Download Maintaining Patient Health After A Hospital Stay.

Presenters:
Kathy Cummings, ICSI
Kattie Bear-Pfaffendorf, MHA
Janelle Shearer, Stratis Health
www.RAREreadmissions.org
James and Martha
Copyright © 2010 by ICSI
How do avoidable
readmissions
impact your
clients?
What challenges
do you face in
preventing
readmissions?
What is happening?
Why is reducing readmissions important?
Business View
• Federal
• 1% penalty on Medicare for “greater
readmissions than expected” in 2013
• Looks at heart attacks, congestive heart failure,
pneumonia, COPD, and potentially other conditions
• Penalty increases 1% per year until reaches 3%
• Only big hospitals (so far)
• MN
• Medicaid payments reduced by 10%, can earn back
5% if reduce avoidable admissions over 2 years
Hospital Compare
2010-2012
Heart Attack
MN
US
Better than national
average
Same as national average
Worse than national
average
Too Small
Heart Failure
MN
US
Pneumonia
MN US
0
30
0
95
30
2338
94
3959
0
93
41
2110
0
37
162
613
0
33
114 4325
0
17
125
376
2013 Penalties
• Range .01 - .81% Maximum was 1%
• Number of hospitals with a penalty
– 28 out of 52
• 13 States have less penalties than
Minnesota
RARE Campaign: Maintaining
patient health after
a hospital stay…
…So We All
Sleep More
Peacefully.
What is the RARE Campaign?
• A campaign across the continuum of care to reduce
avoidable hospital readmissions across Minnesota and
surrounding areas
• Regional approach, supported by hospitals, providers,
health plans, other key stakeholders
• Campaign is engaging other care providers,
acknowledging that readmissions are the result of a
fragmented health care system
Broad Community Support
• Operating Partners:
• Institute for Clinical Systems Improvement (ICSI)
• Minnesota Hospital Association (MHA)
• Stratis Health
Broad Community Support
• Supporting Partners:
• Minnesota Medical Association
• MN Community Measurement
• VHA Upper Midwest
Broad Community Support
• Community Partners:
– Endorse and actively support the campaign
• A growing list of providers, health plans, state health
agencies, home health agencies, nursing homes,
patient advocacy groups and other community
organizations
• Complete list on www.RAREreadmissions.org
Triple Aim Goals
• Population health
– Prevent 6,000 avoidable readmissions within 30 days
of discharge by the end of 2013
– Reduce overall readmissions rate by 20% from the
2009 and maintain that reduction through 12/13/13.
• Care experience
– Recapture 24,000 nights of patients’ sleep in their
own beds instead of in the hospital
• Affordability of care
– Save millions of dollars in health care expenses
Care Across the Continuum
Campaign Design
Five Focus Areas
Patient and Family Engagement
Transition Communication
Comprehensive
Discharge
Plan
Medication Management
Transition Support
Supporting Work Groups
•
•
•
•
•
•
Medication Management
Mental Health
Epic Users
Measurement
Long Term Care
Health Plan Care Managers
Learning Collaboratives
• Project Red
• Safe Transitions
• Care Transitions Intervention
Recommended Actions for
Improved Care Transitions
Patient Family Engagement and Activation
1. Use Teach Back to assess
patient’s understanding of any
instructions
2. Ensure caregivers are
engaged in developing the
plan of care
3. Use Health Literacy
Standards such as AHRQ
Health Literacy Universal
Precautions
Comprehensive Discharge Planning
A written patient centered plan
must include:
1. Reason for hospitalization
including information on disease
in terms patient can understand
2. Medications to be take post
transition:
Purpose, dosage, when and how to take,
how to obtain refills.
3.
4.
5.
6.
Self-care activities
Durable Medical Equipment
Symptom Recognition and
Management
Coordination and planning for
follow-up appointments
Medication Management
1. Medication reconciliation at
each patient transition with
date
2. Medication list should
contain purpose for each
medication
3. Pre/post hospital
medications changes
should be made clear to the
patient
4. Medication discrepancies
need to be evaluated and
acted upon.
