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MSG would like to thank Critical Signal
Technologies for their generous
support of this webinar!
Nancy D. Vecchioni, RN, MSN, CPHQ
Vice President Medicare Operations, MPRO
Co-Lead MI STA*AR
IHI Improvement Advisor
Reducing Re-Hospitalizations: Background
Re-hospitalizations are:
•
•
•
•
Frequent
o 18% of all Medicare hospitalizations are 30 day re-hospitalizations
o Average >20% for certain patient populations
Costly
o 30-day re-hospitalizations account for $15B in Medicare annual spending
o In total, hospitalizations account for one-third >$2T US healthcare spending
Potentially avoidable
o 76% of Medicare re-hospitalizations were “potentially preventable” based on 3M
definition
o 14-46% in general hospital populations in retrospective clinician reviews
Actionable for improvement
o Individual delivery systems and health services researchers have demonstrated
dramatic (30-90%) reduction of 30-day readmission rates for certain patient
populations ( such as patients with HF)
40% of Medicare beneficiaries are discharged
from an acute care hospital stay to a post-acute
care setting; of those, roughly half enter a nursing
home for skilled nursing care or rehabilitation
services. HCUPnet. 2009 [cited 2009 July 21]; Available from:
http://hcupnet.ahrq.gov.
Mor et al. (2010) report that on average 23.5% of
SNF residents are rehospitalized within 30 days of
an acute care hospital discharge amounting to a
total annual cost of $4.35 billion for Medicare
alone based on analysis of CMS data from 20002006; their study further noted a 29% increase in
rehospitalizations during this time period.
Michigan has the sixth greatest SNF resident
readmission rate (25.8%) in the US,
At an estimated $175 million Medicare
expenditure annually.
Michigan also has the fifth greatest rate of prior
nursing home use among rehospitalized residents.
Figure 1: Rehospitalization Rates in Total and by
Prior Nursing Home Use among Medicare
Beneficiaries, 2000-2006 (Mor, V., et al., The Revolving
Door Of Rehospitalization From Skilled Nursing Facilities. Health
Affairs, 2010. 29(1): p. 57-64)
If Re-hospitalizations are Prevalent, Costly, and Able to be
Reduced, Why Haven’t They Been?
• Hospital-level barriers
o Financial disincentives (volume-revenue), no financial incentives, not part of
P4P contracts, not high on priority list, limited disease-specific efforts
• Community-level barriers
o Not common to engage organizations across continuum to collaborate on
improving care, frustration between inpatient and post-acute providers,
unfamiliar with availability of community resources and community based
organizations lack of IT connectivity, no reimbursement for coordination
• State-level barriers
o Lack of population-based data, lack of understanding costs of poor quality
on systems, effect of fragmented payer market and lack of CMS participation
Patients Tell us How to Improve Care
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Inadequately prepared for the next setting
Conflicting advice for illness management
Inability to reach the right practitioner
Difficulty navigating the health care
system
Hospital Readmissions Reduction
Program (section 3025)
•Reduction in payments to hospitals with
excessive readmissions
•Definition of “readmissions” includes the
readmission to the same or another
hospital
•Excessive readmissions will be defined by
the HHS secretary
Readmissions
Healthcare reform provisions
• Up to 3% cut to all DRGs for readmissions over expected
• Up to 1% in FY 2013, 2% in FY 2014, not to exceed 3% in 2015 and
beyond
• Initially AMI, CHF, PN
– Expands to COPD, CABG, PTCA, and other vascular in 2015
• 10 year savings: $7.1 B
Hospital
Readmissions
Penalties
capped at 2%.
