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2 BACKGROUND 1 in 5 individuals admitted to the hospital is readmitted within 6 months Many readmissions considered avoidable and marker for poor quality within the hospital setting, in ambulatory practices and across transitions in care Spending for Medicare readmissions alone accounted for $17 billion in 2004 (Jencks 2009) Reducing hospital readmissions is key approach to curbing health care costs and improving quality and patient experience 2

3 BACKGROUND Efforts to reduce readmissions have focused primarily on Medicare patients and the general population Medicaid patients also experience readmissions, sometimes at rates comparable to Medicare patients As states face continued budget shortfalls, many looking to follow Medicare’s lead to reduce unnecessary readmissions 3

4 BACKGROUND Few resources exist to inform initiatives to reduce readmissions among Medicaid beneficiaries Medicaid patients face unique challenges: Limited access to primary and specialty care Difficulties obtaining medication Discontinuous insurance coverage Less family and social support Language barriers Low health literacy Housing instability Inadequate transportation Poorer health status Higher rates of chronic disease and mental illness 4

5 PROJECT GOALS Identify the critical factors uniquely contributing to hospital readmissions among Medicaid beneficiaries Create and/or adapt existing tools and strategies to reduce readmissions that specifically address the unique challenges of Medicaid patients 5

6 PROJECT COMPONENTS Convene Advisory Panel Recruit States and Hospitals Research Factors Contributing to Medicaid readmissions through: Literature Review Site Visits Interviews Analysis of Medicaid data Modify existing strategies and/or develop new ones Test feasibility of implementing proposed strategies Refine strategies and tools based on hospital feedback 6

7 PROJECT ADVISORY PANEL Medicaid Medical Directors Judy Zerzan, Colorado Medicaid David Kelley, Pennsylvania Medicaid Medicaid Managed Care Plan Medical Director Paul Mendis, Neighborhood Health Plan (MA) Safety Net Hospital Representatives Bruce Siegel and Jill Steinbruegge, National Association of Public Hospitals Rochelle Ayala, Memorial Regional Hospital (FL) Readmissions Researchers Todd Gilmer, UC-San Diego Eric Coleman, The Care Transitions Program, Univ of CO-Denver Darren DeWalt, UNC-Chapel Hill 7

8 LITERATURE REVIEW Conducted search in March 2012 Aim: To identify factors related to readmissions that are unique to Medicaid populations to inform efforts to reduce Medicaid readmissions Searched using SCOPUS database from 1990-2012 Keywords: “Medicaid AND readmission” and “Medicaid AND rehospitalization” Identified additional reports and research briefs for inclusion in the review through Google search and expert advice 8

9 LITERATURE REVIEW Conceptual Model of the Determinants of Preventable Readmissions Source: Vest JR, Gamm LD, Oxford BA, Gonzalez MI, Slawson KM. Determinants of preventable readmissions in the United States: a systematic review. Implementation Science 2010; 5:88. 9

10 Flow Diagram for Literature Review Process 10

11 LITERATURE REVIEW Characteristics and Rates of Medicaid Readmissions: 30-day readmission rates ranging from 11 to 19% Higher risk of readmission than privately-insured patients, lower risk than Medicare patients Risk increases with number of chronic conditions Represent significant expense for state Medicaid programs: Patients with readmissions accounted for nearly half of total inpatient costs for Washington Medicaid in 2008-09 Cost $1 billion/year in New York Medicaid 11

12 LITERATURE REVIEW Literature focuses on patients with mental health or substance abuse issues, who are often high utilizers of health care within the Medicaid population Key factors that increase risk of readmission among Medicaid patients: Medication noncompliance Unstable post-discharge care environments Substance abuse comorbidities Psychosis comorbidities Medicaid payer status is itself a risk factor for readmission Participation in a managed care program thought to affect hospital readmissions, but evidence is mixed 12

13 CASE STUDIES State selection process: Geographically diverse Mix of managed care policies Hospital selection process: Safety net hospital with at least 22% of patients covered by Medicaid (top quartile of Medicaid use) Diversity of ownership Mix of experience with readmissions efforts Affiliation with community providers Process more difficult than anticipated Medicaid readmissions not strong area of focus Quality improvement interests often trumped by resource concerns 13