5. Use Teach Back when
instructing patients on
medication use
Care Transition Support
1. Follow-up appointment
within 5 business days
2. Available appointment
slots
3. Follow-up arranged
with ancillary services
such as PT, OT, RT
4. Within 72 hours a
purposeful contact with
patient is made by a
care team member
Follow-up Visit should focus on:
1. Patient’s goals for the
visit
2. Patient’s needs for
medication adjustment,
test results, advance
directives
3. Instruction on self
management
4. Explanation of warning
signs and how to respond
5. Instructions for seeking
emergency and non
emergency after hours
care.
Transition Communication
1.
2.
3.
4.
5.
PCP notified when patient
admitted or discharged.
Patients know who is
responsible for care and how to
contact them.
Concise transfer forms with key
elements must be sent with the
patient in every transfer.
Direct reports between nursing
staff.
Complete discharge summaries
should be received by the
accepting facilities within 3
business days.
What Clinic Providers Can Do
Medication
Management
• What & How
• Use Teach Back
• Offer Medication
Therapy
Management
What Clinic Providers Can Do
Patient and Family Engagement
• Have the patient and family set goals for care
• Involve caregivers in discussions and
decisions about care
• Use Teach Back when educating the patient
and their caregivers
• Use language and materials that are easy for
the patient and their caregiver to understand
•
What Clinic Providers Can Do
Care Transition Support
Provide access to a post-hospital
appointment within five (5) business days
of patient discharge, or sooner if the
condition warrants
What Clinic Providers Can Do
• The content of the follow-up visit should focus on:
–
–
–
–
–
Patient’s goals for the visit
Factors contributing to admission or ER visit
Patient’s needs for medication adjustment
Follow-up on test results, monitoring and testing
Advance directives, specific future treatments such as
Physician Orders for Life Sustaining Treatment (POLST)
– Patient needs for instruction on self-management using
Teach Back
– Explanation of warning signs and how to respond using
Teach Back
– Instructions for seeking emergency and non-emergency
after-hours care
What Clinic Providers Can Do
• Care Transition Communication
• Work with your local hospital to develop
processes for notifying primary care provider
when the patient is admitted and when they are
discharged
• Contact the patient within 72 hours of discharge
to review their transition plan, medications,
warning signs, current status and selfmanagement
Recommended Actions for
Improved Care Transitions
Mental Illnesses and Substance
Use Disorders
www.RAREreadmissions.org
Participant Resources
Why Do Readmissions Matter to You?
Small Group Discussion:
1. From your perspective, what do you want
other care settings to know about your
setting and the issues with care
transitions?
2. What is being done in your community to
prevent readmissions?
3. What improvements would you like to see
in your community?
“Potentially Preventable
Readmissions”
• Data source – MHA Database
• All-payer inpatient claims for all MN hospitals
• But, can only look at readmit to same facility
– 22% readmits to different facility
• Software – 3M Potentially Preventable
Readmissions
• 3M’s clinical experts developed methodology
• Each record designated as admission or readmission
• Calculates severity-adjusted PPR rates by condition &
by hospital
Overall Observed to Expected Ratios for Potentially Preventable
Readmissions for Minnesota Hospitals, 2009
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
A value <1 means fewer PPRs than
expected; >1 means more than expected
Potentially Preventable Readmissions in Minnesota
2009 - 2012 4th Qtr
1.05
1
Actual to Expected Ratio
0.95
4570 Avoidable Readmission
Prevented
0.9
0.85
18,280 Nights of sleep
At HOME
RARE Campaign
Launched
0.8
0.75
0.7
2009
2010
2011-1
2011-2
2011-3
Goal
2011-4
MN RARE
2012-1
2012-2
2012-3
2012-4
www.RAREreadmissions.org
24,000 Nights At Home
Will Make Our Day.
Thank You For
Helping Everyone Sleep
More Peacefully.