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Project BOOST Reducing Readmissions

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Project BOOST Reducing Readmissions Mark V. Williams, MD, FACP, FHM Professor & Chief, Division of Hospital Medicine Northwestern U. Feinberg School of Medicine – PowerPoint PPT presentation

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Title: Project BOOST Reducing Readmissions


1
Project BOOST Reducing Readmissions
  • Mark V. Williams, MD, FACP, FHM
  • Professor Chief, Division of Hospital Medicine
  • Northwestern U. Feinberg School of
    Medicine Principal Investigator, Project BOOST

2
A Problem for a long time
  • Rosenthal, J. M. and D. B. Miller "Providers
    have failed to work for continuity." Hospitals
    53(10) 79-83. Continuity of patient care between
    different health care settings has been advocated
    for nearly 20 years, but little has been done to
    effect it. The study described here emphasizes
    the current lack of effort by health care
    providers in hospitals and nursing homes to find
    a workable solution.

1979
3
June 2007 MedPAC Report
  • Medicare pays for ALL admissions regardless
  • Initial stay or readmission for same condition
  • 17.6 of admissions result in re-admissions
    within 30 days (6 in 7 days)
  • 15 billion in spending
  • Future
  • CMS proposes to require that all general acute
    hospitals conduct a CARE assessment on every
    Medicare beneficiary being discharged.
  • Continuity Assessment Record and Evaluation
  • Public Disclosure of readmission rates
  • Lower case payments for readmissions

4
  • 1 in 5 Medicare patients rehospitalized in 30
    days
  • Half never saw outpatient doc
  • 70 of surgical readmissionschronic medical
    conditions
  • Costs 17.4 billion

5
Rates of Rehospitalization within 30 Days after
Hospital Discharge
Jencks S, Williams MV, Coleman EA. et al. N Engl
J Med 20093601418-1428
6
Health Affairs 2010 2957-64
7
Average LOS US Hospitals
gt 65 12.6 to 5.5 days
DeFrances et al, Adv data, 2007 Jul 12(385)1-19
8
Harlan M. Krumholz, MD, SM research group
  • Observational study of 6,955,461 Medicare FFS
    hospitalizations for HF 1993 and 2006, with
    30-day f/u.
  • Mean age 80
  • 52 Htn, 38 DM, 37 COPD
  • LOS 8.8 days down to 6.3
  • In-hospital mortality declined from 8.5 to 4.3
  • 30-day mortality declined from 12.8 to 10.7
  • Discharges to SNF increased from 13 to 20
  • Discharge to home decreased from 74 to 67
  • 30 day readmission increased from 17.2 to 20.1
  • Post-discharge mortality increased from 4.3 to
    6.4

9
Preventable Admissions
  • Hospital inpatient care is the most expensive
    type of health care
  • gt 4 million Preventable Admissions
  • Cost nearly 31 Billion
  • Heart Failure and Pneumonia
  • Half of the problem
  • COPD 16
  • Diabetes 13
  • Elderly 2/3 of these hospitalizations - 1 in 5
    Medicare admissions

10
Care Coordination Failure?
  • 5 commercial disease management companies, 3
    community hospitals, 3 AMCs, 1 integrated
    delivery system, 1 hospice, 1 long term care
    facility, 1 retirement community across U.S.
  • No cost savings
  • 2 reduced hospitalizations
  • Sickest patients benefited

11
HospitalCompare.gov
12
Readmission Reduction CBO - 7.1B savings over 10
yrs
  • Hospital Quality Performance Based Payments
  • All DRG payment amounts in hospitals with excess
    readmission are reduced by a factor determined by
    the level of excess, preventable readmissions
  • Effective 2013
  • Excess ratio of actual to expected (risk-adj)
  • Reduction of 1, 2, and 3 first 3 years

13
Readmission Reduction Program
  • NQF endorsed measures
  • Initially AMI, HF, pneumonia
  • Expand in 2015 to 4 more conditions
  • COPD, CABG, PTCA, Other Vascular
  • Measures must have exclusions for readmissions
    unrelated to prior discharge
  • e.g. transfers, planned readmissions
  • Readmission time window specified by Secretary
  • 30 days in NQF measures
  • Report all-payer readmission rates publicly

14
Measures AMA PCPI
  • Care Transitions
  • Work Group
  • Performance Measure Set
  • Reconciled medication list
  • Transition record
  • Timely transmission
  • Discharge Planning/Post-Discharge Support for
    Heart Failure Patients

15
Hospital Discharge - currently
  • Random events connected to highly variable
    actions with only a remote possibility of meeting
    implied expectations.

