1. Innovative Solutions in Preventing Hospitals ReAdmissions
Raymond Carr, DNP, RN, CENP/The Hospitals of Providence Sierra Campus
Patricia Duran, DNP, RN, CENP/Gayle Greve Hunt School of Nsg

2. Overview of Readmission Reduction
Patricia Duran

3. Overview of Hospital Inpatient Quality Reporting Program
The Hospital Inpatient Quality Reporting Program was originally mandated by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003.
The goal of driving quality improvement through measurement and transparency by publicly displaying data to help consumers make more informed decisions about their health care
In addition, intended to encourage hospitals and clinicians to improve the quality and cost of inpatient care provided to all patients.

4. Overview of Readmission Reduction Program (HRRP)
Applying to most inpatient hospitals, the Department of Health and Human Services states that the HRRP will play a role in its new goals to tie an increasing share of traditional Medicare payments to quality or value in the coming years
HRRP is one of 5 Value Bases Purchasing programs for Medicare (Pay for Performance).
Section 3025 of the 2010 Affordable Care Act required the Secretary of the Department of Health and Human Services to establish the HRRP starting October 1, 2012 (i.e., Federal Fiscal Year [FY] 2013).

5. Overview of Readmission Reduction Program (HRRP)
What measures are included in the Hospital Readmissions Reduction Program?
Acute Myocardial Infarction (AMI)
Chronic Obstructive Pulmonary Disease (COPD)
Heart Failure (HF)
Pneumonia
Coronary Artery Bypass Graft (CABG) Surgery
Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA)
*HRRP doesn’t include the Hospital-Wide All-Cause Readmission (HWR) measure, which is included in the Hospital Inpatient Quality Reporting (IQR) Program.

6. Where are we now?
Median hospital 30-day risk standardized readmission rate (%) for certain conditions, July 2010 – June 2013
Key: HF = heart failure; COPD = chronic obstructive pulmonary disease; AMI = acute myocardial infraction; PN = pneumonia. Source: Centers for Medicare & Medicaid Services, 2014 Medicare Hospital Quality Chartbook

7. Readmission Reduction Resources- Tried and True
Patricia Duran

8. Resources Available Agency for Healthcare and Research Quality (AHRQ)
Agency Healthcare and Research Quality – Priorities in Focus
Care Coordination
Hospital Readmission
Programs – RED; BOOST Tool Kits
Taking Care of Myself Guides
Data
Research

9. Robert Wood Johnson Foundation
Healthy Communities
Healthy Children, Healthy Weight
Health Systems
Leadership for Better Health

10. Robert Wood Johnson Foundation- Reducing Hospital Readmissions
Best in Practice Stories – Improving Transitions
Journal Articles - Hospitals With Higher Nurse Staffing Had Lower Odds Of Readmissions Penalties Than Hospitals With Lower Staffing

11. Institute of Hospital Improvement Reducing Hospital Readmissions
Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions
Toolkits
Audio Resources
Video Resources

12. The Staar Program Institute of Hospital Improvement
PARTICIPATING STATES
Massachusetts
Michigan
Washington
Institute of Hospital Improvement

13. State Action on Avoidable Rehospitalizations
May 2009 – June 2013
Dramatically improve the delivery of effective care at a regional scale. 
Reduce rehospitalizations
Working across organizational boundaries
By engaging
Payers,
Stakeholders at the state, regional and national level
Patients and families, and caregivers
IHI provided strategic guidance, support and technical assistance to hospitals and cross-continuum teams to improve transitions in care and reduce avoidable rehospitalizations.

14. Working across organizational boundaries
Improve transitions of care by cultivating a cross-continuum learning collaborative.
Core Process
Communication tools and norms,
Handoff and follow-up delineations of responsibility
Care coordination activities
Engage state-level leadership to understand and mitigate systemic barriers to change.
 Mitigation of barriers to system-wide improvement
Policy and payment reforms that will reduce fragmentation and encourage coordination across the continuum of care.
Prioritizing longitudinal care and reducing avoidable rehospitalizations involves new behaviors, norms, relationships, and partnerships to communicate and coordinate care between disciplines, settings, and organizations. State-level leadership is essential to understand and act on the barriers that front-line teams encounter in doing this work. Similar in many respects to the cross-continuum team at the provider-level, STAAR engages with multi-stakeholder state leaders and steering committees to lead and coordinate this initiative at the state level. This is especially relevant in states coordinating several ACA and delivery reform initiatives simultaneously.

