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Disclosure Statement of
Financial Interest
I, Corley Roberts,
DO NOT have a financial interest/arrangement or
affiliation with one or more organizations that could
be perceived as a real or apparent conflict of interest
in the context of the subject of this presentation.
Strategies in Primary Care
to Decrease Hospital
Readmissions
Corley Roberts
Exercise Physiologist, MHA, CPHQ, ACSM-HFS
Quality Improvement Advisor, Qsource
Shift from Volume to Quality
Begin with the Bottom Line
Begin with the Bottom Line (cont.)
Hospitals with higher than expected readmission rates
for Heart Failure (HF), Acute Myocardial Infarction
(AMI) and Pneumonia targeted
2013 1%
2014 2%
3% FY2015 added
Hospital Readmission Reduction Program (HRRP)
Penalties for Readmissions Section 3025 of
Affordable Care Act
Chronic Obstructive Pulmonary Disease (COPD)
Hip and Knee Replacement
FY2017 adding Coronary Artery Bypass Graft (CABG)
Begin with the Bottom Line (cont.)
Hospital Acquired Condition (HAC) penalties begin
FY2015 (Patient Safety Indicator (PSI) 90 and Infection
domains)
Publicly reported on Hospital Compare in December 2014
Value Based Purchasing (VBP) FY2015 funded by
reduction of base operating payments by 1.5%
35% Clinical care
25% Patient/Caregiver experience of care/care coordination
25% Efficiency/cost reduction
15% Safety
For Physicians and Practitioners
Shift from volume to quality
Empowering providers to deliver coordinated and
integrated care, transition to new models of care, and
improve the doctor-patient relationship.
Better coordination of care for beneficiaries with
multiple chronic conditions
Pay for quality not quantity of care
Providing incentives to hospital outpatient
departments and facilities to deliver efficient,
high-quality care
Shifting to alternative payment and delivery models
TCM-Transitional Care Management
TCM Codes
A reimbursement model for care transitions
CY 2013 Physician Fee Schedule Final Rule published
November 16, 2012 (77 FR 68978-68994)
99495 Moderate TCM Services:
TCM includes services provided to a patient whose medical
and/or psychosocial problems require moderate or highcomplexity medical decision making during transitions in care
from an inpatient hospital setting (including acute hospital,
rehabilitation hospital, long-term acute care hospital), partial
hospital, observation status in a hospital, or skilled nursing
facility/nursing facility, to the patient’s community setting
(home, domicile, rest home, or assisted living).
Communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business days
of discharge
Medical decision making of at least moderate
complexity during the service period
Face-to-face visit, within 14 calendar days of discharge
TCM Codes (cont.)
What is the Reimbursement?
99496 High-Complexity TCM Services:
Communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business days
of discharge
Medical decision making of high complexity during the
service period
Moderate complex 99495: $163 (includes one face to
face E/M visit within 14 days of discharge)
High complexity 99496: $230 (includes one face to
face E/M visit within 7 days of discharge)
Face-to-face visit, within 7 calendar days of discharge
How does TCM work?
Billable TCM Services
Only Claimed by One Provider
Contact within 2 business days is critical—work with
hospitalists, faxing info, etc. may be necessary—miss
this and you eliminate your opportunity to bill
If the visit within 7 business days is missed, e.g., patient
seen at day 10, you need to drop down to the moderate
code that allows for a 14-day window even though the
services met medical necessity for a high level
The person making the contact within 2 business days or
discharging provider should set up the face-to-face visit
Most likely to be primary care providers, but potential for
specialists
Limited as barrier by requirement to furnish multiple
specific services within a restricted time period
Determined by the “first claim” policy, the provider
submitting a claim for TCM first
Starting with the 30th day post discharge or thereafter
Discharge Physician Expectations
Inform the patients that they should receive TCM services
after discharge and that Medicare will pay for these services
More Expectations…
Obtain and review discharge information (for example,
discharge summary, as available, or continuity of care
documents)
Ask the patient to identify the provider they wish to furnish
TCM services
Suggest a specific physician who might be in the best
position to furnish TCM services
Record the three listed requirements in the discharge record
and instructions
More Expectations… (cont.)
