1. Collaborative on Reducing Readmissions in Florida May 2011

2. Overview of Call 1.Overview of Readmission Trends 2.Update on Collaborative Projects 3.CMS Readmission Reduction Program 4.Partnership for Patients 5.Next Steps

3. Congestive Heart Failure Goal <8.0% Readmissions within 15 Days ~ All Readmissions 3

4. Acute Myocardial Infarction Goal <6.5% Readmissions within 15 Days ~ All Readmissions 4

5. Pneumonia Goal <4.0% Readmissions within 15 Days ~ All Readmissions 5

6. CABG Goal <8.0% Readmissions within 15 Days ~ All Readmissions 6

7. Hip Replacement Goal <2.5% Readmissions within 15 Days ~ All Readmissions 7

8. Update on Projects: Standardized Discharge Form Working with FADONA, FMDA, AHCA, CARES 3 rounds of testing 7 th version of form Two pages, designed to capture critical information about patient Finalizing instructions and roll-out approach Statewide testing next Will replace 3008

10. FOS-FHA Hip Readmission Project Began Sept 2010 Improving understanding of why hip replacement patients are readmitted –AHCA data –Case reviews Explore statewide initiatives

11. Hospital-Health Plan Initiatives Aetna, AvMed, BCBSFL, CIGNA, Health First, Humana & United Agreement on standard measure(s) and risk adjustment Sharing information on at risk patients Hospital-Health Plan case manager outreach Inventory of readmission programs underway at hospital and health plans

12. PPACA Directives Related to Readmissions Reduce payments for hospitals with high readmission rates High volume/expenditure, endorsed by an entity under contract with CMS, excludes readmissions unrelated to the prior discharge FY 2013 payments, 3 conditions, expand following year Include an all-condition measure Time frame consistent with endorsed measure Public reporting of rates All patient readmission rates

13. FY 2012 IPPS/LTCH PPS Proposed Rule Selection of applicable conditions Definition of readmission Measures and Methodology for calculating excess readmission –Index hospitalization –Risk adjustment –Risk standardized readmission rate –Data sources –Exclusion of certain readmissions Public reporting of readmissions Applicable period

14. FY2013 IPPS/LTCH PPS Proposed Rule Base operating DRG payment amount Adjustment factor (ratio & floor) Aggregate payments for excess readmissions Applicable hospital

15. General Definition: a readmission is when a patient is discharged from the applicable hospital to a nonacute setting and then is readmitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization Counts as one readmission regardless of how many readmissions within the period Time period : 30 days after discharge from index admission Data Source: Medicare FFS data, minimum of 25 cases

16. Selection of Conditions/Measures AMI, heart failure, pneumonia –High volume, high expenditure criteria –Endorsed by an entity under contract –Exclusions for readmissions unrelated to prior discharge Measures –AMI 30-day Risk Standardized Readmission Measure (NQF # 0505) –Heart Failure 30-day Risk Standardized Readmission Measure (NQF# 0330) –Pneumonia 30-day Risk Standardized Readmission Measure (NQF#0506)

17. Exclusions for Unrelated Readmissions General –Transfers to another acute care hospital –In-hospital deaths –Patients leaving Medicare FFS within 30 days post- discharge –Discharged against medical advice AMI –Excludes those readmissions when PTCA or CABG unless principal dx for readmission is Heart failure, AMI, Unstable angina, Arrhythmia, Cardiac arrest Heart Failure/Pneumonia –None

18. Measures Except with AMI, includes readmissions for all causes, without regard to the principal dx of the readmission –Patient perspective –Prevents gaming –No clinically sound strategies for identifying readmissions unrelated to hospital quality based on document cause of readmission

19. Risk adjustment Patient risk factors (patient demographics, co- existing medical conditions, indicators of patient frailty) identified from inpatient & outpatient claims for 12 months prior to hospitalization Calculates a hospital risk standardized readmission ratio If no claims in prior 12 months, only co- morbidities from the index admission will be used

20. Time Window 30 days –Clinically meaningful to collaborate with medical communities to reduce readmission risk –Accepted standard in research & measurement –Motivates hospital & community partners to work together Ready to be discharge Improves communication across providers Reduces risk of infection Educating patients on symptoms to monitor Where to seek follo up care

21. Applicable Time Period Hospital Compare uses 3 years of data Proposing to use July 1, 2008 through June 30, 2011 to calculate excess readmission rates Conducting analyses to look at using longer or shorter data periods

22. Other Provisions Must publicly report the hospital specific data from the readmission reduction program Calculation of all patient readmission rate –Hospitals or state or other entity will have to submit the data Excess readmission methodology Risk adjusted actual readmissions Risk adjusted expected readmissions

23. Medicare Spending Per Beneficiary CMS required to include efficiency measure in VBP for FY 2014 Hospital specific measure Part A & Part B spending 3 days before admission – 90 days post discharge Baseline period: May 15, 2010 though Feb 14, 2011 Measure: May 15, 2012 – Feb 14, 2013

24. CMS Partnership for Patients 1.Reduce harm caused to patients in hospitals. By end of 2013, reduce preventable HACs by 40% from 2010. 2.Improve care transitions. By end of 2013, decrease preventable complications during a transition from one care setting to another, resulting in a 20% reduction in readmissions.

25. Community-Based Care Transition Program $500 million Accepting applications –Hospitals with high readmission rates, partnering with CBO –CBOs providing care transition services –Must demonstrate reduced 30 day all-cause readmission rates 10 th Scope of Work –Assistance from QIO www.healthcare.gov/center/programs/partnership /join/index.htmlwww.healthcare.gov/center/programs/partnership /join/index.html

26. Discussion 1.Have you reviewed the NQF measures for readmission? 2.Do you believe they adequately exclude for planned or unrelated readmissions? 3.What time window do you think is appropriate to measure the hospitals performance on reducing readmissions? 4.Time period for measurement: how much data do you think is adequate to measure readmission rates? 5.Where should CMS get all payer data? 6.Are you interested in applying for a Care Transitions grant? 7.How actively are you following the IPPS rule? 8.Is your hospital assessing the proposed rule and incorporating estimated impacts into the budget?

27. Next Steps Workgroups will continue Statewide partnership on Readmissions Monthly calls/meetings to share best practices