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Improving Transitions from Hospital to Community Care: Models that Work David G. Schulke Vice President, Research Health Research and Educational Trust.

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Presentation on theme: "Improving Transitions from Hospital to Community Care: Models that Work David G. Schulke Vice President, Research Health Research and Educational Trust."— Presentation transcript:

1 Improving Transitions from Hospital to Community Care: Models that Work
David G. Schulke Vice President, Research Health Research and Educational Trust (202) October 18, 2011

2 The Health Research and Educational Trust (HRET)
HRET’s mission is to transform health care through research and education. AHRQ has retained HRET to support state-based Learning Networks with trainings for providers that wish to use AHRQ’s patient safety tools. Primary tools supported include Project RED (readmissions reduction), HCAHPS (patient satisfaction), VTE prevention, ED flow management.

3 Overview of Presentation
Review research behind new financial incentives to reduce readmissions in the Patient Protection and Affordable Care Act (ACA). Examine the importance of patient centered care and the relationship between hospitals and other providers in the community. Describe proven strategies hospitals use to improve care and protect against financial penalties, focusing on Project RED.

4 The Discharge Process and Post-hospital Care Influence Rehospitalization Rates
19% of Medicare inpatients are readmitted by 30 days. Only half of the patients re-hospitalized within 30 days saw their doctor before their readmission. As many as 90% of rehospitalizations within 30 days appear to be unplanned. Cost to Medicare estimated at $17 Billion/year. Source: Jencks et al N Engl J Med 2009;360:

5 How Many Readmissions Should be Prevented?
What proportion of readmissions are truly “preventable,” with good care? No one knows. Evidence suggests many rehospitalizations result from poor practices and are preventable-- Many rehospitalized before seeing a physician High inter-hospital and inter-state variation Randomized clinical trials testing interventions achieve 30+% reduction in readmissions

6 Business Case for Hospital Action on Readmissions
ALOS for rehospitalized patients is 0.6 day (13.2%) longer than the stay for patients in the same DRG who were not hospitalized in the previous 6 months Medicare payment for rehospitalizations is 4% lower than for index hospitalization For hospitals with excess readmissions: Penalty of 1% of all Medicare PPS payments in FY 13 (rising to 3% in FY15) Value-based purchasing penalty of 1% of all PPS payments (grows to 2% in future years) If your system has competitive pricing pressure: these are all inefficiencies others are driving out of their systems

7 Federal Penalties for Avoidable Readmissions
Penalties on hospitals with readmissions above expected rates for targeted conditions (AMI, CAP, CHF), starting October 1, 2012 Penalties will reduce hospital payments by at least $7 Billion over 10 years Exempt: Sole community hospitals, Medicare-dependent rural hospitals, low volume conditions CMS proposes more conditions for 2014— Chronic Obstructive Lung Disease Coronary Artery Bypass Graft surgery Percutaneous Coronary Interventions Vascular Procedures How much will this hurt hospitals financially? It could hurt a lot. PPACA allows CMS to withhold up to 1 percent of all inpatient Medicare payments starting in FFY 2013, up to 2 percent of payments in FFY 2014, and up to 3 percent in FFY 2015 and thereafter. These percentages will be calculated on a hospital’s HEALTHCARE REFORM: PENDING CHANGES TO REIMBURSEMENT FOR 30-DAY READMISSIONS 2 HEALTHCARE REFORM: Readmission Reimbursements aggregate Medicare payments for all discharges, Estimates saving $7billion over the next 10 years.

8 Potential Financial Impact of Readmissions Penalty at a Small Community Hospital
Laurens County Health System (76 acute, 14 SNF beds) and SCHA modeled potential annual effect of penalties: Heart Attack Heart Failure Pneumonia Patient Discharges 139 244 Readmissions w/in 30 Days 32 37 Risk-Adjusted Readmit Rate 0.0% 22.7% 15.3% Medicare Payments at Risk $0 -$278,900 -$478,900 Mounting pressures relative to decreased reimbursement/increased need for quality and good patient outcomes

9 Financial Incentives: Medicare Hospital Value Based Purchasing
Medicare VBP program pays hospitals for actual performance on quality measures, not just reporting measures, beginning FY13 The VBP program will apply to all acute-care PPS hospitals (VBP demonstration for CAHs) Funded by reducing all Medicare DRG payments by 1%, redistributed to best performers A hospital that meets or exceeds the performance standards will be eligible to earn back the initially withheld money (or more if others perform poorly)

10 Value Based Purchasing: Higher Scores with Strong Discharge and Follow up Processes
H-CAHPS accounts for 30% of hospital VBP score Four patient perceptions measured by H-CAHPS are better predictors of readmissions than core clinical measures: “During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?” and “During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?” “How do you rate the hospital overall?” “Would you recommend the hospital to friends and family?”

