Follow Through is Everything Care Transitions: Length of Stay and Readmission Management Leslie Foti, RN BSN ACM

Presenter Disclosures Leslie Foti, RN BSN ACM No relationships to disclose.

Why Do Care Transitions, Length of Stay (LOS), and Readmission Matter? Setting the Table

New Payment Structure: Incentivizing Value and Quality It’s Here! Hospital Value-Based Purchasing Pay-for-Performance Readmission Penalties Increased Scrutiny of Utilization Medicare Hospital Value based Purchasing total of 2% of payment withheld Paid back to hospital if meets targets new in 2015 - 20% Efficiency measured by Cost per Episode of Care (3 days prior to admission, the inpatient stay and 30 days post dc P4P - +$ for hitting targets – LOS, complications, quality measures Readmission – stroke not currently a diagnosis for Medicare Readmission Penalty, but is for commercial payers carve out payments on medically unnecessary days, retrospective audits for medical necessity

Why Does Length of Stay (LOS) and Readmission Matter? Financial Sustainability Appropriate Stewardship of Resources The Right Thing to Do for the Patient! Most payments are Episode or DRG based – a lump sum that does not change regardless of length of stay, based on diagnosis, procedures and comorbidities – pts stay longer we use resources and may not cover cost of care. If pt’s readmit, reduced payment. This puts financial pressure on organizations to reduce costs, sometimes staff reductions. We are not transitioning to the new payment model – it is already here from payers. Organizations that can adjust will survive, those that cannot adjust will weaken financially. Just because its not easy doesn’t mean its not right. We need to be efficient on the more straightforward cases so to average out the overruns from outliers. These changes are really in the best interest of the patient. We may not like the models but they are trying to incentivize the right thing. Patients expect quality care and do not want to readmit to the hospital.

What are Care Transitions? “Transition of Care – The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another” (CMS, 2010) Goal – the shortest, safest, most efficient hospital stay with discharge to a level of care that has the needed resources and knowledge to manage the patient’s care outside of the hospital setting Includes movement between levels of care within the hospital

Who “Owns” Care Transitions? Case Management The Health Care Team The Patient and Family All of the Above

What is the Target?

Transition Needs of the Stroke Population Stroke - a leading cause of serious long-term disability

To Coordinate … in an Average of 2-6 days! Ancillary Services Therapy Dietician Pharmacy Case Management Teaching Core Measures for Stroke New Diagnoses New Medications New Diet New Equipment

To Coordinate … in an Average of 2-6 days! Screen and Assess for : Depression Caregiver Burden Respite care Support groups Discharge needs Support Level of care Resources Financial Barriers

Integrate & Deliver Services in Alignment with LOS Goals Communication, Coordination, Collaboration

Managing LOS Ensure everyone knows the goal! Create systems that ensure all patient needs are addressed without over utilization Know the players on your team & ensure they know what position they’re playing! Establish a consistent communication plan Goal – educate your ancillary staff about length of stay, general care plan, and what the target goals are. The team can’t reach a target if they don’t know what they’re aiming for. Discuss internal transition times/ events daily with care team. Include family and discuss anticipated transitions so they know what to expect Check lists or preprinted order sets are great, but make sure you allow for customization that items are not pre-checked on orders to reduce the chance of over utilization (i.e. Maybe they don’t need occupational therapy?) Get to know the workflow of the ancillary services – who does what, what hours do they work, what is there coverage like, how do they respond to consults? IE therapy makes their schedule in the morning , if you don’t put your consult in when admitting the patient but enter it on rounds the next day you will lose a day. Who has ownership of patient and family education or activity? If there is anything in the system that is not optimized, assess current state and determine ownership to work on improvements Communication: whether it is an inter disciplinary round or a certain type of note, the entire team needs to know where to go to get the most accurate information; be consistent. IDRs are an best practice way to reduce LOS and create efficient; For outliers from the ICU, extra attention to advancing activity and discontinuing unneeded medications. Weekends – do things stop on the weekends? Does the patient admitted on a Friday afternoon and discharged on a Sunday or Monday morning receive the same level of care. What is the staffing of the ancillary services and diagnostics? These ancillary departments are serving the entire hospital and we need to collaborate with the hospital administration other departments to improve if it is a barrier. If it is impacting your length of stay, collect data, see if there is a business to assess for change – maybe there is and maybe there isn’t

Managing LOS Basic Nursing Care – advancing diet, activity, weaning medications and O2, and Teaching! Special vigilance with longer ICU, intermediate stays Dysphasia – PEG or not to PEG? Adequate intake on modified diets Look at your weekends – is it a black hole?

