1. READMISSION MANAGEMENT Jacquelyn Paynter, RN, MPH, CCM Executive Director of Care Management

2. Burden of Readmissions How big is the problem?

3. Fiscal YearFFY2013FFY2014FFY2015 Targeted ConditionsHeart Failure, AMI, Pneumonia COPD, CABG, PCI, Vascular Procedures Aggregate payment withhold penaltiesUp to 1%Up to 2%up to 3% The Top 15 DRG drivers of readmissions at Dekalb Medical are Heart Failure, Renal Failure, Psychosis, Sepsis, COPD, Pneumonia, Respiratory Failure, Red Blood Cell Disorders, GIB, UTI,and Diabetes. These patient populations represent 33% (ND) and 48%(HD) of the overall readmission volume with an average readmission rate of 15.5%. According to an IHI sponsored demonstration project, the key drivers of unplanned readmissions were driven by health care delivery system failures in 4 key areas: ENHANCED ADMISSION ASSESSMENT PATIENT AND FAMILY CAREGIVER EDUCATION HANDOVER COMMUNICATION DISCHARGE PLANNING COMMUNITY CONNECTION Beginning October 1, 2012 (Federal Fiscal Year 2013), the Patient Protection and Affordable Care Act (PPACA) statute will penalize hospitals and integrated delivery systems with higher than expected readmission rates. Readmission Management Imperatives

4. Natl Avg Crude Rate Eligible Discharges Number of Readissions Predicted Risk Adjusted Hospital Rate Expected Risk Adjusted National Rate Excess Readmission Ratio North Decatur AMI 19.21092522.121.6 1.0230 HF 24.656012522.723.6 0.9636 CAP 18.54947916.617.6 0.9446 Hillandale AMI 19.223320.321.1 0.9612 HF 24.61453122.923.7 0.9645 CAP 18.5952519.016.6 1.1412 CMS Hospital Compare FFY13 Pay for Performance Period: 7/1/08-6/30/11 Implemented heart failure focused care coordination Structured systematic readmission risk assessment Processes to identify ED and inpatient recidivist populations Expanded ED social work coverage and scope Bedside Rx delivery Post-discharge phone calls Diagnosis based ZONES discharge education Readmission Achievement

5. Medicare All Cause All Hospital Readmission Trend FFY12 Q1 PEPPER Report – North Decatur

7. Medicare All Cause All Hospital Readmission Trend FFY12 Q1 PEPPER Report - Hillandale

9. Multidisciplinary Collaborative Care Coordination Program What did we do?

10. ADMISSION ASSESSMENT Readmission Risk Assessment ED Case Management* Medication Reconciliation* PATIENT/FAMILY EDUCATION Zone Education Walgreens Bedside Rx Delivery and 72hr f/up calls VNHS Preferred Home Health Provider HANDOVER COMMUNICATION Hospitalists fax discharge summary and medication reconciliation to PCP Case Management provides an electronic discharge summary to post-acute providers (HHA,SNF,Dialysis) DISCHARGE PLAN Walgreens Bedside Rx Delivery Medication Reconciliation* Post Acute Services (HHA, DME, SNF, Dialysis, Hospice) COMMUNITY CONNECTION VNHS Preferred Home Health Provider 48 hr Post-Discharge Calls PCP Follow-up Appointments* Post-Discharge Transition Clinic* Implementation of the 5 Care Transition Pillars at Dekalb Medical

11. CARE TRANSITION FOCUS DISCHARGE PROCESS Implemented Walgreens Bedside Rx Delivery ND Campus (May 2011) Hillandale Campus(January 2012) Key Functions Ensures patient receives the medication upon discharge Supports patient satisfaction with discharge experience Pharmacy consultation provided, if needed Caregiver included in consult Reaffirms understanding of medication while patient still in healthcare system Immediate start of therapy on discharge 15-30 minute turn-around time Provides 30-day supply of medications Ability to refill at any pharmacy of patients choice Follow-up phone call from clinical pharmacist within 72 hours of discharge

12. Methods & Results How well did we do it?

13. CARE TRANSITION FOCUS DISCHARGE PROCESS Walgreens Bedside RX Delivery Results at Dekalb Medical Volume StatisticsNorth DecaturHillandale Discharges4551810 Non-Bedside Rx Discharges3701503 Bedside Rx Discharges85307 Penetration Rate18.7%17.0% Dekalb Medical is among the highest volume Bedside Delivery programs in the U.S.

14. Results Submitted study to Dekalb’s institutional review board (IRB) Approved on April 25, 2012 (DM Protocol #040512) Retrospective cohort Census of all discharges (all payors) Controls from a.Hospital’s historic data (a type of retrospective cohort study) b.Contemporaneous matches from non-participating facility (i.e., Hillandale campus compared to North Decatur campus ) Multiple logistic regression, controlling for demographic and clinical variables

15. Descriptive Statistics Variable Historic Hillandale Contemporaneous Hillandale Historic North Decatur Contemporaneous North Decatur Bedside Delivery North Decatur n (count of qualifying admits) 4232 7024 13283 19089 1516 30-day readmit (%, n)9.5%40010.8%75710.6%140811.5%21915.6%85 LOS (mean ± SD)4.35.14.39.65.56.45.1240.74.04.2 age > 65 (%, n)30.8%130531.3%219741.1%545941.8%798829.3%444 age (mean ± SD)54.918.055.018.459.517.759.518.055.715.3 HF_case (%, n)3.5%1482.1%1461.7%2271.1%2070.3%5 AMI_case (%, n)1.3%561.1%741.0%1301.4%2711.6%24 PN_case (%, n)4.872064.22953.524683.656961.7226 Medicaid (%, n)12.0%50912.8%9029.9%131210.6%20289.3%141 Race: Other (%, n)2.1%901.3%935.0%6695.5%10404.2%64 Race: Black (%, n)92.3%390892.8%652162.1%824263.1%1203859.8%907 Race: White (%, n)5.5%2345.8%41032.9%437231.5%601136.0%545 30 Readmission Rates are comparatively lower for Bedside Rx patients

16. Adjusted risk of readmission Independent variables and covariatesOR95%CIPr > ChiSq Male0.9540.8961.0140.1316 Age 65 +1.3021.2211.389<.0001 Medicaid1.4371.311.577<.0001 Race (Reference Group: White)0 Black1.2431.1531.339<.0001 Other0.8960.7571.0610.2019 Month1.0191.011.029<.0001 LOS1.0261.0221.031<.0001 CMS Conditions (Reference: without condition) HF1.5541.2671.905<.0001 AMI0.4280.2920.627<.0001 Interventional group comparison (Reference Group: Bedside Delivery)0 Historic Hillandale1.5721.2322.0050.0003 Contemporaneous Hillandale1.8791.4882.373<.0001 Historic North Decatur1.8281.4582.293<.0001 Contemporaneous North Decatur2.0711.6552.591<.0001 The lower readmission rate for Bedside Rx patients is statistically significant

17.  Facilitate PCP identification/referrals/appointments  Accurate medical history and medication reconciliation  Provide structured patient/family education  Establish nurse navigator/coach programs  Implement ED Case Management 7 day/wk 11a-11p  Provide transitional care clinic for P4P readmission discharges  Strengthen systematic handover communication between care providers  Further enhance use of Care Transition Home Health Visits and 30 day Post Discharge Medication Management Care Coordination Enhancement Opportunities

18. DISCUSSION