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No Place Like Home: A Community Approach to Reduce Avoidable
Hospital Readmissions and Improve Medication Management
Barb Averyt, BSHA Program Director, Care Coordina8on Health Services Advisory Group (HSAG)
September 18, 2015
HSAG: Your Partner in Healthcare Quality
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HSAG is the Medicare QIN-‐QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands.
Nearly 25 percent of the naEon’s Medicare beneficiaries
Objec8ves
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Illustrate why a community approach is necessary to reduce avoidable hospital readmissions.
Describe how the community approach is actually working in the Phoenix West Valley.
Iden8fy current strategies being used to effect medica8on management across the con8nuum.
Centers for Medicare & Medicaid Services (CMS) Hospital Readmission Penalty
• Age 65 or over • Discharged from non-‐federal acute-‐care hospitals • Not transferred to another acute care facility • Enrolled in Part-‐A Medicare for the 12 months prior to the date of the index admission
• Penalty determined by readmissions for CHF, AMI, PNE, COPD, TKA/THA; however, applied to all DRG payments
• Can be up to a 3% financial penalty for the year
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Source document: 2014 Measures Updates and Specifica8ons Report Hospital-‐Wide All-‐Cause Unplanned Readmission – Version 3.0, CMS, March 2014 5
The Inclusion/Exclusion Algorithm for Index Admission
Na8onal Impact: How Did Hospitals Fare?
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FY 2013 Began Oct. 2012
FY 2014 Began Oct. 2013
FY 2015 Began Oct. 2014
Total hospitals penalized 2,217 2,225 2,610
Hospitals receiving maximum penalty 307 at 1% 154 at 1%
18 at 2% 39 at 3%
Na8onal average fine 0.42 0.38 0.63
$$ recouped by CMS $280 million $227 million $428 million
What Is in Store for Fiscal Year 2016?
• Based on claims data from July 1, 2011, to June 30, 2014
• Up to 3 percent financial penalty to all readmissions • The penalty determining diagnos8c-‐related group (DRGs) remain the “big five”: 1. Acute myocardial infarc8on (AMI) 2. Pneumonia (PNE) 3. Conges8ve heart failure (CHF) 4. Chronic obstruc8ve pulmonary disease (COPD) 5. Total knee arthroplasty/total hip arthroplasty (TKA/THA)
• For fiscal year 2017, coronary artery bypass gran (CABG) will be added
7 Source Document: Federal Register / Vol. 80, No. 83 / Thursday, April 30, 2015 / Proposed Rules
What Does the 2016 Penalty Look Like?
• CMS es8mates that 2,666 hospitals will have their payments reduced.
• Na8onally, es8mated payment reduc8on of approximately $420 million in fiscal year 2016.
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$280
$227
$428 $420
$200
$250
$300
$350
$400
$450
2013 2014 2015 2016
$ Recouped by CMS, in Millions
Arizona Impact: How Did Arizona Hospitals Fare?
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27
14
31 34
43
5
0 3 2
0 2
0
5
10
15
20
25
30
35
40
45
50
2013 2014 2015
No penalty
< or =50%
> or =51%
Full penalty
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Readmission Penal8es Are Coming to Others
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Why a Community Approach Makes Sense
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Medicare Fee-‐For-‐Service Pa8ent Ac8vity in 2013
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30-‐Day Readmissions by Volume—2013
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All-‐Cause Readmissions to Another Hospital
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West Valley 2013: Five or More Emergency Department (ED) Visits
• 458 dis8nct Medicare beneficiaries (MBs); 3,532 ED visits annually
• Treat and release—not admited • The top diagnoses for ED visits were due primarily to causes such as abdominal pain, urinary-‐tract infec8ons, headaches, and backaches
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Diagnosis Code DescripEon
789.09 Abdominal pain, other specified site
599.0 Urinary tract infec8on, site not specified
784.0 Headache
789.00 Abdominal pain, unspecified site
724.5 Backache, unspecified
Hot-‐Spoung by Zones
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Hot-‐Spoung: Blue Zone 126 MBs—751 Admissions/Readmissions
ZIP Code
# of MBs
Admissions A[ributed
85310 3 18
85027 13 77
85382 15 81
85381 9 55
85373 8 41
85351 29 168
85345 19 126
85308 10 62
85306 13 83
85053 7 40
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Hot Spoung: Orange Zone 58 MBs—351 Admissions/Readmissions
ZIP Code
# of MBs
Admissions A[ributed
85340 2 11
85395 7 42
85392 5 26
85323 3 17
85353 1 6
85043 3 26
85035 1 7
85033 5 36
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Source of Readmissions Within 7 Days of Hospital Discharge
846, 60% 204, 15%
11, 1% 110, 8%
229, 16%
Readmited from these care seungs
Home HHA Hospice Other Nursing Home
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• 60 percent of pa8ents readmited within 7 days from hospital discharge had been discharged to home without home health agency (HHA).
7-‐Day Readmissions and High-‐Risk Medica8ons
• Of the 1,400 pa8ents readmited within 7 days of hospital discharge, 396 pa8ents were on high-‐risk medica8ons.
• That is more than one out of every four.
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Group Ques8on
Which high-‐risk medica8on had the largest usage? A. An8coagulants B. Diabe8c medica8ons C. Opioids
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High-‐Risk Medica8ons
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• Readmissions drug category breakdown: – An8coagulants = 80 pa8ents
– Diabe8c agents = 104 pa8ents
– Opioids = 212 pa8ents
20% 26% 53%
Community Root Cause Analysis
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WVCCC Structure
WVCCC Steering
Commitee
7-‐Day Care TransiEon Workgroup
MedicaEon Management Workgroup
Hospice and PalliaEve Care Workgroup (pending)
Community Paramedicine StandardizaEon
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7-‐Day Care Transi8on
Hospital Discharges
Medicare FFS or ACO* pa8ents
Discharged to home
Pa8ents on High Risk Meds and/or AMI, CHF, PNE, and COPD**
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* Fee-‐for-‐service (FFS), accountable care organiza8on (ACO) ** Acute myocardial infarc8on (AMI), conges8ve heart failure (CHF), pneumonia (PNE), chronic
obstruc8ve pulmonary disease (COPD)
The interven8on is to have a face-‐to-‐face “touch-‐point” within 24–72 hours of hospital discharge.
Target Popula8on for Interven8on
Community Paramedicine Standardiza8on
• Involves nine city fire departments • Six-‐month pilot project underway with Buckeye Fire Department and Banner Estrella Medical Center
• Gleaning the lessons learned from the pilot and establishing standardized elements to the visits for a community approach
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Medica8on Management Workgroup
Chair: Tim Ranney, MD
Chief Medical Officer, Banner Estrella Medical Center
Comm. Pharmacy/ Health Plan
Subcommi[ee Interven8on: Appointment-‐Based Model 1. Medica7on Synchroniza7on 2.Monthly pt. call 3. Scheduled monthly visit
In Home/ Home Health Subcommi[ee Interven8on:
U7lizing monthly rapid-‐cycle process improvement. One focus: Opioids
Nursing Homes Subcommi[ee Interven8on: Medica7on reconcilia7on upon admission and/or discharge from hospital to nursing home.
Hospital Subcommi[ee Interven7on: Obtain an accurate medica7on history for
admiIed pa7ents using a pharmacy technician model.
Technology Subcommi[ee Interven8on: Interoperability across provider
seJngs .
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Next Steps – Spread to East Phoenix
EVEVCCC
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This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organiza8on for Arizona, 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. Publica8on No. AZ-‐11SOW-‐C.3-‐08202015-‐01
