
334
15
53
405
538569
71
4
Pay CatCommercialMedicaidMedicareOther InsUninsured
Age Cat18 - 39
40 - 64
65 - 74
75 - 84
85+
Source: VHHA
READMISSIONS BY DAY POST-DISCHARGE
Source: VA Medicare FFS data, courtesy of VHQC
~25% <4 days of discharge
RE-EXAMINE A NARROW FOCUS ON KEY DIAGNOSES
Source: VA Medicare FFS data, courtesy of VHQC
Top 10 Medicaid Dx: 1. Mood disorder2. Schizophrenia3. Diabetes complications4. Comp. of pregnancy5. Alcohol-related6. Early labor7. CHF8. Sepsis 9. COPD10. Substance-use related
Top 10 Medicare Dx: 1. CHF2. Sepsis3. Pneumonia4. COPD5. Arrythmia6. UTI7. Acute renal failure8. AMI9. Complication of device10. Stroke
Methods: - Used CCS groupers- Included OB
Q1 Q2 Q3 Q4Home 16.4 16.4 15.5 15.8HHA 20.2 20 21.3 20.6SNF 19.9 20.6 20.1 20State Avg 18.6 18.5 18.7 18.6
10
12
14
16
18
20
22
Axis
Titl
e
Medicare FFS Readmission Rates, by Discharge Setting: Home, SNF, HH
READMISSIONS BY DISCHARGE DISPOSITION
20% PAC
15% HOME
Source: VA Medicare FFS data, courtesy of VHQC
HU Readmission Rate = 40%Non-HU Readmission Rate = 8%
Source: 2016 MA All Payer State-wide Readmission Analysis
READMISSIONS BY ZIP CODE
Source: VA Medicare FFS data, courtesy of VHQC
DATA-INFORMED STRATEGIC FOCUS
Modeling the impact of high leverage strategic focus on the goal
DATA-INFORMED, STRATEGIC FOCUS
• Total Medicare discharges: 227,639• Total Medicare readmissions: 50,524• Medicare readmission rate: 18%
PAC discharges: 111,000PAC readmissions: 22,000PAC readmission rate: 20%% of all readmissions from PAC: 22,000/50,500 = 44%
HU discharges: 46,958HU readmissions: 21, 881HU readmission rate: 46%% of all readmissions among HU: 21,881/50,500 = 43%
Home discharges: 116,000Home readmissions: 18,000Home readmission rate: 15%% of all readmissions from home: 18,000/50,500 = 35%
OPPORTUNITY: PATIENTS DISCHARGED TO POST-ACUTE CARE
Total Medicare discharges 277,639Total Medicare readmissions 50,524Medicare readmission rate 18.2%Total Medicare discharges to PAC* 111,000
% of total discharges to PAC 40%Total Medicare readmissions from PAC 22,000
% of total readmissions from PAC 44%Medicare PAC readmission rate 19.8%
*PAC = Home Health or SNF
OPPORTUNITY: READMISSIONS AVOIDED FROM POST-ACUTE CARE
Total Medicare discharges 277,639Total Medicare readmissions 50,524Medicare readmission rate 18.2%Total PAC readmissions 22,00020% reduction PAC readmissions 2. x 22,000 =4,400Remaining PAC readmissions 22,000 – 4,400 =17,600 New PAC readmission rate 17,600 / 111,000 =15.8%New Medicare readmission rate 46,124 / 277,639 = 16.6%
*PAC = Home Health or SNF
OPPORTUNITY: PATIENTS WITH HIGH UTILIZATION*
Total Medicare discharges 277,639Total Medicare readmissions 50,524Medicare readmission rate 18.2%Total HU discharges 46,958
% HU of total discharges 17%Total HU readmissions 21,881
% HU of total readmissions 43%HU readmission rate 47%
*HU = 4+ admissions in past 12 months
OPPORTUNITY: READMISSIONS AVOIDED FOR HU PATIENTS*
Total Medicare discharges 277,639Total Medicare readmissions 50,524Medicare readmission rate 18.2%Total HU readmissions 21,88120% reduction HU readmissions 2. x 21,881 =4,376Remaining HU readmissions 21,881 – 4,376 =17,505 New HU readmission rate 17,505 / 46958 =37%New Medicare readmission rate 46,148 / 277,639 = 16.6%
*HU = 4+ admissions/12 mo
20% REDUCTION IN POST-ACUTE CARE READMISSIONS + 20% REDUCTION IN HU READMISSIONS
Total Medicare discharges 277,639Total Medicare readmissions 50,524Medicare readmission rate 18.2%Total PAC + HU readmissions* 22,000 + 21,88120% reduction PAC readmissions 4,400 20% reduction HU readmissions 4,376Total avoided PAC+HU readmissions* 8,776New Medicare readmission rate 41,748 / 277,639 = 15%
*illustrative; not strictly additive
PORTFOLIO OF STRATEGIES
Reduce Readmissions Hospital Wide and State-Wide by 20%
by 2020
Reduce PAC Readmissions
Improve processes & practices for SNF
discharges
Improve processes & practices for Home Health discharges
Reduce HU Readmissions “Whole-person” care
Reduce Readmissions from Home
SIM/AAA investments in transitional care