Managing LOS Newer Anticoagulants Financial Barriers Delirium, Dementia, & Restraints Managing Patient and Family Expectations Nursing care – prevent complications – highest level of activity patient can tolerate, advancing diet – feeding, aggressively wean what is not needed Newer anticoagulants can shorten time transitioning from Coumadin to Heparin but need to ensure patient can afford and whether medication requires pre-authorization. Financial barriers – address self pay patients with significant deficits early for your financial counselors and case managers to assess quickly – lack of a Medicaid pending number Dysphasia – coordination of many ancillary services, emotional barrier for patient/ family for PEG, consults to service to place PEG, calorie counts to determine PEG need all take time High risk for delirium, exacerbation of dementia, confusion – leads to restraints for safety; Make sure that when trying to manage confusion all staff knows, nights shift needs to

Reducing Readmission Starts with Discharge Preparation 30% of acute stroke patients experience a hospital readmission within 90 days of discharge (Roger, et al., 2011)

Discharge – Where the Ideal Meets Reality Home discharge – we must prepare the patient and family to self-manage their care Willingness & Readiness Teaching is Vital! Access to Care Do they have a PCP? Can they afford their medications? What to do with the VA?!? Home Health vs. Outpatient therapy

Readmission Reduction Strategies for the Home Discharge Structured Teaching –Teach Back Discharge Instructions Should include EVERYTHING they need to know! What to know about risk factors, lab targets, medications, signs and symptoms Who to contact with phone numbers Follow-up appointments made prior to discharge Post Discharge call backs within 24 hours Respite and Support Resources

Discharge – Where the Ideal Meets Reality Facility Discharge –LTACH, Acute Rehab, SNF, Custodial Care - which level? What Impacts the Determination Acuity Payer Support system Increased scrutiny of acute rehab Observation status Patient ability to participate in therapy

Readmission Reduction Strategies for the Facility Discharge Choose the RIGHT level of care Handoff to post hospital care providers Discuss custodial care early if it is anticipated Family conferences and palliative care Don’t promote one level of care as being superior over another – communicate finding the RIGHT level of care for the patient

Other Strategies Consider: Partner with post hospital care providers and support them with stroke specific education Telephonic support for 30 days post discharge Reassess for Cognitive Decline, Depression, Caregiver Burnout with every follow up

Thank you!

References & Links Centers for Medicare and Medicaid (CMS), (2011). Eligible professional meaningful use menu set measures measure 8 of 10, stage 1, transition of care summary. E.H.R Incentive Programs. Retrieved from http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/8TransitionofCareSummary.pdf CMS, (2013). Hospital value-based purchasing program. Department of Health and Human Services Centers for Medicare & Medicaid Services. Retrieved from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf CMS, (2013). FY 2014 final rule tables. Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html CMS, (2015, January 26th). Fact sheets: better care. smarter spending. healthier people: paying providers for value, not volume. Retrieved from http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html Coleman, E.A., Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), p. 556-7. Olson, D.M., Prvu Bettger, J. , Alexander, K.P., Kendrick, A.S., Irvine, J.R. , Wing, L., … Graffagnino, C. , (2011). Transition of care for acute stroke and myocardial infarction patients: from hospitalization to rehabilitation, recovery, and secondary prevention. Agency for Healthcare Research and Quality, Publication No. 11(12)-E011. Mozaffarian D, Benjamin EJ, Go AS, et al., (2015) Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation,e29-322 Naylor, M.D., Aiken, L.H., Kurtzman, E.T., et al., (2011) The importance of transitional care in achieving health reform. Health Affairs (Millwood)30 (4), p. 46-54. Poston, K. M., Dumas, B. P., & Edlund, B. J., (2013). Outcomes of a quality improvement project implementing stroke discharge advocacy to reduce 30-day readmission rates. Journal of Nursing Care Quality, 29 (3), p. 237-44. Roger, V.L, Go, A.S., Lloyd-Jones, D.M., Adams, R.J., Berry, J.D., Brown, T.M., Carnethon, M.R., … Wylie-Rosett, J., (2011).Executive summary: heart disease and stroke statistics—2011 update: a report from the American Heart Association. Circulation 123 (4):459-463. Links: Joint Commission Core Measures: http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx Joint Commission Comprehensive Stroke Center requirements: http://www.jointcommission.org/certification/advanced_certification_comprehensive_stroke_centers.aspx