(FY 2014)
Hospital Readmissions – HHS
Shares data with hospitals on 3
Selected conditions: Penalties
Capped at 1% (FY 2013)
2010
2011
2012
2013
2014
2015
Hospital Readmissions
Penalties capped at 3%
(FY 2015 and beyond)
2016
2017
10
PRODUCT Line
30-Day All Cause Readmissions- Time Period: CY2008- PROVISIONAL DATA
Payers: HAP, Health Plus, Medicaid, Priority Health, Medicare, BCN, BCBSM
See Data Definitions for Column Descriptions
a
b
c
d
e
f
g
Type of Index Discharges
RA to the Same Hospital
RA to a Different Hospital
at Risk
AGE GROUP Admission
Reporting Template:
Adult
Pediatric
Commercial
Post-neonatal
Neonatal
M
S
O
M
S
O
M
S
M
S
Total
Adult
Medicaid FFS
(managed care data not
shown for presentation
purposes)
Pediatric
Post-neonatal
Neonatal
M
S
O
M
S
O
M
S
M
S
Total
Medicare (FFS)
Adult
Total
Total by Age Group Adult
Pediatric
Post-neonatal
Neonatal
Grand Total
11
Adult Medical
Discharges
Pediatric Medical
N
N
%
Discharges
81,735
8,659
10.6%
M
S
84,878
41,667
11,260
3,537
547
3,173
878
24,935
386
252,996
64,017
18,513
31,200
7,039
1,296
1,151
2,472
355
31,498
73
157,614
280,012
117,311
398,836
737,544
26,378
7,365
58,481
829,768
4,480
997
774
181
20
196
52
286
26
15,671
5,234
1,013
940
1,406
131
35
233
51
347
5
9,395
45,250
9,797
55,419
78,696
2,591
553
702
82,542
Overall Rate
5.3%
2.4%
6.9%
5.1%
3.7%
6.2%
5.9%
1.1%
6.7%
6.2%
8.2%
5.5%
3.0%
20.0%
10.1%
3.0%
9.4%
14.4%
1.1%
6.9%
6.0%
16.2%
8.4%
13.90%
10.7%
9.8%
7.5%
1.2%
9.9%
N
%
2,844
1,123
174
194
32
6
58
24
149
10
4,614
2,134
317
203
104
13
13
86
11
403
5
3,289
11,657
2,712
14,573
21,884
369
183
581
23,017
h
I
RA to Any Hospital
N
3.5%
1.3%
0.4%
1.7%
0.9%
1.1%
1.8%
2.7%
0.6%
2.6%
1.8%
3.3%
1.7%
0.7%
1.5%
1.0%
1.1%
3.5%
3.1%
1.3%
6.9%
2.1%
4.2%
2.3%
3.7%
3.0%
1.4%
2.5%
1.0%
2.8%
11,505
5,603
1,171
968
213
26
254
76
435
36
20,287
7,368
1,330
1,143
1,510
144
48
319
62
750
10
12,684
56,907
12,509
69,992
100,583
2,960
736
1,283
105,562
%
14.1%
6.6%
2.8%
8.6%
6.0%
4.8%
8.0%
8.7%
1.7%
9.3%
8.0%
11.5%
7.2%
3.7%
21.5%
11.1%
4.2%
12.9%
17.5%
2.4%
13.7%
8.1%
20.3%
10.7%
18.0%
13.6%
11.2%
10.0%
2.2%
12.7%
Michigan Medicare Patient 30-Day All Cause
Readmission Rates (%) by County, 2009
Statewide Medicare Patient
Readmission Rate= 18.8%
Readmission Rates are Greatest
in Southeast Michigan
Medicare FFS Inpatient Data, ISAT Database
Race
White
Black
Other
Age
<65
65-74
Sex
>74
M
F
0
5
10
15
20
30-Day All-Cause Readmission Rate
25
30
30-Day All Cause Readmission Rate by Age, Race & Sex, Michigan
Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from
January 1, 2008 through June 30, 2010
CHF
Diagnosis (Dx)
AMI
PNE
COPD
Mental Health (Secondary Dx)
Other
0
5
10
15
20
25
30 Day All Cause Readmission Rate (%)
30-Day All Cause Readmission Rate by Selected Diagnoses, Michigan
Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from
January 1, 2008 through June 30, 2010
30
Urbanicity of Hospital
Urban
Rural
0
5
10
15
20
30 Day All Cause Readmission Rate (%)
25
Urban vs. Rural Hospital 30-Day All Cause Readmission Rate, Michigan
Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from
January 1, 2008 through June 30, 2010
30 Day all Cause Readmission
Rate (%)
30
25
20
15
10
5
0
No
Yes
Physician Follow-up
30-Day All Cause Readmission Rate by Physician Follow-up Prior to
Readmission or 30 days, Michigan Medicare (FFS) Beneficiaries
Discharged from a Michigan hospital from January 1, 2008 through June
30, 2010
Factors Contributing to Re-hospitalizations
• Health Literacy
• Lack of coordinated care
– From inpatient to outpatient settings (follow-up appointments,
medication management, etc.)