coaching + linkage to services
Reduce Readmissions for THR/TKR
Improve pre-op, peri-op, post-op and
rehab practices & processes
BEST PRACTICES
Improvement in PAC, HU, and THR/TKR readmissions is possible
ALIGNED INCENTIVES:
READMISSIONS AND MEDICARE SPENDING PER BENEFICIARY
• Effectively exposes all hospitals into a “bundle” payment• Hospitals must find ways to reduce cost of care overall
• CMS will provide cost broken down by: • 3 days before hospitalization• Cost of hospitalization• Cost 30-days post discharge• Overall by: inpatient, outpatient, home health, SNF, hospice, DME
• Hospitals judged by both performance and improvement
“POTENTIAL FOR EFFICIENCY IMPROVEMENTS IN POST ACUTE CARE UTILIZATION…..”
“CONDITIONS FOR WHICH POST ACUTE CARE ACCOUNTS FOR A LARGE PERCENT OF EPISODE PAYMENTS PROVIDE HOSPITALSWITH A STRONGER INCENTIVE TO EFFICIENTLY MANAGE POST
ACUTE SERVICES.”
CMS technical guidance on MSPB
ALIGNED INCENTIVES: COST OF HOSPITALIZATIONS FROM SNF
Reason for Hospitalization Total Cost $ / HospitalizationSepsis $3 billion $17,430Pneumonia $850 million $9,500CHF $640 million $8,700Aspiration Pneumonia $618 million $12,200Complications $450 million $14,600
OIG November 2013
• Hospitalization of patients from SNF/LTC averages $11,255
• Average Medicare hospitalization cost is $8,447
• 33% higher
PAC BEST PRACTICE #1SNF WARM HANDOFFS WITH “CIRCLE BACK”
Warm RN-RN Handoff to SNF
Hospital calls back SNF 3-24h after d/c to ask 6 questions1. Did the patient arrive safely?2. Did you find admission packet in order?3. Were the medication orders correct?4. Does the patient’s presentation reflect the information you received?5. Is patient and/or family satisfied with the transition from the hospital to your facility?6. Have we provided you everything you need to provide excellent care to the patient?
Source: Emily Skinner, Carolinas Healthcare System
PAC BEST PRACTICE #2ACUTE CARE MANAGEMENT TEAM “WARM FOLLOW UP”
• ACO or Bundle clinical coordinator• Air traffic control (lists of patients, PAC provider, coordinates virtual co-management rounds)
• Physical rounds in SNF • Acute Care Team sends RN / NP to see patient, discuss plan with SNF staff• Respond to changes in clinical status to manage in setting
• Virtual care management rounds with SNF• Weekly telephonic rounds ACO/bundle coordinator and SNF• LOS, progress toward discharge goals, discharge planning
• Tele-medicine consults in SNF for follow up• Tele-evals for change in clinical status
• Direct admit to SNF from home if need escalated care• Leverage the “continuum” to avoid readmissions
Key lessons:
• Took a while to develop collaborative rapport v. “hospital is in-charge”
• No substitute for verbal communication and problem solving
PAC BEST PRACTICE #3INTERACT: INTERVENTIONS TO REDUCE ACUTE CARE TRANSFERS
https://interact2.net/tools_v4.html
• Hallmark Health System • 2 hospital system, 20 ED docs, 17 PAs• “Why are almost all SNF patients admitted?”• “Patients only seen once a month”; “can’t do IVs”, etc• “If they send them here they can’t take care of them”
• Actions:• Asked ED clinicians “5 whys”• Education: posted INTERACT SNF capacity sheets in ED• Simplicity : establish contacts, standard transfer information
• Results: increase in number of patients transferred from ED to SNFSource: Dr Steven Sbardella, CMO and Chief of ED
Hallmark Health System Melrose, MA
PAC BEST PRACTICE #4HALLMARK HEALTH SYSTEM TREAT-AND-RETURN TO SNF
0
10
20
30
40
1 2 3 4 5 6 7 8 9
# Treat-and-Return to SNF
PAC BEST PRACTICE #5SNF TRANSITION TO HOME PROGRAM
• “Home and Healthy Program” • Comprehensive discharge planning: appointments, services made• Reviews all information with resident, family, caregiver• Direct contact after SNF discharge
• Phone call next day• Once a week for a month• Once a month for 3 months
Courtesy of Keswick Multi-Care, Maryland
HU BEST PRACTICE #1STRATEGIES FOR MANAGING THE CARE OF HIGH UTILIZERS
1. Real-time identification
2. Identify the “drivers” of utilization• Not the cc or primary dx, not even the chronic dz, but rather the social, behavioral, clinical