Educate patient, family, guardian and/or caregiver
Establish or reestablish referrals and arrange for needed
community resources
Assist in scheduling any required follow-up with community
providers and services
Review need for or follow-up on pending diagnostic tests
and treatments
Interact with other qualified health care professionals who
will assume or reassume care of the patient’s systemspecific problems
One More Expectation
Medication Reconciliation
Expected at the point of contact with the patient within
2 business days of discharge
Non billable if occurs any later than initial face-to-face
TCM service
Why Medication Management?
2006 IOM report
Preventing Medication Errors
400,000 preventable drug-related injuries occur in
U.S. hospitals each year, each costing about $8,750
2010 U.S, Office of Inspector General
44% hospital adverse events (AE) were preventable
The most common preventable AEs were related to
medications (42%)
Journal for Healthcare Quality
Vol. 36, No. 6, pp. 58–68 C 2014 National Association for Healthcare Quality
High Risk Medications
Why Medication Reconciliation? (cont.)
28 to 60% of ADEs (Adverse Drug Events) leading to
hospital admission are preventable
— 2014 Annals of Pharmacotherapy
Patients readmitted within 30 days have more complex
medication regimens
— 2002 Annals of Pharmacotherapy
Emergency hospitalizations for recognized ADEs in older
adults most often result from warfarin, insulin, antiplatelets
and oral hypoglycemic agents
— 2001 Pharmacoepidemiology and Drug Safety
Willson MN, et al. Medication regimen complexity and hospital readmission for an
adverse drug event. Ann Pharmacother. 2014 Jan;48(1):26-32.
Jha AK, et al. Identifying hospital admissions due to adverse drug events using a
computer-based monitor. Pharmacoepidemiol Drug Saf. 2001 Mar-Apr;10(2):113-9.
McDonnell PJ, Jacobs MR. Hospital admissions resulting from preventable adverse
drug reactions. Ann Pharmacother. 2002 Sep;36(9):1331-6.
Overarching Goals
for Reducing Readmissions
Reduce hospital readmission and admission rates in the
Medicare program by 20 percent by 2019
From 19.5% to 17.8% in 2012 (4th quarter) CMS
Increase the patient’s time spent at home after discharge
by 10 percent by 2019
Reduce the prevalence of ADEs that contribute to
significant patient harm, ED visits, observation stays,
hospital admissions or readmissions occurring as a result
of the care coordination process
From New England Journal of Medicine 2011; 365:2002-12
Strategies for reducing readmissions:
Local Community
Implement national goals on a local level by
developing and sustaining care coordination
communities
Tennessee has 9 communities made up of
multidisciplinary stakeholders working together
toward reducing readmissions
Strategies for reducing readmissions:
Local Community (cont.)
Integrate clinical pharmacy services to include
medication therapy management (MTM) and pharmacists
into care coordination community settings
Reduce percentage of ADEs per 1,000 screened
patients with Medicare
Implement best practice strategies and interventions that
demonstrate improvement and sustainability over 6
month period
Data Driven Improvement
That which is measured,
tends to improve.
That which is
measured publicly,
tends to improve faster.
Strategies for reducing
readmissions: Physicians
Alternative payment models rewarding value based care:
better coordinated and integrated care, and better patient
outcomes.
Chronic Care Management (CCM codes)
PQRS
Value Based Payment Modifier
Transition Care Management (TCM codes)
Alternative care delivery models
Accountable Care Organizations (ACO)
Patient Centered Medical Home (PCMH)
Strategies for Care Delivery
Improved communication and documentation between
providers, transitions, care settings and with patients
Improved patient-physician communication:
䇺the patient experience䇻
Patient and Family Engagement
HCAHPS (Hospital Consumer Assessment of
Healthcare Providers and Systems)
( http://www.hospitalcompare.hhs.gov )
Value Based payment includes patient experience
Case Study: The Story of Abbie
‘Abbie’ is a 51 year old female patient who was referred
for a Fitness Consult by her primary care physician.