– Amongst clinicians in outpatient settings (primary and specialty
care, home care and primary care, etc.)
• Unreliable medication management
• Natural history of disease
• Patient/family caregivers’ lack of understanding of care needs
• Barriers to access (including the uninsured, geographical distance,
difficulty arranging post-discharge follow-up appointments, etc.)
• Missed opportunities with discharge planning
• Unreliable identification of need for and referral to services
18
Health Literacy
Capacity to:
• Obtain, process, understand basic health
information and services
• Make appropriate healthcare decisions (act on
information)
• Access/navigate healthcare system
Health Literacy
• 90 million adults have trouble understanding
and acting on health information
• Population of US in 2009 = 307,065,550
• 29% of the United States Population
• Approximately one in three people on this call
Red Flags for Health Literacy
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Frequently missed appointments
Incomplete registration forms
Non-compliance with medication
Unable to name medications, explain purpose or dosing
Identifies pills by looking at them, not reading label
Unable to give coherent, sequential history
Ask fewer questions
Lack of follow-through on tests or referrals
“How would you take this medicine?”
395 primary care patients in 3 states
Patient Safety: Medication Errors
• 46% did not understand instructions ≥ one label
• 38% with adequate literacy missed at least one label
Davis TC , et al. Annals Int Med 2006 105 Health Literacy
Universal Precautions Toolkit
Rates of Correct Understanding verses Demonstration
“Take Two Tablets by Mouth Twice Daily”
Handing Off
and
Receiving
the Baton
Deficits in Information Handover between Acute Care
and Extended Care Facilities
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22% of transfers had no formal summary of information;
Legible summaries were available only 56% of the time;
Secondary diagnoses were missing from 30% of transfers;
Only 51% had allergies documented;
Mental status was missing in 33% of cases;
Lab, chest x-ray, and EKG results were missing 31%, 67%, and 61% of the time,
respectively;
Do-not-resuscitate (DNR) orders and advanced directives were absent from 87% of
transfers;
Dietary information was missing 19% of the time; and
Clarification of information was difficult because identification of hospital physician
was only legible 41% of the time and phone numbers only 33% of the time.
Nearly Half of U.S. Adults Report Failures to Coordinate Care
Percent U.S. adults reported in past two years:
Your specialist did not receive basic
medical information from your
primary care doctor
13
Your primary care doctor did not
receive a report back from a specialist
15
Test results/medical records were not
available at the time of appointment
19
Doctors failed to provide important
medical information to other doctors
or nurses you think should have it
21
No one contacted you about
test results, or you had to call
repeatedly to get results
25
Any of the above
47
0
20
40
Source: S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S. Health System Organization:
A Call for New Directions (New York: The Commonwealth Fund, Aug. 2008).
60
Mr. Smith. It looks like you
have severe congestive heart
failure. Your cardiac enzymes
were negative, but your
ejection fraction was only
30%. You’ll need to take
some diuretics, an ACE-I, a
beta blocker, and aspirin.
hmmmm……. heart
failure?...
……(what?)….
30%......aspirin….
Yes
doctor.