11 Inadequate communication with primary care physicians
Discharge Process Must Address Breakdowns Leading to Avoidable Readmissions Breakdowns include: Inadequate communication with primary care physicians Inadequate education of patient Drug therapy Poor coordination with other community providers

12 Process Breakdown: Poor Transfer of Information to Primary Care Physician
25% pts require additional outpt work-ups: 1/3 incomplete (Source: Archives of Internal Medicine. 2007; 167: ) 41% inpatients discharged w/ pending test result 2/3 of physicians unaware of results 37% of tests actionable and 13% urgent (Source: Annals of Internal Medicine. 2005; 143(2): 121-8) Discharge summary not readily available: Only 12-34% at first post-discharge appt; 51-77% at 4 weeks Discharge summary lacking key components: Hospital course (7-22%) Discharge medications (2-40%) Test results (33-63%) Pending tests (65%) Follow-up plans (2-43%) (Source: JAMA 2007; 297(8): )

13 Process Breakdowns: Poor Pre-discharge Patient Education
Poor transfer of information to patient: 37% able to state purpose of all medications 14% knew the common side effects 42% able to state their diagnosis Result: Poor patient understanding of how to use medications after hospital discharge Patient doesn’t understand warning signs that warrant an emergency call to their physician Lack of clarity on patient’s end of life care preferences lead to unwanted rehospitalization Source: Courtesy of Michael Paasche-Orlow, MD, Mayo Clinic Proceedings. August 2005; 80(8):

14 Adverse Drug Events in the Transition from Hospital to Home
Studied 400 consecutive hospital patients discharged home. 19% of patients had an adverse event (AE) within 3 weeks of discharge home. 66% of AEs were adverse drug events Most ADEs were preventable or ameliorable, unlike other Adverse Events. Clinical process improvements suggested by the authors: Identify unresolved problems at discharge Patient education re: treatment plan Post-discharge monitoring and follow up (Source: Forster et al, Annals Int Medicine, Feb 2003)

15 Rates of Rehospitalization within 30 days after Hospital Discharge
Source: Jencks SF, et al. N Engl J Med 2009;360:

16 Hospital Admissions Vary for Ambulatory Sensitive Conditions
2007 Medicare SAF data

17 Hospital Admissions of Short Stay Nursing Home Residents
2006 Medpar Data

18 Hospital Admissions of Home Health Patients
OASIS data in 2008 AHRQ National Healthcare Quality Report

19 Implications Nursing home, home health agency, hospice, pharmacy, and physician practices influence your hospital admission rates Coordinating with these providers can help your hospital escape penalties for patient care breakdowns Reducing readmissions cannot be done as effectively with interventions only within the hospital’s walls Hospitals should improve their discharge process, but also talk with referral partners to see how to work better together

20 Help for Hospitals in Reducing Avoidable Readmissions

21 Mathematica Study of Effective Care Coordination (March 2009)
Most claims of high impact care coordination interventions are unproven Mathematica concluded 3 types of change packages are proven effective: Transitional care interventions (Naylor and Coleman) Self-management education interventions (Lorig and Wheeler) Coordinated care interventions (a few sites from the Medicare Coordinated Care Demonstration)

22 Mathematica Study: Key Components of Effective Transitional Care
Engage patients early in hospitalization Give patients comprehensive post-discharge instructions on medications, self-care, and symptom recognition and management Assist patients in setting up and keeping follow-up physician appointments Follow patients post-discharge

23 Reengineered Hospital Discharge Program (Annals of Internal Medicine, Feb. 2009)

24 Impact of Project RED on Hospital Use

25 Impact of Project RED: Reengineering the Hospital Discharge
RED reduced health spending vs. control group More patients reported seeing their PCP Inpatient and ED care reduced by 30% Net: Saved $412/patient (~$19/month) Three key components in Project RED: Discharge Advocate educates hospital patient Give “After Hospital Care Plan” to patient, PCP Pharmacist calls patients 2-4 days post-discharge (most hospitals struggle to arrange pharmacist calls)

26 RED 11-point Checklist RED has eleven mutually reinforcing components:
Medication reconciliation Patient education Follow-up appointments Outstanding tests Post-discharge services Reconcile discharge plan with national guidelines What to do if problem arises Written discharge plan Assess patient understanding Discharge summary sent to PCP Telephone reinforcement 26 26

27 RED Component #1: Reconcile the Medications
Reconcile the patient’s home medication list upon admission to the hospital Review each medication; make sure that the patient knows why they take it Discuss new medications each day with medical team and with patient 27 27