15. Improving Transitions of Care
Provide an enhanced assessment of post-hospital needs
Involve family caregivers and community providers as full partners in completing a needs assessment of  patients’ home-going needs. 
Reconcile medications upon admission. 
Create a customized discharge plan based on the assessment.
Provide effective teaching and facilitate enhanced learning
Customize the patient education materials and processes for patients and caregivers.
Identify all learners on admission  
Use Teach Back regularly throughout the hospital stay to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self- care.
STAAR hospital teams focus on the implementation of four key recommended process-level improvements that require extensive collaboration between the hospitals and their community partners to effectively co-design better processes.

16. Improving Transitions of care (cont)
 Provide Real-time Handover Communications
Reconcile medications at discharge. 
Provide customized, real-time critical information to next clinical care provider(s). 
Give patients and family members a patient-friendly discharge plan. 
For high-risk patients, a clinician calls the individual listed as the patient’s emergency contact to discuss the patient’s status and plan of care.
Ensure Timely Post-Hospital Care Follow-Up
Identify each patient’s risk for readmission. 
 Prior to discharge, schedule timely follow-up care and initiate clinical and social services based upon the risk assessment.

17. Outcome/Process Measures: Readmissions
30-Day All-Cause Readmissions (overall hospital and pilot-unit)
Counter Measures – Observation Hours

18. Available Resources through IHI
How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations
How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations
Readmissions Diagnostic Worksheet

19. Readmission Improvement
The Hospitals of Providence East Campus
Raymond Carr, DNP, RN, CENP

20. Improving Transitions of Care
In 2016, A Discharge Collaborative was held with Home Health Agencies
Feedback Obtained
Form to Improve information at TOC developed
Implemented on a pilot unit
Improvement spread after pilot successful

21. Improving Transition Processes at “EAST”
Improving the process of Teach Back
Improving Understanding for Pt/Family
Improving Self-Management
Improving Knowledge of Transition of Care
2016 saw an improvement of All Cause Readmission from 17% to 13%

22. Readmission Reduction at East - 2017
Higher Risk Score – Patients identified by a High Risk Calculator by Tenet now available
Targeted Diagnosis – Data Analysis done to determine
Focus of patients with co-morbidities
Team approach used – Integrated with Patient Rounds for Patient Experience

23. Process High Risk Patient identified daily
Tool for Team documentation in chart
Integrated into Patient Experience Rounds
Intense Education to patient/family along with supplies for discharge and self-management
Teach Back used by educator and by nursing staff

25. Challenges to Readmission Reduction
Patient/Family Illiteracy of Disease Process
Reinforcement of Patient/Family to see PCP circumvented by PCP when sent to ED
PCP office visits not available within chosen time frame

26. Pilot Outcomes Summary:
Table 1. Readmissions presented as number of occurrences
January 2017
February 2017
March 2017
Var, Feb - March
Total Admissions
988
974
1084
110
Overall Readmissions 79 68
100 32
Total Related Readmissions 24 42 18
COPD 2 1 -1
CHF 3
Pneumonia
AMI
Table 2. Readmissions presented as a percentage of "Total Related Readmissions"
January
February
March
%Var, Feb - Mar 8% 7% 9% 2%
30%
35%
42% 4% 0%
-4%
13% 5%
-8% 1%
Summary:
As shown in Table 2 and line graph below, there was a decrease in COPD, CHF, and Pneumonia readmissions in March compared to February. There was a 2% increase in total readmissions, a 7% increase in readmissions related to previous visit and a 1% increase in AMI readmissions.

27. Pilot Outcomes

28. SOLUTIONS FROM Robert Wood Johnson Foundation

29. References
Agency for Research Health and Quality. (2018). Readmission Reduction Retrieved June 15, 2018 from Instruments/HospitalQualityInits/HospitalRHQDAPU.html
Agency for Research Health and Quality. (2018). Readmission Reduction tools Retrieved June 15, 2018 from
Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective Interventions to Reduce Rehospitalizations: A Compendium of Promising Interventions. Cambridge, MA: Institute for Healthcare Improvement; 2009.
Boutwell, A. Jencks, S. Nielsen, GA. Rutherford, P. STate Action on Avoidable Rehospitalizations (STAAR) Initiative: Applying early evidence and experience in front-line process improvements to develop a state-based strategy. Cambridge, MA: Institute for Healthcare Improvement; 2009.
Centers for Medicare and Medicaid Services (2017). Readmission Reduction Program. Retrieved June 27, 2018 from Reduction- Program.html
Institute of Hospital Improvement (2018). Reduce Avoidable Readmissions Retrieved July 1, 2018 from