Medication Use in the Elderly
• 20% community dwelling elderly (>65) take 10 or more medications
• Adherence drops with increasing the number of doses per day
– Average adherence falling from 80% (once daily) to 50% (4 times a day)
• Studies documented an average of 1 unnecessary drug per patient
• Adverse events occur with number of medications
– 5 to 35% per year
– Responsible for 10% of readmissions
• Communication gaps resulted in 37% of remediable adverse drug
events
• Hospitalized elderly-44% were discharged with at least 1
unnecessary medication
Barriers to Medication Adherence and
Targeted Solutions
• Forgetting to take
• Patient believes drug is not needed, ineffective
or too many
• Difficulty taking (opening bottles, swallowing)
• Cost
Current Discharge Process
• 81% of patients requiring assistance with basic functional
needs failed to have a home-care referral
• 64% said no one at the hospital talked to them about
managing their care at home
• Flawed Process
– Discontinuity between inpatient and outpatient providers
– Inadequate Communication
– Lack of medication reconciliation
– Inadequate patient education
Incidence and Severity of Adverse Events Affecting
Patients after Discharge from the Hospital
MI STA*AR Overview
• An Institute for Healthcare Improvement (IHI) initiative to
reduce avoidable 30-day rehospitalizations
– Commonwealth Fund grant
• May 2009 – May 2013
• MPRO and MHA co-leading statewide initiative
– Improvement Advisors to assist teams
• Three states selected as partners in this initiative
(Massachusetts, Michigan, Washington)
Goals
• Increase patient and family satisfaction
with transitions in care and with
coordination of care
• Reduce each state’s all-cause 30-day
rehospitalization rates by 30 percent
Steering Committee Members
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Tina Abbate Marzolf
Caroline Blaum, MD, MS
Amy Boutwell, MD, MPP
Peggy Brey
Laura Champagne
Ed Gamache
David Herbel
Jeanette Klemczak, RN, MSN
David LaLumia
Cecelia Montoye, RN, MSN, CPHQ
Susan Moran
Richard Murdock
Julie Novak
Larry Abramson, DO
Appointment Pending
Tom Simmer, MD
Nancy Vecchioni, RN, MSN, CPHQ
Sam R. Watson, MSA, MT (ASCP)
Appointment Pending
Robert Yellan, JD, MPH
Harvey Zuckerberg
CEO, Area Agency on Aging 1-B
Gerontologist, University of Michigan
Institute for Healthcare Improvement
Deputy Director, Office of Services for the Aging, MDCH
Executive Director, Citizens for Better Care
President, Michigan MICAH
President & CEO, Aging Services of MI
Chief Nurse Executive, MDCH
President & CEO, HCAM
Michigan Chapter , American College of Cardiology
Bureau Director, Medicaid Program Operations and QA
Executive Director, MAHP
Executive Director, MSMS
Michigan Osteopathic Association
Michigan Hospice & Palliative Care
Senior VP & CMO, BCBSM
VP Medicare Operations, MPRO
Senior VP Patient Safety and Quality, MHA
Policy Advisor, Office of Governor
President and Chief Executive Officer, MPRO
Executive Director, MHHA
Strategies to Reduce Rehospitalization
AC LTAC EC HH PO
Perform an Enhanced Assessment of Post-transition Needs
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Provide Effective Teaching and Facilitate Learning
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Provide Real-time Patient Centered Handover Communications
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Ensure timely Post- Transition Care Follow-Up
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Ensure staff ready and capable to care for the patient
Engage the patient and family members in a partnership to create
an overall plan of care
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Obtain a timely consultation when the patient’s condition changes
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Identify patients at high risk of rehospitalization and implement
interventions to reduce risk
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Coordinate care across acute care and outpatient providers and
settings
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Interventions
Acute Care
• Providing from three to 30-day supply of medications at transition home
• Health plans overriding their formulary
• Switch from brand to generic medications e.g., 8 medications 40 dollars a month
• Follow-up appointments made prior to the patient transition
• Nurse calls patients 48 hours post transition