14 CASE STUDIES Site Visit Process One-day meeting in summer 2012 Open-ended agenda including: Showcase of readmissions initiatives Roundtable discussion Representatives from quality improvement, emergency department, admitting department, case managers/care coordinators, 14

15 CASE STUDIES: ST. LUKE’S, SIOUX CITY, IOWA Part of St. Luke’s Health System Faith-based, not-for-profit health system 11 hospitals and related health services in the Kansas City area and surrounding region Flagship hospital in Kansas City opened in 1882 Provided more than $20.9 million in charity care, community benefit, other uncompensated care and taxes in 2011 15

16 CASE STUDIES: ST. LUKE’S, SIOUX CITY, IOWA Hospital information: Staffs 160 beds 11,202 admissions and 65,765 outpatient visits in 2011 30-day readmission rate: 11.9 Payer mix for readmissions: 24% Medicaid 41% Medicare 29% Private Top reasons for readmission: CHF COPD Diabetes 50% of readmissions come from home health and nursing homes 16

17 CASE STUDIES: ST. LUKE’S, SIOUX CITY, IOWA Initiatives to Reduce Readmissions: Physician champion who reviews all readmissions each day and consults with departments to address issues Collaboration with nursing homes and FQHCs to improve communication Developed consistent teaching tools used at all facilities Inform providers when their patients are readmitted Schedule follow-up appointments within 48-72 hours 17

18 CASE STUDIES: ST. LUKE’S, SIOUX CITY, IOWA Initiatives to Reduce Readmissions: “360” review with all readmitted patients to understand what went wrong Staff use of care map which shows what should happen each day as a patient progresses through treatment CHF tele-management program 12 Care coordinators Screen for “home situation” upon admission Call to check on patients within 48-72 hours 18

19 CASE STUDIES: ST. LUKE’S, SIOUX CITY, IOWA Key Challenges: Medication reconciliation (no pharmacy on-site) Unwarranted admissions from nursing homes Repeat patients with mental health issues who don’t have acute needs Communication between hospital and outside providers (PCPs, nursing homes, etc.) Looking ahead: Plan for a virtual pharmacist who will review discharge records and provide medication reconciliation 19

20 CASE STUDIES: HARBORVIEW MEDICAL CENTER, SEATTLE, WASHINGTON Academic medical center owned by King County and managed by the University of Washington Serves as the only Level 1 Adult and Pediatric Trauma and Burn Center for the states of Washington, Alaska, Montana and Idaho Has received numerous accolades for its commitment to serving the community and providing high-quality care Provided $189 million in charity care in 2011 Targets particularly vulnerable populations, such as: prisoners, mentally ill, persons with STDs, substance abusers, indigenous, LEP, and victims of domestic violence and sexual assault 20

21 CASE STUDIES: HARBORVIEW MEDICAL CENTER, SEATTLE, WASHINGTON Hospital Information Staffs 413 beds, including 89 critical care and 66 psychiatric beds 19,424 admissions and 65,515 ED visits in 2011 30-day readmission rate: 9.1% Medicaid: 13.5% Medicare 9.3% Medicare and Medicaid patients account for 61 percent of readmissions: Medicaid patients represent 23% of admissions and 30% of readmissions Medicare patients represent 27% of admissions and 31% of readmissions 21

22 CASE STUDIES: HARBORVIEW MEDICAL CENTER, SEATTLE, WASHINGTON Hospital Initiatives to Reduce Readmissions: Unit-based discharge facilitator (UDF) program: 13 UDFs follow all admitted patients, providing coordination related to patients' different therapies, social work, financial counseling, nursing, discharge pharmacy, post hospital services, etc Monitor patients using electronic real-time “at-a-glance” white board with indicates a series of steps that must be completed prior to discharge Enhanced care management for high-utilizers: Very proactive program for extremely vulnerable, disengaged patients Patients must have mental health or substance issue Use harm reduction approach Key component is finding stable housing 22

