1. Follow Through is Everything
Care Transitions: Length of Stay and Readmission Management
Leslie Foti, RN BSN ACM

2. Presenter Disclosures
Leslie Foti, RN BSN ACM
No relationships to disclose.

3. Why Do Care Transitions, Length of Stay (LOS), and Readmission Matter?
Setting the Table

4. New Payment Structure: Incentivizing Value and Quality
It’s Here!
Hospital Value-Based Purchasing
Pay-for-Performance
Readmission Penalties
Increased Scrutiny of Utilization
Medicare Hospital Value based Purchasing total of 2% of payment withheld
Paid back to hospital if meets targets
new in % Efficiency measured by Cost per Episode of Care (3 days prior to admission, the inpatient stay and 30 days post dc
P4P - +$ for hitting targets – LOS, complications, quality measures
Readmission – stroke not currently a diagnosis for Medicare Readmission Penalty, but is for commercial payers
carve out payments on medically unnecessary days, retrospective audits for medical necessity

5. Why Does Length of Stay (LOS) and Readmission Matter?
Financial Sustainability
Appropriate Stewardship of Resources
The Right Thing to Do for the Patient!
Most payments are Episode or DRG based – a lump sum that does not change regardless of length of stay, based on diagnosis, procedures and comorbidities – pts stay longer we use resources and may not cover cost of care. If pt’s readmit, reduced payment. This puts financial pressure on organizations to reduce costs, sometimes staff reductions.
We are not transitioning to the new payment model – it is already here from payers. Organizations that can adjust will survive, those that cannot adjust will weaken financially.
Just because its not easy doesn’t mean its not right. We need to be efficient on the more straightforward cases so to average out the overruns from outliers.
These changes are really in the best interest of the patient. We may not like the models but they are trying to incentivize the right thing. Patients expect quality care and do not want to readmit to the hospital.

6. What are Care Transitions?
“Transition of Care – The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another” (CMS, 2010)
Goal – the shortest, safest, most efficient hospital stay with discharge to a level of care that has the needed resources and knowledge to manage the patient’s care outside of the hospital setting
Includes movement between levels of care within the hospital

7. Who “Owns” Care Transitions?
Case Management
The Health Care Team
The Patient and Family
All of the Above

8. What is the Target?

9. Transition Needs of the Stroke Population
Stroke - a leading cause of serious
long-term disability

10. To Coordinate … in an Average of 2-6 days!
Ancillary Services
Therapy
Dietician
Pharmacy
Case Management
Teaching
Core Measures for Stroke
New Diagnoses
New Medications
New Diet
New Equipment

11. To Coordinate … in an Average of 2-6 days!
Screen and Assess for :
Depression
Caregiver Burden
Respite care
Support groups
Discharge needs
Support
Level of care
Resources
Financial Barriers

12. Integrate & Deliver Services in Alignment with LOS Goals
Communication, Coordination, Collaboration

13. Managing LOS Ensure everyone knows the goal!
Create systems that ensure all patient needs are addressed without over utilization
Know the players on your team & ensure they know what position they’re playing!
Establish a consistent communication plan
Goal – educate your ancillary staff about length of stay, general care plan, and what the target goals are. The team can’t reach a target if they don’t know what they’re aiming for. Discuss internal transition times/ events daily with care team. Include family and discuss anticipated transitions so they know what to expect
Check lists or preprinted order sets are great, but make sure you allow for customization that items are not pre-checked on orders to reduce the chance of over utilization (i.e. Maybe they don’t need occupational therapy?)
Get to know the workflow of the ancillary services – who does what, what hours do they work, what is there coverage like, how do they respond to consults? IE therapy makes their schedule in the morning , if you don’t put your consult in when admitting the patient but enter it on rounds the next day you will lose a day. Who has ownership of patient and family education or activity? If there is anything in the system that is not optimized, assess current state and determine ownership to work on improvements
Communication: whether it is an inter disciplinary round or a certain type of note, the entire team needs to know where to go to get the most accurate information; be consistent. IDRs are an best practice way to reduce LOS and create efficient;
For outliers from the ICU, extra attention to advancing activity and discontinuing unneeded medications.
Weekends – do things stop on the weekends? Does the patient admitted on a Friday afternoon and discharged on a Sunday or Monday morning receive the same level of care. What is the staffing of the ancillary services and diagnostics? These ancillary departments are serving the entire hospital and we need to collaborate with the hospital administration other departments to improve if it is a barrier. If it is impacting your length of stay, collect data, see if there is a business to assess for change – maybe there is and maybe there isn’t

14. Managing LOS
Basic Nursing Care – advancing diet, activity, weaning medications and O2, and Teaching!
Special vigilance with longer ICU, intermediate stays
Dysphasia – PEG or not to PEG? Adequate intake on modified diets
Look at your weekends – is it a black hole?

