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Improving Transitions from
Hospital to Community Care:
Models that Work
David G. Schulke
Vice President, Research
Health Research and Educational Trust
[email protected]
(202) 626-2319
October 18, 2011
The Health Research and Educational Trust
(HRET)
• HRET’s mission is to transform health care
through research and education.
• AHRQ has retained HRET to support statebased 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 Presentation
1.
2.
3.
Review research behind new financial
incentives to reduce readmissions in the
Patient Protection and Affordable Care
Act (ACA).
Examine the importance of patient
centered care and the relationship
between hospitals and other providers in
the community.
Describe proven strategies hospitals use
to improve care and protect against
financial penalties, focusing on Project
RED.
The Discharge Process and Post-hospital Care
Influence 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
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
Hospital 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 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, Medicaredependent rural hospitals, low volume conditions
• CMS proposes more conditions for 2014—

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Chronic Obstructive Lung Disease
Coronary Artery Bypass Graft surgery
Percutaneous Coronary Interventions
Vascular Procedures
Potential Financial Impact of Readmissions
Penalty at a Small Community Hospital
Laurens County Health System (76 acute, 14 SNF beds)
and SCHA modeled potential annual effect of penalties:
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
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:
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“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
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
(Source: Archives of Internal Medicine. 2007; 167: 1305-11)
• 41% inpatients discharged w/ pending test result
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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 available:
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Only 12-34% at first post-discharge appt; 51-77% at 4 weeks
• Discharge summary lacking key components:
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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:
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37% able to state purpose of all medications
14% knew the common side effects
42% able to state their diagnosis
• Result:
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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:
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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
after Hospital Discharge
Source: Jencks SF, et al. N Engl J Med 2009;360:1418-1428
Hospital Admissions Vary for Ambulatory
Sensitive Conditions
2007 Medicare SAF data
Hospital Admissions of Short Stay
Nursing Home Residents
2006 Medpar Data
Hospital Admissions of Home Health Patients
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
Effective Transitional Care
• Engage patients early in hospitalization
• Give patients comprehensive postdischarge 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 Use
Impact of Project RED:
Reengineering 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 postdischarge (most hospitals struggle to arrange
pharmacist calls)
RED 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:
Reconcile 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 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
Plan 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
RED Component #4: Make appointments for
clinician follow-up and post-discharge testing
• 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 #5: Discuss with Patient
Pending 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:
Organize 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
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
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 discharge
HCAHPS questions about the discharge process:
•
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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,
and 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
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:
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“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
of the After Hospital Care Plan after Discharge
• RED intervention calls for a pharmacist to call
the patient within 72 hours after discharge
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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
Checklist to find Improvement Opportunities
Sample Current State
Project RED components
Process
Med Reconciliation
Discharge order
National guideline used
Discharge Instruction
Follow up Appointment
Form
Outstanding Tests
Discharge teaching on
Post DC services
day of discharge
Written DC Care Plan
No Discharge Advocate
Problem vs. Emergency
No appt scheduled
Patient Education
No post DC phone call
Assess Patient Learning
No PCP DC Summary
DC Summary to PCP
Post DC Phone Call
Source: JCR
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/qu
al/goinghomeguide.pdf
Health Care Leader Action Guide
Provides strategies for you
to–
 Examine your hospital’s
current rate of readmissions
 Assess and prioritize your
improvement opportunities
 Develop 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_resou
rces/interventionpackages/hra.aspx
• QIO program originated toolkit for nursing
homes: Interact2.net
Thank you!
Your Questions and
Comments are Welcome!
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