23 CASE STUDIES: HARBORVIEW MEDICAL CENTER, SEATTLE, WASHINGTON Hospital Initiatives to Reduce Readmissions: Respite and Health Care for the Homeless: Extensive shelters and health care services for the homeless in downtown Seattle PCMH strategies: Data system to monitor inpatients and ED patients to ensure they have a PCP or connect them with one if they don't and to let PCPs know when their patients are in the hospital Post-discharge clinical pharmacist visit: primary care patients in the adult medicine clinic with medium to high risk of readmission receive clinical pharmacist during inpatient stay for medication reconciliation, etc. 23

24 CASE STUDIES: HARBORVIEW MEDICAL CENTER, SEATTLE, WASHINGTON Hospital Initiatives to Reduce Readmissions: Aftercare clinic: Provides follow-up PCP visits for patients who cannot get into other clinics within 2 weeks because they are full Connects patients with PCP following aftercare visit STAAR CHF project: Participated in State Action on Avoidable Rehospitalizations (STAAR) initiative focusing on heart failure readmissions 70% of CHF patients <65 Patients assessed for both social and clinical risk at intake and receive an action plan with prompts for assessing their health status 24

25 CASE STUDIES: HARBORVIEW MEDICAL CENTER, SEATTLE, WASHINGTON Key Challenges: Being over capacity in many of their programs (enhanced case management, respite care, etc.) Readmissions from skilled nursing facilities Effectively utilizing the wealth of data collected to improve care 25

26 CASE STUDIES: MEDICAL UNIVERSITY OF SOUTH CAROLINA (MUSC), CHARLESTON Academic medical center founded in 1824 700 beds 6 colleges that train approximately 2600 health care professionals per year 32,672 admissions in 2008 26% Medicaid 27% Medicare Site visit scheduled for later this month Project will focus on pediatric asthma readmissions 26

27 EARLY FINDINGS—IMPRESSIONS Medicaid as a group is not often looked at separately Efforts usually targeted to conditions rather than populations When Medicaid population is targeted, tends to include uninsured as well Not generally using standardized tools with Medicaid populations Homegrown strategies particularly for Medicaid/uninsured Very different approaches between 2 hospitals visited so far 27

28 NEXT STEPS Final Site Visit Create and/or adapt strategies and tools tailored for Medicaid patients Feasibility testing of strategies and tools with hospitals Refine strategies and tools for widespread dissemination 28

29 SUGGESTED REFERENCES Boutwell, A.E., Johnson, M.B., Rutherford, P., Watson, S.R., Vecchioni, N., Auerbach, B.S., Griswold, P., Noga, P., & Wagner, C. (2011). An early look at a four-state initiative to reduce avoidable hospital readmissions. Health Affairs, 30, 1272-1280. Bruen, B., Jensen, R., Riley, P., Lara, A. & Lu, X. (April 2011). Medicaid Cost Containment Options for Washington State. George Washington University report for the Washington State Legislature and the Washington State Institute for Public Policy. Gilmer, T. & Hamblin, A. (December 2010). Hospital Readmissions among Medicaid Beneficiaries with Disabilities: Identifying Targets of Opportunity. New Jersey: Center for Health Care Strategies. Jencks, S., Williams, M., & Coleman, E. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360, 1418-1428. Jiang, H.J. & Wier, L.M. (2010). All-cause hospital readmissions among non-elderly Medicaid patients, 2007 (HCUP Statistical Brief #89). Agency for Healthcare Research and Quality. Raven, M. C., Doran, K. M., Kostrowski, S., Gillespie, C. C., & Elbel, B. D. (2011). An Intervention to Improve Care and Reduce Costs for High-Risk Patients with Frequent Hospital Admissions: A Pilot Study. BMC Health Services Research, 11, 270. Raven, M. C., Carrier, E. R., Lee, J., Billings, J. C., Marr, M., & Gourevitch, M. N. (2012). Substance Use Treatment Barriers for Patients with Frequent Hospital Admissions. Journal of Substance Abuse Treatment, 38, 22-30. Vest JR, Gamm LD, Oxford BA, Gonzalez MI, Slawson KM. Determinants of preventable readmissions in the United States: a systematic review. Implementation Science 2010; 5:88. Wier, L.M., Barrett, M.L., Steiner, C., & Jiang, H.J. (June 2011). All-Cause Readmissions by Payer and Age, 2008 (HCUP Statistical Brief #115). Agency for Healthcare Research and Quality, Retrieved from: 29


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