factors that drives repeated use• Often best identified using a non-clinical lens
3. Address the driver(s) of utilization• High frequency contact in the community• Problem-solving occurs over time until driver is addressed • Frequently social workers and navigators are effective
4. Use “care plans” to convey utilization history, driver(s) of utilization, services in place, and key advice to ED staff to guide care at next presentation
HU BEST PRACTICE #2HU PROGRAM AT LARGE COMMUNITY HOSPITAL
• Target population: all adults with 4+ hospitalizations in past 12 months• 427 people, collectively utilized 2200 admissions; 38% readmission rate
• Flag to identify in real-time• Identify patients upon admission when it’s their 4th or more visit in past 12 mos• IT produces a daily report – goes to a dedicated HU team
• MD, RN, SW, CHW dedicated team• Identify clinical/behavioral/social issues that may be “driving” utilization• Generate “first draft” care plan in 5 minutes – living document evolves over time
• Timely follow up• Goal is 100% contact within 48 hours of discharge
• Connection, contact, problem solving, resource mobilization to achieve “stability”• Everything effective occurs outside the limited time constraints of the clinical encounter
• Measure to drive programmatic improvement• % patients with timely follow up, % patients with care plans, # contacts, # F2F visits, # readmissions
0204060
Q1 Q2 Q3
HU Readmission Rate
ReadmissionRate
HU BEST PRACTICE #3HU PROGRAM AT LARGE COMMUNITY HOSPITAL
• Identifying HU in real-time is essential• Time to establish initial contact is while they are in-house• Essential to facilitate successful post-hospital engagement• Executive prioritization of creating the flag is needed
• Take a “continuation of care” approach• Offer to continue to care for them post-discharge to ensure their needs are met• Avoid offers to “enroll” them in a “special program” – not working well in the field
• Be proactive, persistent, and patient• Once identified as a HU, consistently engage and re-engage on subsequent visits• Establishing a trusted, helpful presence is key
• Don’t over-medicalize repeated hospital utilization• What is most “complex” about HU are the unmet social needs or behavioral influences• Rarely is the medicine itself truly complex
THR/TKR BEST PRACTICESVIRGINIA BASED SUCCESSFUL APPROACHES
• Understand the penalty – what’s being measured• Understand your data• Form a committee: inter-departmental, inter-disciplinary• Improve patient education materials – Zones with Action Steps• Perioperative Nurse Navigation• Review all readmissions: “every readmission matters”
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 300
50
100
Num
Total Knee Post Discharge Days Drgdesc
0 5 10 15 20 25 30 35 40Tka Num
POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC
RED BLOOD CELL DISORDERS W/O MCC
PULMONARY EMBOLISM W/O MCC
G.I. HEMORRHAGE W CC
CELLULITIS W/O MCC
SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W MCC
COMPLICATIONS OF TREATMENT W CC
MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTR..
RENAL FAILURE W CC
PERIPHERAL VASCULAR DISORDERS W CC
AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TIS..
38
19
18
27
13
10
24
14
22
12
11
Most Common TKR Readmission DRGs for Patients Admitted (<5 Days)
Courtesy Centra and VA Hospital Center
COORDINATED ACTION
Activities to support aligned learning & action
Statewide Learning & Action
• Statewide collaborative June 2016 to November 2018• Focus on PAC, HU, THR/TKR in parallel• Engage with partners in PAC• Engage with VHQC for cross-continuum work• Engage with AAAs for community based care/CTI• Provide, use, interpret data from VHHA & VHQC
Planned Activities for Learning & Action
June 16tth* High Leverage Strategies
August 17th* PAC & HU Data/Measurement
Sept. TBD Learning & Action Workshop
October 19th* High Utilizers
December 6th* PAC Readmissions
February 1 Learning & Action Workshop
*All webinars will be offered at 10am
DISCUSSION
ADJOURN