• Home visits to patient within 1 to 2 days of transition
• Extended care, home health and health plan case managers make visits to hospitalized
patients and discuss case with the hospital team
• Patients/care givers assist in design of educational materials
• Standardization of communication handover
• Transitions to nursing homes between 11am and 2pm
• Non nursing staff conducting Teach Back
• Standardized transition form
• Case managers in emergency department
• Integration of interventions in EMR
Interventions
Extended Care/LTAC
Home Health Care
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Total implementation of INTERACT
– Standardized communication
– Standardized process for determining
transfers to hospital
– Care paths
Consistent assignment/consolidated med
pass
Verbal communication prior to transition
Work with patient/care giver to make followup appointment to PCP
Call patient 48-72 hours after transition home
Shift huddles to discuss high risk residents
Standardized transition form
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Front load visits
Sliding scale medications
SBAR communication
After hours care-24-7
Telehealth
EMR bracelet
Standing orders
Program redesign to incorporate
patient coaching model
Emergency department liaison
Standardize transition form
Teach Back
• Explain needed information to the patient or family
caregiver
• Ask in a non-shaming way for the individual to explain
in his or her own words what was understood
• If a gap in understanding is identified, offer additional
teaching or explanation followed by a second request
for Teach Back
Schillinger D et al. Closing the loop: physician communication... Arch Intern Med. 2003;163:83-90.
Teach Back: Measuring Patient Understanding
Teach Back questions for patients with
HF:
1. What is the name of your “water
pill”?
2. What weight gain should you report
to your doctor?
3. What foods should you avoid?
4. Do you know what symptoms to
report to your doctor?
INTERventions to reduce Acute Care Transfers
• Goals
• Increase the use of strategies and tools that may help reduce
ACT of nursing home residents by utilizing the INTERACT
TOOL KIT, and
• Decrease the number of potentially avoidable ACT of nursing
home residents that result in emergency room visits and/or
hospitalizations.
http://www.qualitynet.org/dcs/ContentServer?c=MQTools&pagename=Medqic%2FMQTools%2FToolT
emplate&cid=1211554364427
INTERventions to reduce Acute Care Transfers
• Communication about residents with acute changes in
condition among staff at the nursing home as well as
between the nursing home and hospital;
• Care paths for common acute conditions in nursing
home residents that guide treatment in the nursing home
when feasible; and
• Advance care planning that will assist in reducing
potentially avoidable acute care transfers of residents who
are terminally ill and/or on a palliative care plan
To improve the quality of care
people receive at the end of life
through effective communication
of patient wishes, documentation
of medical orders and a promise
by health care professionals to
honor these wishes.
http://www.ohsu.edu/polst/
Standardization of communication and
information between sending and
receiving organizations
– Acute and Post Acute Care providers
identified critical information
– Implementing into EMRs and
electronic communication between
providers
Does not replace verbal handover
communication
Additional Community Initiatives
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FUSE
Patient coaching provided by area agencies on aging
Call to Care
Aligning processes with between healthcare and
community based organizations and resources
• SOAR (Stepping Stones to Recovery)
• Medication Reconciliation across the continuum of care
• Many more
Readmission Rate (%)
25
24
23
22
21
20
19
18
17
16
15
MI STA*AR
Qtr. 1 Qtr. 2 Qtr. 3 Qtr. 4 Qtr. 1 Qtr. 2 Qtr. 3 Qtr. 4 Qtr. 1 Qtr. 2
2008
2009
2010
30-Day All Cause Readmission Rate by Quarter among Medicare (FFS)
Beneficiaries Discharged from a Michigan hospital between January 1,
2008 and June 30, 2010
HEALTH CARE/COMMUNITY
TEAM CO-OPERATIVE
to prevent rehospitalization
I continue to believe that if we keep doing
the right thing , for the right reasons , with
the right resources , at the right time .....we
will achieve good outcomes
Deborah Hall Turner
Nancy D. Vecchioni, RN,
MSN, CPHQ
[email protected]
248-465-7454