Diagnosis:
Diabetes (A1c 6.8)
Hypertension (193/85 - uncontrolled but on meds)
Other conditions include:
Arthritis in knees with pain performing some activities
Hates to exercise!
Scored 1 ‘don’t like it’ on MyFitScript™ Likeit Scale
( ‘1’ don’t like it/ ‘5’ love it)
Low self-confidence level (scored 2 ‘somewhat confident’)
(1 ‘very confident’)
Reference: MyFitScript™ Exercise for Chronic Disease
Likeit Scale 2015, http://www.myfitscript.com
Strategies for Care Delivery (cont.)
Improved patient self-management skills and knowledge
Traditional teaching is not working
Evidence based health coaching techniques changes
behavior (motivational interviewing)
Exercise, weight management, disease management
Integration of behavioral health strategies
Education alone does not change behavior
Reminders, goal setting, tracking, reinforcement
Timely follow up with discharged patients
Case Study: The Story of Abbie (cont.)
Risk factors include (as defined by ACSM - American
College of Sports Medicine - guidelines):
Obesity
BMI 44.3 (≥ 30 Obese), body fat 46.9% (≥ 33%), waist girth
49.75” (≥ 35”)
Inactivity - line dance 2x/wk/60min (minimum 150 minutes week)
High blood pressure 193/85 (≥140 and/or ≥ 90)
HDL 35 mg/dL (< 40 mg/dL)
Goals for Abbie
Control diabetes and hypertension within normal range
Improve self management skills and confidence regarding
her Diabetes/HTN
Check blood glucose levels regularly and with exercise
Monitor blood pressure regularly
Improve knowledge of current disease state, benefits of
physical activity, and risk factors
Goals for Abbie (cont.)
Improve awareness of nutrition habits and
implement needed changes toward achieving a
healthy weight
Increase physical activity to recommended levels
Integrate behavioral strategies to increase exercise
adherence and treatment plan compliance
Tools used with Abbie
Tools used with Abbie (cont.)
Evidence based health coaching techniques (how we
talk to patients)
Listening verses talking
Asking verses telling
Open ended questions that promote discussion
Helping her explore her reasons, her 䇺why䇻 for
wanting to be healthy
Including her in 䇺our䇻 plan as the real change agent
(physician/exercise physiologist/patient)
Assessments for
Health status (current/history) (family/individual),
medications, dietary/exercise habits
Evaluated level of exercise likeability
Measured indicators (BP, BF%, waist girth,
exercise volume, dietary changes, exercise
likability, HDL and A1c when available, self
confidence)
Reference: MyFitScript™ Exercise for Chronic Disease, 2015,
http://www.myfitscript.com
Tools used with Abbie (cont.)
Exercise Prescription (MyFitScript™ Diabetes Rx age and
chronic disease specific)
Food log for 7 days, another for 2 weeks
Exercise log with glucose readings pre/post exercise,
morning
Reference: MyFitScript™ Exercise for Chronic Disease, 2015,
http://www.myfitscript.com
Tools used with Abbie (cont.)
Toolkit (MyFitScript™ FitKit)
Education on exercise principles and safety, ‘how to’
RPE (Rate of Perceived Exertion/Borg)
Weight management education and worksheets for
manageable change (1 lb = 3500 kcal) (500 kcal/day)
(250 burned/250 less consumed)
Exercise tracking tools for weekly documentation
Goal setting worksheet using SMART goals method
Barriers and solutions worksheet
Reference: MyFitScript™ Exercise for Chronic Disease, 2015,
http://www.myfitscript.com
Process used with Abbie
Process used with Abbie (cont.)
