1. © Joint Commission Resources Reducing Hospital Readmissions Deborah Morris Nadzam, PhD, BB, FAAN Project Director AHRQ and CMS Contracts Joint Commission Resources dnadzam@jcrinc.comdnadzam@jcrinc.com 630-261-5048

2. © Joint Commission Resources Hospital Readmissions  19.6% Medicare patients readmitted within 30 days (that’s 2 million patients!)  90% of the readmissions deemed unplanned  Only 50% of those readmitted had seen their physician prior to readmission  These readmissions estimated at $17.4 billion for one year (2004) - Jencks et al, 2009.

3. Medicare Payment Advisory Committee (MedPAC)  2007 Report to Congress –Readmissions affect patients and are costly –7 conditions contribute to 30% of readmissions and may be preventable Heart Failure Acute M.I. Pneumonia COPD CABG PTCA Other vascular procedures  CMS adds 3 readmission measures to reporting requirements (HF, AMI, Pneumonia)

4. © Joint Commission Resources National Readmission Rates (July 2007-June 2010) Measure National Average 30-day readmission of acute myocardial infarction patients 19.8% 30-day readmission of heart failure patients 24.8% 30-day readmission of pneumonia patients 18.4%

5. © Joint Commission Resources Readmission Reduction Program Proposed Regulations  FY 2012 – submission of data for HF, AMI, and Pneumonia readmission measures  FY 2013 – payment penalty for ‘excess readmission rates” –up to 1% reduction of Medicare payment –will apply to entire related DRG for one year  FY 2014- possible increase of penalty up to 2%  FY 2015 – possible increase of penalty up to 3% and addition of more readmission measures

6. © Joint Commission Resources CMS Penalties Hit October 2013 Readmissions for CHF, AMI and Pneumonia Measurement period for benchmarking Jul 1, 2008 – Jun 30, 2011Oct 1, 2011 – Sept 30, 2012Oct 1, 2013 First Measurement Period Penalties Assessed

7. Partnership for Patients: Better Care, Lower Costs 1.Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010. –About1.8 million fewer injuries to patients with more than 60,000 lives saved over the next three years. 2.Help patients heal without complication. By the end of 2013, all hospital readmissions would be reduced by 20% compared to 2010. –More than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge. Potential to save up to $35 billion dollars over three years.

8. © Joint Commission Resources Health Care Providers Respond  Transitional Care Model - www.transitionalcare.info/www.transitionalcare.info/  Care Transitions Program - www.caretransitions.orgwww.caretransitions.org  Project BOOST - www.hospitalmedicine.org/BOOST/www.hospitalmedicine.org/BOOST/  Project RED - www.bu.edu/fammed/projectred/www.bu.edu/fammed/projectred/  National Transitions of Care Coalition - www.ntocc.orgwww.ntocc.org

9. © Joint Commission Resources So? Why Should You Care and What Can You Do?

10. VCSQI- AMI- 30 Day Unplanned Readmissions – (July 2007 – June 2010) 10 U.S. Rate = 19.8%

11. VCSQI- HF- 30-day Unplanned Readmissions – (July 2007- June 2010) U.S. Rate = 24.8%

12. VCSQI- PN: 30-Day Unplanned Readmissions – (July 2007 – June 2010) U.S. Rate = 18.4%

13. VCSQI- Isolated CABG- 30 Day Readmissions - 2011 VCSQI Rate = 8.49%

14. VCSQI- Isolated CABG Readmissions 2010 and Half 2011 VCSQI Rate = 8.44%

15. VCSQI- CABG and Valve- Readmissions-2010 and Half of 201122 VCSQI Rate = 11.56%

16. VCSQI Valve Only – Readmissions 2010 and Half of 2011 VCSQI Rate = 9.94%

17. © Joint Commission Resources Re-Engineered Discharge (Project RED) – One Solution Set  AHRQ-funded research grant: Principal Investigator, Brian Jack, M.D., Boston Medical Center  30% reduction in readmissions among patients who understood discharge instructions  Study published in Annals of Internal Medicine, February 2009

18. © Joint Commission Resources Project RED Checklist Eleven mutually reinforcing components: 1. Medication reconciliation 2. Reconcile discharge plan with national guidelines 3. Follow-up appointments 4. Outstanding tests 5. Post-discharge services 6. Written discharge plan 7. What to do if problem arises 8. Patient education 9. Assess patient understanding 10. Discharge summary sent to PCP 11.Telephone reinforcement Adopted by National Quality Forum as one of 30 US "Safe Practices“ http://www.ahrq.gov/qual/impptdis.htm

19. © Joint Commission Resources Distribution of Project RED Hospitals

20. © Joint Commission Resources Project RED Hospitals by AHA Bedsize

21. © Joint Commission Resources Training and Technical Support  Each hospital is assigned a consultant for technical support  Online training program available 24/7 for self-paced completion  Handouts and tools available to guide re-engineering of discharge program and to measure impact  Audio/web conferences October 2011

22. © Joint Commission Resources Project RED Training and Support

23. © Joint Commission Resources Your current state may look like this…

24. © Joint Commission Resources

26. Readmissions Data Readmissions/total cases Prior to Intervention: 159/515 Post Without Intervention :165/558 Post With Intervention: 36/184 Prior Year Oct. 2009 – May 2010 Non PR Oct. 2010 – May 2011 PR Oct. 2010 – May 2011 Post: October 2010-May 2011

27. © Joint Commission Resources Results  50% launched pilot or have spread  Consistent demonstration of reduced readmission rates and increased patient experience scores for discharge-related items  Discovery of strengths  Discovery of broken systems and redundant processes

28. © Joint Commission Resources Keys to Success  Leadership support and expectations  Physician engagement and champions  Systematic approach to analysis of ‘current state’  Methodical planning  Starting small (pilot)  Measurement of process and results  Comprehensive use of all components

29. © Joint Commission Resources Summary  Inadequate discharge preparation and weak transitions of care contribute to patient morbidity and adverse events, readmission, higher costs  Public and private payers are taking action to improve transitions of care and reduce adverse event and readmission  Effective models exist to help hospitals improve discharge programs and transitions of care

30. Homemade M.A.R.

31. © Joint Commission Resources Thank You! Any Questions?

32. © Joint Commission Resources After Hospital Care Plan

33. © Joint Commission Resources