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Project BOOST Reducing Readmissions Mark V. Williams, MD, FACP, FHM Professor & Chief, Division of Hospital Medicine Northwestern U. Feinberg School of.

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Presentation on theme: "Project BOOST Reducing Readmissions Mark V. Williams, MD, FACP, FHM Professor & Chief, Division of Hospital Medicine Northwestern U. Feinberg School of."— Presentation transcript:

1 Project BOOST Reducing Readmissions Mark V. Williams, MD, FACP, FHM Professor & Chief, Division of Hospital Medicine Northwestern U. Feinberg School of Medicine Principal Investigator, Project BOOST

2 A Problem for a long time Rosenthal, J. M. and D. B. Miller "Providers have failed to work for continuity." Hospitals 53(10): 79-83. Continuity of patient care between different health care settings has been advocated for nearly 20 years, but little has been done to effect it. The study described here emphasizes the current lack of effort by health care providers in hospitals and nursing homes to find a workable solution. 1979

3 June 2007 MedPAC Report Medicare pays for ALL admissions regardless  Initial stay or readmission for same condition 17.6% of admissions result in re-admissions within 30 days (6% in 7 days)  = $15 billion in spending Future  “CMS proposes to require that all general acute hospitals conduct a CARE assessment on every Medicare beneficiary being discharged.” Continuity Assessment Record and Evaluation  Public Disclosure of readmission rates  Lower case payments for readmissions

4 1 in 5 Medicare patients rehospitalized in 30 days Half never saw outpatient doc 70% of surgical readmissions–chronic medical conditions Costs $17.4 billion

5 Jencks S, Williams MV, Coleman EA. et al. N Engl J Med 2009;360:1418- 1428 Rates of Rehospitalization within 30 Days after Hospital Discharge

6 Health Affairs 2010; 29:57-64

7 Average LOS: US Hospitals DeFrances et al, Adv data, 2007 Jul 12;(385):1-19 > 65 = 12.6 to 5.5 days

8 Observational study of 6,955,461 Medicare FFS hospitalizations for HF; 1993 and 2006, with 30-day f/u.  Mean age = 80  52% Htn, 38% DM, 37% COPD LOS 8.8 days down to 6.3 In-hospital mortality declined from 8.5% to 4.3% 30-day mortality declined from 12.8% to 10.7% Discharges to SNF increased from 13% to 20%  Discharge to home decreased from 74% to 67% 30 day readmission increased from 17.2% to 20.1%  Post-discharge mortality increased from 4.3% to 6.4% Harlan M. Krumholz, MD, SM research group

9 Preventable Admissions Hospital inpatient care is the most expensive type of health care > 4 million Preventable Admissions Cost nearly $31 Billion Heart Failure and Pneumonia  Half of the $ problem COPD – 16% Diabetes – 13% Elderly – 2/3 of these hospitalizations - 1 in 5 Medicare admissions

10 Care Coordination Failure? 5 commercial disease management companies, 3 community hospitals, 3 AMCs, 1 integrated delivery system, 1 hospice, 1 long term care facility, 1 retirement community across U.S. No cost savings 2 reduced hospitalizations Sickest patients benefited


12 Readmission Reduction CBO - $7.1B savings over 10 yrs Hospital Quality & Performance Based Payments All DRG payment amounts in hospitals with excess readmission are reduced by a factor determined by the level of “excess, preventable readmissions”  Effective 2013  Excess = ratio of actual to expected (risk-adj)  Reduction of 1%, 2%, and 3% first 3 years

13 Readmission Reduction Program NQF endorsed measures  Initially AMI, HF, pneumonia  Expand in 2015 to 4 more conditions COPD, CABG, PTCA, Other Vascular  Measures must have exclusions for readmissions unrelated to prior discharge e.g. transfers, planned readmissions  Readmission time window specified by Secretary 30 days in NQF measures Report all-payer readmission rates publicly

14 Measures – AMA PCPI Care Transitions  Work Group  Performance Measure Set Reconciled medication list Transition record Timely transmission Discharge Planning/Post-Discharge Support for Heart Failure Patients

15 Hospital Discharge - currently “Random events connected to highly variable actions with only a remote possibility of meeting implied expectations.” Roger Resar, MD Agent of Tremendous Change and Global Innovation Seeker Luther Midelfort – Mayo Health System Senior Fellow, IHI

16 Dangers of Discharge 19% of patients had a post discharge AE - 1/3 preventable and 1/3 ameliorable Ann Intern Med 2003; Vol. 138 23% of patients had a post discharge AE - 28% preventable and 22% ameliorable CMAJ 2004;170(3)

17  1095 of 2644 (41%) inpatients discharged with test result pending - 191 (9.4%) potentially required action - Survey of MDs involved: almost 2/3 unaware of results - Of these: 37% actionable and 13% urgent Dangers of Discharge Ann Intern Med 2005;143(2):121-8

18 Dangers of Discharge ¼ of discharged patients require additional outpatient work-ups > 1/3 not completed Increased time to post-discharge f/u associated with lack of work-up completion Availability of discharge summary increased likelihood of work-up being done Arch Intern Med. 2007;167:1305-1311

19 Hospitalist to PCP Info transfer and communication deficits at hospital discharge are common  Direct communication 3-20%  Discharge summary availability at 1 st post- discharge appt 12-34%; 51-77% at 4 weeks  Discharge summaries often lack info Dx test results (33-63%), hospital course (7-22%), discharge meds (2-40%), pending test results (65%) Follow-up plans (2-43%), Counseling (90-92%) Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW JAMA 2007;297:831-41.

20 Discharge Summary J Gen Intern Med 2009;24:1002-6 “Discharge summaries are grossly inadequate at documenting both tests with pending results and appropriate f/u providers.”

21 Northwestern Solution Significantly improved the quality and timeliness. Better documentation of f/u issues, pending tests, and info provided to patients and/or family. PCPs more satisfied with timeliness and quality >95% of discharge summaries completed in < 1 week Journal of Hospital Medicine 2009;4:219

22 Discharge Planning - is it THE answer? 21 RCTs: 4509 medical, 2285 med-surg; 440 Ψ  LOS: mean decrease -0.91 (95% CI: -1.55 to -0.27)  Readmission rates: RR 0.85 (0.74 to 0.97)  Elderly medical pts: mortality RR 1.04 (0.74 to 1.46)  Discharged to home: RR 1.03 (0.93 to 1.14)  Improved patient satisfaction  Subset analysis: improved functional status Cochrane Database of Systematic Reviews 2010;1

23 Randomized 363 patients age > 65 “Comprehensive discharge planning” and home follow-up with APNs ~70% completion rate Readmissions at 24 weeks 20% vs 37%  Reduced multiple readmissions 6.2% vs 14.5%  Prolonged time to first readmission  Medicare reimbursements cut in half

24 Elderly patients transitioning to SNF/home Randomized: Intervention group paired with “Transition Coach” vs. standard care Empowerment and education: 4 pillars  Facilitate self management/adherence  Maintain a personal health record  Timely follow-up  Knowledge and management of complications Education during hospitalization  including meds and med reconciliation Phone calls and personal visits by TC post discharge Reduced rehospitalization and costs Arch Intern Med 2006;166:1822-1828

25 Results Rehospitalization IntervCont P(adj) OR (95%CI) Within 30d 8.311.9 0.048 0.59 (0.35-1.00) Within 90d* 16.7 22.5 0.04 0.64 (0.42-0.99) Within 180d* 25.6 30.7 0.28 0.80 (0.54-1.19) Costs($)Interv Cont Unadj Log Transformed At 30d 784 918 0.048 0.06 At 90d15192016 0.02 0.02 At 180d20582546 0.04 0.049 Arch Intern Med 2006;166:1822-1828 *Also significantly improved for “Rehospitalization for same diagnosis as index admission.”

26 Or should it be a Pharmacist? N=221 randomized at UCSF All receive pharmacist facilitated discharge 110 got 2 day phone call by pharmacist:  Check on clinical status  Remind about follow-up  Check on medications (did they obtain them; any problems taking them; any side effects; did they know which to take and how; etc…) Am J Med 2001;111(9B):26S-30S

27 Results Contacted 79 or 110  25% had questions about their meds  11% had questions about their care  11% had questions about follow-up  19% had been unable to get their meds  15% reported new problems  Greater satisfaction in intervention group: 86% vs. 61% very satisfied (p=0.007)  10% vs. 24% patients came to ED at UCSF at 30d (p=0.005)  15% vs. 25% rehospitalized at 30d (p=0.07)

28 Pharmacy Literature Schnipper et al:  N = 178 medical patients randomized  Intervention: Med reconciliation done at d/c by Pharmacist Pharmacist counseling at d/c and 3day follow-up call At d/c, pharmacist recommended med changes in 60% At 3d call, unexplainable discrepancies between d/c meds and reported home meds in 29%  At 30d Fewer preventable ADEs: 1% vs. 11% (p=0.01) Fewer preventable med related ED visits: 1% vs. 8% (p=0.03) 49% had med discrepancies! No difference in total ADEs, health care utilization, patient satisfaction, or med adherence Arch Intern Med 2006;166:565-71

29 Pharmacists Work! Swedish ward-based pharmacists 16% reduction in hospital visits 47% reduction in ER visits Drug-related readmissions reduced 80% Intervention group cost < control Arch Intern Med. 2009;169(9):894-900


31 Project RED RCT of 749 hospitalized adults Intervention  Nurse Discharge Advocate F/U appt, Medication Reconciliation Patient education  Individualized instruction booklet  Pharmacist call 2-4 days post-discharge Review medications Limitations  Urban, academic, safety net hospital

32 Project RED Outcomes Intervention (n = 370) Control (n = 368) ER Visits* 16.5%24.5% Rehospitalization** 15%21% PCP f/u in 30 days* 62%44% Prepared for Discharge* 65%55% *p < 0.05 **p = 0.09