With ongoing communication between Exercise Physiologist/physician
With ongoing communication between Exercise Physiologist/physician
Initial assessment Pre exercise plan
Weekly follow up phone call
30 day assessment
Re assessment of key indicators
Education and plan adjustments as needed
Referred to physician regarding blood pressure
(medication adjusted)
Biweekly follow up phone call
60 day assessment
Re assessment of key indicators
Education and plan adjustments as needed
Biweekly follow up phone call
90 day assessment (continued for month 4, 5, and 6)
Re assessment of key indicators
Education and plan adjustments as needed
Registered dietician referral (started food log)
Biweekly follow up phone call/email/text
Key Factors for Abbie’s Success
Results for Abbie
Pre Program
Weight 243.6
BMI 44.3
Waist 49.75”
Body Fat 46.9%
HDL 35 (TC 144, LDL 91)
BP 193/85
A1c 6.8
5 risk factors
0 exercise days/week
2 physical activity d/week
2 Self confidence level
1 Likeit Scale (don’t like)
Post Program
Weight 237.4 䕰
BMI 44 䕰
Waist 48” 䕰
Body Fat 46% 䕰
HDL 33 (TC 138, LDL 87 䕰)
BP 139/80 䕰
A1c 7.3
4 risk factors 䕰
4 exercise days/week 䕦
2 physical activity/week
1 Self confidence level 䕦
5 Likeit Scale (LOVE it!) 䕦
Key Factors for Abbie’s Success (cont.)
Improved self management skills and confidence level
Integrated behavior modification techniques into plan
Cognitive-behavioral approach (tools, social reinforcement led to
autonomy/ownership)
Physician that promotes health and wellness and provided
access to resources
Communication between physician/patient, patient and
fitness consultant, physician/consultant (team approach)
Relationship building and trust
Accountability built into process
In Summary: Reducing Readmissions
Where’s the Biggest Bang for Our Buck?
The right tools and education
at the right time
delivered in the right way
‘Slick Willie’ Sutton
Willie Sutton. (2015). The Famous People website. Retrieved 10:20, Feb 26, 2015, from
//www.thefamouspeople.com/profiles/willie-sutton-3413.php.
Read more at http://www.thefamouspeople.com/profiles/willie-sutton3413.php#LgUtxkS3C3j1OK4A.99
Where are most of the patients?
Home
Who’s caring for these patients and
what care are they providing?
Caregivers
From http://www.uhfnyc.org/publications/880853
Who are these patients?
Aging Population
Older patients have different patterns of emergency
department (ED) use and different needs than younger
counterparts
Higher number of visits
More urgent visits
Longer visits
More frequent returns to the ED
Higher rates of complications
What can we do for our patients?
Increase access to primary care (especially in rural areas)
Participate in community and statewide efforts
— TN efforts have decreased costs of readmissions
(% Reduction from Apr-Sept 2013)
Chattanooga 17.3%
Jackson
21.8%
Johnson City 27.1%
Kingsport
19.3%
Knoxville
20.2%
Memphis
6.0%
12.5%
Nashville
What can we do for our patients? (cont.)
Improve follow up care
Improve hospital discharge planning process
Partner with other community providers and stakeholders
Partner with patients and their families and caregivers
Thank you!
What can we do for our patients? (cont.)
Better coordination of care and at transitions
Improve communication between providers, settings and
with patients, family, and caregivers
American Medical Association critical role for physicians:
Keep organized patient information on medical issues, health goals,
functional and psychological status, behavioral and social issues
Be explicit with patients about social, economic, cultural and other
factors (age) that may impede their care
Use behavior change techniques like lists to help with selfmanagement
Use motivational interviewing techniques (health coaching)
Use pharmacy to ensure medication reconciliation
Allocate TIME to address care
Contact
Corley Roberts, MHA, CPHQ, ACSM-HFS
Quality Improvement Advisor
[email protected]
(615) 574-7234
www.atomAlliance.org
This material was prepared by atom Alliance, the Quality Innovation Network-Quality
Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana,
Mississippi and Alabama under a contract with the Centers for Medicare & Medicaid Services
(CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not
necessarily reflect CMS policy. 15.SS.TN.C3.02.002