15. Managing LOS Newer Anticoagulants Financial Barriers
Delirium, Dementia, & Restraints
Managing Patient and Family Expectations
Nursing care – prevent complications – highest level of activity patient can tolerate, advancing diet – feeding, aggressively wean what is not needed
Newer anticoagulants can shorten time transitioning from Coumadin to Heparin but need to ensure patient can afford and whether medication requires pre-authorization.
Financial barriers – address self pay patients with significant deficits early for your financial counselors and case managers to assess quickly – lack of a Medicaid pending number
Dysphasia – coordination of many ancillary services, emotional barrier for patient/ family for PEG, consults to service to place PEG, calorie counts to determine PEG need all take time
High risk for delirium, exacerbation of dementia, confusion – leads to restraints for safety; Make sure that when trying to manage confusion all staff knows, nights shift needs to

16. Reducing Readmission Starts with Discharge Preparation
30% of acute stroke patients experience a hospital readmission within 90 days of discharge (Roger, et al., 2011)

17. Discharge – Where the Ideal Meets Reality
Home discharge – we must prepare the patient and family to self-manage their care
Willingness & Readiness
Teaching is Vital!
Access to Care
Do they have a PCP?
Can they afford their medications?
What to do with the VA?!?
Home Health vs. Outpatient therapy

18. Readmission Reduction Strategies for the Home Discharge
Structured Teaching
–Teach Back
Discharge Instructions
Should include EVERYTHING they need to know!
What to know about risk factors, lab targets, medications, signs and symptoms
Who to contact with phone numbers
Follow-up appointments made prior to discharge
Post Discharge call backs within 24 hours
Respite and Support Resources

19. Discharge – Where the Ideal Meets Reality
Facility Discharge –LTACH, Acute Rehab, SNF, Custodial Care - which level?
What Impacts the Determination
Acuity
Payer
Support system
Increased scrutiny of acute rehab
Observation status
Patient ability to participate in therapy

20. Readmission Reduction Strategies for the Facility Discharge
Choose the RIGHT level of care
Handoff to post hospital care providers
Discuss custodial care early if it is anticipated
Family conferences and palliative care
Don’t promote one level of care as being superior over another – communicate finding the RIGHT level of care for the patient

21. Other Strategies Consider:
Partner with post hospital care providers and support them with stroke specific education
Telephonic support for 30 days post discharge
Reassess for Cognitive Decline, Depression, Caregiver Burnout with every follow up

22. Thank you!

23. References & Links
Centers for Medicare and Medicaid (CMS), (2011). Eligible professional meaningful use menu set measures measure 8 of 10, stage 1, transition of care summary. E.H.R Incentive Programs. Retrieved from
CMS, (2013). Hospital value-based purchasing program. Department of Health and Human Services Centers for Medicare & Medicaid Services. Retrieved from
CMS, (2013). FY 2014 final rule tables. Retrieved from
CMS, (2015, January 26th). Fact sheets: better care. smarter spending. healthier people: paying providers for value, not volume. Retrieved from
Coleman, E.A., Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), p
Olson, D.M., Prvu Bettger, J. , Alexander, K.P., Kendrick, A.S., Irvine, J.R. , Wing, L., … Graffagnino, C. , (2011). Transition of care for acute stroke and myocardial infarction patients: from hospitalization to rehabilitation, recovery, and secondary prevention. Agency for Healthcare Research and Quality, Publication No. 11(12)-E011.
Mozaffarian D, Benjamin EJ, Go AS, et al., (2015) Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation,e29-322
Naylor, M.D., Aiken, L.H., Kurtzman, E.T., et al., (2011) The importance of transitional care in achieving health reform. Health Affairs (Millwood)30 (4), p
Poston, K. M., Dumas, B. P., & Edlund, B. J., (2013). Outcomes of a quality improvement project implementing stroke discharge advocacy to reduce 30-day readmission rates. Journal of Nursing Care Quality, 29 (3), p
Roger, V.L, Go, A.S., Lloyd-Jones, D.M., Adams, R.J., Berry, J.D., Brown, T.M., Carnethon, M.R., … Wylie-Rosett, J., (2011).Executive summary: heart disease and stroke statistics—2011 update: a report from the American Heart Association. Circulation 123 (4):
Links: Joint Commission Core Measures:
Joint Commission Comprehensive Stroke Center requirements: