Partnership for Patients: Readmission Reduction Presented by: Rachel Cicerchi, MPH Program Manager, Texas Center for Quality & Patient Safety Texas Hospital Association Phone: 512/ Fax: 512/ Mailing: P.O. Box , Austin, Texas Physical: 1108 Lavaca, Suite 700, Austin, Texas April, 2012

Today’s Agenda I. The Need to Reduce Readmissions II. Introduction to Project RED III. Readmission Reduction Tools & Resources IV. Data Metrics & Collection V. Developing an Action Plan VI. Teach Back VII. Next Steps, Timeline of Events, Questions 2

Readmission Statistics  Almost 1 in 5 patients are readmitted within 30 days of discharge. –34% are rehospitalized within 90 days.  90% of rehospitalizations within 30 days appear to be unplanned and approximately 75% are considered avoidable.  Only half of patients rehospitalized within 30 days had a physician visit before readmission. Source: S. F. Jencks, M. V. Williams, and E. A. Coleman, “Rehospitalizations Among Patients in the Medicare Fee-for-Service Program,” New England Journal of Medicine, April 2, (14):1418–28. 3

Readmission Statistics (cont.)  CMS estimates the cost of avoidable readmissions at more than $17 billion a year, 20 percent of all Medicare payments.  There is enormous variation in readmission rates across states. Ranging from a low in Idaho of 13.3% to a high in Maryland of 22%. Source: S. F. Jencks, M. V. Williams, and E. A. Coleman, “Rehospitalizations Among Patients in the Medicare Fee-for-Service Program,” New England Journal of Medicine, April 2, (14):1418–28. 4

Readmission Rates by State 5 Source: S. F. Jencks, M. V. Williams, and E. A. Coleman, “Rehospitalizations Among Patients in the Medicare Fee- for-Service Program,” New England Journal of Medicine, April 2, (14):1418–28.

Dartmouth Atlas Findings  Little change in readmission rates from 2004 to –Surgical 30-day readmission rates were 12.7% in 2004 and 2009 –Medical 30-day readmission rates rose slightly from 15.9% in 2004 to 16.1% in Source: Dartmouth Institute for Health Policy & Clinical Practice

Medical Discharges Number of Patients in Cohort Percent readmitted within 30 days of discharge Percent seeing a primary care clinician within 14 days of discharge to home Percent having an emergency room visit within 30 days of discharge Texas244,883217, United States 3,632,8113,250, Source: Dartmouth Institute for Health Policy & Clinical Practice

Surgical Discharges 8 Number of Patients in Cohort Percent readmitted within 30 days of discharge Percent seeing a primary care clinician within 14 days of discharge to home Percent having an emergency room visit within 30 days of discharge Texas138,030126, United States 2,013,7951,809, Source: Dartmouth Institute for Health Policy & Clinical Practice

National Trends by Cause of Initial Hospitalization Condition% ReadmissionRelative Change (%) Absolute Change (%) Medical <0.5 CHF <0.5 AMI Pneumonia <0.5 Hip Fracture <0.5 Surgical12.7 <0.5 9 Source: Dartmouth Institute for Health Policy & Clinical Practice

National Trends by Post-Discharge Location Condition% Discharged to home % Discharged to facility-based rehabilitation % Discharges to other location Medical CHF AMI Pneumonia Hip Fracture Surgical Source: Dartmouth Institute for Health Policy & Clinical Practice

Why do readmissions occur? Factors include: –Quality of downstream providers (nursing homes, home health agencies, and downstream providers) –Patient characteristics that lead to admissions also lead to readmissions  Behavioral comorbidities –Big Picture Factors: social support, community demographics, hospital staff communication and processes. 11

Common process breakdowns leading to readmissions  Poor communication between staff and patient –Lack of patient understanding of how to take medications post-discharge –Patient doesn’t recognized warning signs of complications, and what to do if a problem arises  Poor transfer of information to post-discharge providers –Between hospital staff and nursing home staff or PCP 12

Common process breakdowns leading to readmissions (cont.)  Lack of timely visit with PCP post-discharge –Patient doesn’t have a PCP/Lack of PCPs in area –Issues with patient transportation to appointments  Patient confusion over how, when, and why to take medications –Financial issues in obtaining medications 13

Project RED  What is Project RED?  The Re-Engineered Hospital Discharge Intervention (Project RED) is a patient safety initiative that has been demonstrated to create a more efficient discharge process and consequently decrease hospital readmissions.  Developed by Boston Medical Center, Project RED is the product of five years of work with more than $7.5 million from the Agency for Health Research and Quality, and the National Heart, Lung and Blood Institute.  Consists of 3 main components: –The Discharge Advocate –The After Hospital Care Plan –A follow-up phone call

Project RED 15

Principles of Project RED 1. Explicit delineation of roles and responsibilities 2. Discharge process initiation upon admission 3. Patient education throughout hospitalization 4. Timely accurate information flow: –From PCP > Among Hospital team > Back to PCP 5. Complete patient discharge summary prior to discharge 16

Principles of Project RED (cont.) 6. Comprehensive written discharge plan provided to patient prior to discharge 7. Discharge information in patient’s language and literacy level 8. Reinforcement of plan with patient after discharge 9. Availability of case management staff outside of limited daytime hours 10. Continuous quality improvement of discharge process 17

3 Central Components of the RED Model: 1. The Discharge Advocate –Each patient is assigned a Discharge Advocate (DA) who acts as a central resource for the patient during and after his/her hospital stay. During the hospital stay the DA explains all aspects of the patient’s care from diagnosis. –The DA follows an 11-item checklist which includes making follow-up appointments, reviewing the medication plan, and conducting patient education. –The DA role is often filled by a nurse or case manager. 18

Discharge Advocate  Is notified when patients in target population are admitted/diagnosed  Initiates 11-step checklist  Educates patient and family on diagnosis, medications, and post-discharge plans  Reviews After Hospital Care Plan with patient and family  Collects process and outcome data specific to project and patient population 19

11-Item Checklist Educate the patient about his her diagnosis throughout the hospital stay. 2. Make appointments for clinician follow-up and post- discharge testing. –Make appointments with input from the patient regarding the best time & date of the appointment. –Coordinate appointments with physicians, testing, and other services. –Discuss reason for and importance of physician appointments. –Confirm that the patient knows where to go, has a plan about how to get to the appointment; review transportation options and other barriers to keeping these appointments.

11-Item Checklist (cont.) 3. Discuss with the patient any tests or studies that have not been completed in the hospital and discuss who will be responsible for following up with the results. 4. Organize post-discharge services (e.g. PT, OT, SLT). –Be sure patient understands the importance of such services. –Make appointments that the patient can keep. –Discuss the details about how to receive each service 21

11-Item Checklist (cont.) 5. Confirm the medication plan. –Reconcile the discharge medication regimen with those taken before the hospitalization. –Explain what medications to take, emphasizing any changes in the regimen. –Review each medication’s purpose, how to take each medication correctly, and important side effects to watch out for. –Be sure patient has a realistic plan about how to get the medications. 6. Reconcile the discharge plan with national guidelines and critical pathways. 7. Review with the patient appropriate steps of what to do if a problem arises. –Instruct on a specific plan of how to contact the PCP (or coverage) by providing contact numbers for evenings and weekends. –Instruct on what constitutes an emergency and what to do in cases of emergency. 22

11-Item Checklist (cont.) 8. Expedite transmission of the discharge summary to clinicians accepting responsibility for the patient’s care after discharge that includes: –Reason for hospitalization with specific principal diagnosis –Significant findings –Procedures performed and care, treatment, and services provided to the patient –The patient’s condition at discharge –A comprehensive and reconciled medication list (including allergies). –A list of acute medical issues, tests, and studies for which confirmed results are pending at the time of discharge and require follow-up. –Information regarding input from consultative services, including rehabilitation therapy. 23

11-Item Checklist (cont.) 9. Assess the patient’s understanding of this plan. –May require removal of language and literacy barriers by utilizing professional interpreters. –May require contacting family members who will share in the care-giving responsibilities. 10. Give the patient the discharge plan which includes: –Reason for hospitalization. –Discharge medications including what medications to take, how to take them, and how to obtain the medication. –Instructions on what to do if their condition changes. –Coordination & planning for follow-up appointments that the patient can keep. –Coordination & planning for follow-up of tests and studies for which confirmed results are not available at the time of discharge. 11. Call the patient within 72 hours of discharge to reinforce the discharge plan and help with problem solving. 24

3 Central Components of the RED Model: 2. The After Hospital Care Plan (AHCP) –A hardcopy of the AHCP is presented to the patient upon discharge and includes detailed instructions on medication administration, all post- discharge appointments with physicians, testing, and other services, and contact information for the DA and providers. 25

After Hospital Care Plan 26 Template from AHRQ Free, downloadable, fill-able PDF form Store on your server for easy access by DA Integrate with your current systems as able Hard copies available from AHRQ Provided by TCQPS for Project RED participants

3 Central Components of the RED Model: 3. The Follow-Up Phone Call –Preferably a clinical pharmacist, but more commonly the DA, follows up with the patient within 72 hours of discharge to ensure the patient understands when and how to take all medications and answers any questions the patient may have. –Questions include:  Does the patient feel that he/she knows how and when to take each medication?  Does the patient feel that he/she was able to follow discharge instructions when at home?  Does the patient understand the importance of follow-up with a physician/clinic post-discharge?  Does the patient feel he/she received all the answers to any questions prior to leaving the hospital? 27

Project RED Introductory Webinars Module 1: Preparing to Redesign your Discharge Program Tuesday, May 8 th at 10:00 CT Module 2: The Re-Designed Discharge Process – Patient Admission and Care & Treatment Education Tuesday, May 15 th at 10:00 CT Module 3: The Re-Designed Discharge Process – Patient Discharge & Follow-Up Care Tuesday, May 22 nd at 10:00 CT Module 4: Re-Engineering Discharge: The Hospital Launch Tuesday, May 29 th 10:00 CT 28

Readmission Reduction Tools & Resources  The 11-Step Checklist  Example of an Education Plan  Discharge Advocate Documentation Forms  Patient Discharge Survey  Project RED Patient Tracking Tool  CHF Survival Kit  Follow-Up Phone Call Script –General and CHF specific 29

Readmission Reduction Tools & Resources  All of the tools mentioned here, plus many, many more can be found on the Healthcare Communities website. Communities > My Communities > TCQPS HEN > Browse Community Documents > Readmissions Resources 30

Data Metrics and Collection  Data Dictionary –1 outcome metric –1 process metric  How do you currently monitor hospital readmissions?  TCQPS PfP Data Portal

Action Planning  Refer to Action Planning worksheet in your packet. 32

Next Steps  Mark your calendar for Project RED Implementation Webinars & watch your for dial-in information –Tuesday, May 8 th at 10:00 CT –Tuesday, May 15 th at 10:00 CT –Tuesday, May 22 nd at 10:00 CT –Tuesday, May 29 th at 10:00 CT  Register on to gain access to Readmission Resourceswww.healthcarecommunities.org  Gather baseline data for 30-day readmission rates monthly data is ideal, but we are willing to work with what you have available (i.e. quarterly, or shorter duration). 33

Questions? 34

Serving Texas Hospitals/Health Systems 35