28 RED Component #2: Educate the Patient
Educate patient throughout the hospital stay The Project RED intervention starts within 24 hours of the patient’s admission to the hospital and continues daily until completion of the post-discharge telephone follow up call to the patient 28 28

29 RED Component #3: Reconcile Discharge Plan with National Guidelines
Example: Discharge medication orders for ACEIs/ARBs for Heart Failure patients Communicate with medical team each day about the discharge plan Recommend actions that should be taken for each patient under a given diagnosis 29

30 RED Component #4: Make appointments for clinician follow-up and post-discharge testing
Schedule PCP appointment for the patient, to occur within 2 weeks after discharge Review, with the patient, the provider’s location, transportation and plan to get to appointment Consult with patient regarding best day and time for appointments Discuss, with the patient, the reasons for and importance of all follow-up appointments and testing 30 30

31 Encourage the patient to discuss tests his/her PCP
RED Component #5: Discuss with Patient Pending Tests/studies and Who will Follow up Explain tests and studies done while in the hospital and tell the patient which clinician is responsible for reviewing the results Encourage the patient to discuss tests his/her PCP Let the patient know that this information will be listed on the AHCP 31 31

32 RED Component #6: Organize Post-discharge Services
Collaborate with case manager and social worker about patient needs and post-discharge services Provide patient with contact information for these services (phone number, name of company, etc.)

33 RED Component #7: Give the Patient a Written Discharge Plan Before Discharge
The After Hospital Care Plan (AHCP) should include, in plain language understandable to the patient: 1) Principal discharge diagnosis 2) Discharge medication instructions 3) Follow-up appointments with contact information 4) Pending test results 5) Tests that require follow up 33 33

34 RED Component #8: Review with the Patient Steps to Take if a Problem Arises
What’s an emergency vs. a common problem What to do if a question or a problem arises Where in After Hospital Care Plan to find contact information for the discharge advocate and PCP to answer questions after discharge HCAHPS questions about the discharge process: Q 19: “During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?” Q 20: “During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?” 34 34

35 Communicate this information to the accepting physician
RED Component #9: Teach the Patient the AHCP, and ask the Patient to Tell You the Details of the Plan Explain post hospital care and post-discharge medications in a way the patient understands, including how to take the meds and how and where prescription can be filled  Communicate this information to the accepting physician Deliver information to reach those with a low health literacy level Include caregivers when appropriate Utilize professional interpreters as needed 35 35

36 RED Component #10: Expedite Transmission of the Discharge Summary to the PCP
Fax the discharge summary and AHCP to PCP within 24 hours after discharge National Quality Forum Safe Practice SP-15: “Reliable information from the primary care physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods” “A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.” 36 36

37 RED Component #11: Telephone Reinforcement of the After Hospital Care Plan after Discharge
RED intervention calls for a pharmacist to call the patient within 72 hours after discharge If pharmacist unavailable, have pharmacist help with “script” and available for back up Why? Because most patients leave with drug therapy, most post-discharge adverse events are drug problems, and 2/3 of adverse drug events are preventable or ameliorable Assess patient status Review medication plan Review follow-up appointments Take appropriate actions to resolve problems 37 37

38 Compare Your Discharge Process with RED Checklist to find Improvement Opportunities
Sample Current State Process Project RED components Med Reconciliation Discharge order National guideline used Discharge Instruction Form Follow up Appointment Outstanding Tests Discharge teaching on day of discharge Post DC services Written DC Care Plan No Discharge Advocate Problem vs. Emergency No appt scheduled Patient Education No post DC phone call Assess Patient Learning No PCP DC Summary DC Summary to PCP Post DC Phone Call Source: JCR

39 AHRQ’s Consumer Version of the Project RED “After Hospital Care Plan"
Project RED research team created this tool to help-- Keep track of medications Patients talk with hospital staff and primary care doctor Family assist patients Get it free from AHRQ:

40 Health Care Leader Action Guide
Provides strategies for you to– Examine your hospital’s current rate of readmissions Assess and prioritize your improvement opportunities Develop an action plan of strategies to implement Monitor your hospital’s progress Get it free at

41 Other AHRQ and CMS-funded Tools to Help Reduce Avoidable Readmissions (continued)
TeamSTEPPS, a method for improving team communication and patient safety culture among hospital staff Care Transitions Toolkit–free resources at QIO site: QIO program Home Health Quality Improvement project’s patient risk assessment tool for Home Health Agencies: rces/interventionpackages/hra.aspx QIO program originated toolkit for nursing homes: Interact2.net

42 Thank you! Your Questions and Comments are Welcome!


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