33 Low-cost Intervention “user-friendly” Patient Discharge Form Telephone outreach from a nurse post- discharge Improved outpatient follow-up Reduced ER visits and rehospitalizations from historical controls JGIM 2008

34 1.Med Rec by PharmD 2.RN Care Coordinator D/C Planning 3.Phone Follow-up 4.PHR, Supplemental Discharge Form Reduced ER visits, Reduced Readmission

35 SHM Initiatives Discharge Checklist Halasyamani L et al. Transition of care for hospitalized elderly patients --development of a discharge checklist for hospitalists. J of Hosp Med 2006:354. Resource Room Safe STEPs Project BOOST  Better Outcomes for Older adults through Safe Transitions  John A. Hartford Foundation $1.4 million

36 Safe STEPs Safe and Successful Transitions for Elderly Patients John A. Hartford Foundation Grant

37 Safe STEP Interventions Medication reconciliation  Pharmacy reviews: admission and d/c  Geriatric friendly medication forms Education  Patients: pre-d/c appointment  Providers: geriatric h&p PCP communications  “Fast facts”

38 Safe STEPs 237 elderly patients at three hospitals  Academic, community 5 component intervention  Admission form with geriatric cues  Fax to PCP  Interdisciplinary worksheet  Pharmacist-physician medication reconciliation  Pre-discharge planning appointments Reduced ED visits and readmissions by 1/3

39 Project BOOST Team Tina Budnitz, MPH Eric Coleman, MD, MPH Jeff Greenwald, MD Eric Howell, MD Lakshmi Halasyamani, MD Mark V. Williams, MD Janet Nagamine, MD Dan Dressler, MD, MS Kathleen Kerr Greg Maynard, MD Arpana Vidyarthi, MD

40 Advisory Board Social work Case management Clinical pharmacy Geriatric medicine Geriatric nursing Health IT Blue Cross/Blue Shield United Health Health systems NQF AHRQ TJC CMS National Consumer’s League Other content experts Chair: Eric Coleman, MD, MPH Co-Chair: Mark V. Williams, MD with organizational representatives from:


42 What is BOOST Today? Intervention  Tailored clinical Tools: Comprehensive Risk Assessment Team-based care Patient centered discharge process 72 Hour follow-up call for “high-risk” patients Scheduled outpatient follow-up visits Standardized PCP Communication  Tailored processes, work-flow  Project management tools

43 BOOST components (cont) Technical Support  Mentors calls, email, resources  Teleconferencing across sites  Education (webinars, newsletters)  Enduring Materials (Teachback DVD) Peer Support  Listserv  Document sharing  Moral support Infrastructure Development  Train the trainer curricula  Mentor Guides  Mentor University

44 NEW CONCEPT: Health information, advice, instructions, or change in management Adherence / Error reduction Explain new concept / Demonstrate new skill Patient recalls and comprehends / Demonstrates skill mastery Assess patient comprehension / Ask patient to demonstrate Clarify and tailor explanation Re-assess recall and comprehension / Ask patient to demonstrate Teach Back Modified from Schillinger, D. et al. Arch Intern Med 2003;163:83-90

45 Planning Analyze processes Institutional Support Assemble Team Baseline Data 2 Day Training Intervention Toolkit Teach-back Training Peer- learning Project Planning Mentor reviewed action plan Implementation Redesign care processes Staff education Tailor tools Develop policies, procedures, order sets Evaluation Plan InterventionSurveillance Implement intervention Keep stakeholders informed Monitor core elements Analyze data Adjust intervention components Report to stakeholders Spread gains Life-Cycle Project BOOST Training & PreparationIndividualized Mentoring Training-6months 6-9 months 9-12 months

46 BOOST Network BOOST eNewsletter  Key milestones  BOOST updates  Site status reports, aggregate outcomes  Forum for sharing ideas, challenges, mini studies BOOST Network  E-mail, call between sites  BOOST listserv




50 End-Result Network of Institutions using the guide and interventions Understanding Impact of Interventions Understanding Implementation facilitating factors and barriers

51 BOOST Mentor Sites

52 Projected Growth Cohort 1: 9/08 6 sites Cohort 2: 3/0924 sites MI Collaborative 5/1014 sites Tuition pilot 5/102 sites CA Collaborative20 sites Fall 10 Tuition Cohort15 sites Online in 2010 = 81 sites

53 So what happens to readmission rates? Hierarchical time series analysis of readmission rates (one year prior to kick-off through one year post kick-off) 12/10 Cohort 1 (n=6) kickoff Implementation Survey Cohort 2 (n=24) kickoff 12/08 6/0912/0912/10

54 Prelim Results Across all sites overall readmission rates decreased from 13% to 11%.  BOOST Intervention Units  6 months post “go live” Readmission rates rose in non-BOOST units by 2% Marked increased patient satisfaction at some sites.

55 A Hospital Nurse “Project BOOST brings me back to what I thought nursing was really about. BOOST helps patients and families understand what they need to do to go home. This is why I went into nursing.”

56 THANKS!!! The John A. Hartford Foundation

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