1. CTIC of Southeast Michigan Feb. 17, 2016 Gloria Pizzo, R.N., BSN Senior clinical quality consultant, MPRO

2. 2 What We know: A Review of the Data Medicare Readmission Penalties Year 4: Oct. 1, 2015 – Sept. 30, 2016 Up to 3 percent reduction in all Medicare payments for hospitals with high 30-day readmissions for AMI, HF, PNA, COPD and hip/knee replacement 2,592 hospitals penalized; losing $420 MILLION http://khn.org/news/half-of-nations-hospitals-fail-again-to-escape- medicares-readmission-penalties/

3. 3 SNF Utilization Patterns Are Increasingly Visible SNF hospitalizations cost more than average Hospitalization of patients from SNF/LTC averages $11,255 Average Medicare hospitalization cost is $8,447 33% higher OIG November 2013

4. 4 Why Is This Important? CMS has data on all SNF readmissions - reported quarterly for U.S. and state-by-state CMS defined a SNF 30-day all cause readmission measure Oct. 2015 Public reporting of SNF readmissions (Oct. 2017) 2% withhold of SNF payments (Oct. 2018) Projected penalties to total $2.2 billion over 10 years Office of the Inspector General’s Nov. 2013 report analyzed hospitalizations from SNFs; SNF by SNF

5. 5 “Potential for Efficiency Improvements in Post Acute Care Utilization...” “Conditions for which post acute care accounts for a large percent of episode payments provide hospitals with a stronger incentive to efficiently manage post acute services.” CMS technical guidance on MSPB

6. 6 Top Diagnoses Leading to Hospitalization from SNF OIG November 2013

7. 7 Cost of Hospitalization From SNF Reason for Hospitalization Total Cost $/Hospitalization Sepsis $3 billion $17,430 Pneumonia $850 million $9,500 CHF $640 million $8,700 Asp. Pneumonia $618 million $12,200 Complications $450 million $14,600 OIG November 2013

8. 8 It’s Time To Get Serious… 6 very important messages 1.Readmission reduction “pays” – at least inaction hurts 2.Hospitals must update & standardize transitional care processes 3.Reducing readmissions is a cross-continuum effort 4.Attend to non-clinical needs for post-hospital supports & services 5.Start working on all best ideas 6.Reducing readmissions requires better data

9. 9 Know Your Data Using data to dispel assumptions, expand opportunities for focus.

10. 10 CTIC Community

11. 11 CTIC Acute Care Providers Beaumont Health Farmington Hills Beaumont Health Dearborn Beaumont Health Taylor Beaumont Health Trenton Beaumont Health Wayne Garden City Hospital St. Mary’s Hospital of Livonia St. Joseph Mercy Hospital Ann Arbor Henry Ford Hospital Wyandotte

12. 12 CTIC All-Cause 30 Day Readmission Rates (Q42012-Q32015)

13. 13 CTIC All-Cause 30 Day Readmission Rates (Q42012-Q32015)

14. 14 CTIC Admissions (Q42012-Q32015)

15. 15 CTIC Admissions (Q42012-Q32015)

16. 16 All-Cause 30 Day SNF Readmissions (Q42012-Q32015)

17. 17 All-Cause 30 Day SNF Readmissions (Q42012-Q32015)

18. 18 CTIC All-Cause 30 Day HHA Readmissions (Q42012-Q32015)

19. 19 CTIC All-Cause 30 Day HHA Readmissions (Q42012-Q32015)

20. 20 All-Cause Readmission Within 30 Days of Index Discharge by Top 10 Diagnosis Related Group (DRG) Oct. 1, 2014 - Sep. 30, 2015

21. 21 Factors Contributing to All-cause 30-day Readmissions A structured case series across 18 hospitals 250 (47 percent) deemed potentially preventable Found an average of nine factors contributed to each readmission Assessed factors related to five domains 73% - Care transitions planning & care coordination 80% - Clinical care 49% - Logistics of follow up care 41% - Advanced care planning & end of life 28% - Medications 250 readmissions identified 1,867 factors! There is never one reason for readmission… Feingenbaum et al Medical Care 50(7): July 2012 from Kaiser Permanente

22. 22 Develop A Multifaceted Portfolio of Efforts Improve facility-based care processes for all patients Collaborate with cross-setting partners, including payers Provide enhanced services Use data, analytics, flags, workflow prompts, automation Dashboards to support continuous improvement, ensure reliability, drive to results There is no single bullet; we are engaged in system transformation.

23. 23 Improve Standard Care for All: Standard Discharge 1.Have a process 2.Know your data: Track rates & review readmissions 3.Assess & reassess patients for post-hospital needs 4.Engage patients and caregivers 5.Teach self-care to patients & caregivers 6.Provide a written discharge plan for all inpatients 7.Communicate effectively with “receiving” providers 8.Know the capabilities of area providers, including support services 9.Arrange for post-acute services, including support services http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey- and-Cert-Letter-13-32.pdf

24. 24 Effect of Hospital-SNF Referral Linkages on Readmission MI Tri-County SNF Collaborative efforts are working! “Stronger hospital-SNF linkages were found to reduce readmission rates” “The greater proportion of discharges a hospital sends to a single SNF, the lower the rate of readmission” Specifically lower rates of immediate bounce-backs (days 0-3) Effect of hospital-SNF referral linkages on readmission Rahman et al, December 2013

25. 25 INTERACT II “Interventions to Reduce Acute Care Transfers” Developed by Dr. Joe Ouslander & colleagues Quality improvement approach & tools Focused on identifying changes early & providing staff tools to act on those observations Provides protocols for managing common issues on-site Supports improved communication between SNF-ED Increase hospital awareness of SNF capabilities Advanced care planning Adaptations to assisted living & home health care settings

26. 26 SNF Circle Back–Warm Handoffs SNF Circle Back Questions (hospital calls back SNF 3-24h after d/c) 1.Did the patient arrive safely? 2.Did you find admission packet in order? 3.Were the medication orders correct? 4.Does the patient’s presentation reflect the information you received? 5.Is patient and/or family satisfied with the transition from the hospital to your facility? 6.Have we provided you everything you need to provide excellent care to the patient?

27. 27 Getting Back Home Program Comprehensive discharge planning: appointments, medication management, services made Review all information with resident, family, caregiver Direct contact after SNF discharge Follow–up phone call next day Once a week for a month Once a month for three months

28. 28 Patient Engagement and Activation Ask Your Patients “Why” Understand the “story behind the chief complaint” Interview patients, caregivers for the “story” Ask patients & support persons why they returned, if readmitted Ask patient & support persons what help they need; share with them their needs/risk assessment Use teach-back, target the appropriate “learner”

29. 29 Save the Date MPRO’s 2016 Care Coordination Summit A Focused Approach: Hypertension and Diabetes Crystal Gardens Banquet Center, Howell, MI June 2, 2016 More information to come

30. 30 This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI-C3-16-34 02161 Follow us online @LakeSuperiorQIN MPRO represents Michigan in the Lake Superior Quality Innovation Network.