Roger Resar, MD Agent of Tremendous Change and
Global Innovation Seeker Luther Midelfort Mayo
Health System Senior Fellow, IHI
16
Dangers of Discharge
  • 19 of patients had a post discharge AE
  • - 1/3 preventable and 1/3 ameliorable

Ann Intern Med 2003 Vol. 138
  • 23 of patients had a post discharge AE
  • - 28 preventable and 22 ameliorable

CMAJ 2004170(3)
17
Dangers of Discharge
Ann Intern Med 2005143(2)121-8
  • 1095 of 2644 (41) inpatients discharged with
    test result pending
  •  - 191 (9.4) potentially required action
  •  - Survey of MDs involved almost 2/3 unaware of
    results
  •  - Of these 37 actionable and 13 urgent

18
Dangers of Discharge
Arch Intern Med. 20071671305-1311
  • ¼ of discharged patients require additional
    outpatient work-ups
  • gt 1/3 not completed
  • Increased time to post-discharge f/u associated
    with lack of work-up completion
  • Availability of discharge summary increased
    likelihood of work-up being done

19
Hospitalist to PCP
  • Info transfer and communication deficits at
    hospital discharge are common
  • Direct communication 3-20
  • Discharge summary availability at 1st
    post-discharge appt 12-34 51-77 at 4 weeks
  • Discharge summaries often lack info
  • Dx test results (33-63), hospital course
    (7-22), discharge meds (2-40), pending test
    results (65)
  • Follow-up plans (2-43), Counseling (90-92)

Kripalani S, LeFevre F, Phillips CO, Williams MV,
Basaviah P, Baker DW JAMA 2007297831-41.
20
Discharge Summary
J Gen Intern Med 2009241002-6
Discharge summaries are grossly inadequate at
documenting both tests with pending results and
appropriate f/u providers.
21
Northwestern Solution
Journal of Hospital Medicine 20094219
  • Significantly improved the quality and
    timeliness.
  • Better documentation of f/u issues, pending
    tests, and info provided to patients and/or
    family.
  • PCPs more satisfied with timeliness and quality
  • gt95 of discharge summaries completed in lt 1 week

22
Discharge Planning - is it THE answer?
  • 21 RCTs 4509 medical, 2285 med-surg 440 ?
  • LOS mean decrease -0.91 (95 CI -1.55 to -0.27)
  • Readmission rates RR 0.85 (0.74 to 0.97)
  • Elderly medical pts mortality RR 1.04 (0.74 to
    1.46)
  • Discharged to home RR 1.03 (0.93 to 1.14)
  • Improved patient satisfaction
  • Subset analysis improved functional status

Cochrane Database of Systematic Reviews 20101
23
  • Randomized 363 patients age gt 65
  • Comprehensive discharge planning and home
    follow-up with APNs
  • 70 completion rate
  • Readmissions at 24 weeks 20 vs 37
  • Reduced multiple readmissions 6.2 vs 14.5
  • Prolonged time to first readmission
  • Medicare reimbursements cut in half

24
Arch Intern Med 20061661822-1828
  • Elderly patients transitioning to SNF/home
  • Randomized Intervention group paired with
    Transition Coach vs. standard care
  • Empowerment and education 4 pillars
  • Facilitate self management/adherence
  • Maintain a personal health record
  • Timely follow-up
  • Knowledge and management of complications
  • Education during hospitalization
  • including meds and med reconciliation
  • Phone calls and personal visits by TC post
    discharge
  • Reduced rehospitalization and costs

25
Arch Intern Med 20061661822-1828
  • Results
  • Rehospitalization Interv Cont P(adj) OR
    (95CI)
  • Within 30d 8.3 11.9 0.048 0.59
    (0.35-1.00)
  • Within 90d 16.7 22.5 0.04 0.64
    (0.42-0.99)
  • Within 180d 25.6 30.7 0.28 0.80
    (0.54-1.19)
  • Costs() Interv Cont Unadj Log
    Transformed
  • At 30d 784 918 0.048 0.06
  • At 90d 1519 2016 0.02 0.02
  • At 180d 2058 2546 0.04 0.049

Also significantly improved for Rehospitalizatio
n for same diagnosis as index admission.
26
Or should it be a Pharmacist?
  • N221 randomized at UCSF
  • All receive pharmacist facilitated discharge
  • 110 got 2 day phone call by pharmacist
  • Check on clinical status
  • Remind about follow-up
  • Check on medications (did they obtain them any
    problems taking them any side effects did they
    know which to take and how etc)

Am J Med 2001111(9B)26S-30S
27
  • Results
  • Contacted 79 or 110
  • 25 had questions about their meds
  • 11 had questions about their care
  • 11 had questions about follow-up
  • 19 had been unable to get their meds
  • 15 reported new problems
  • Greater satisfaction in intervention group 86
    vs. 61 very satisfied (p0.007)
  • 10 vs. 24 patients came to ED at UCSF at 30d
    (p0.005)
  • 15 vs. 25 rehospitalized at 30d (p0.07)

28
Pharmacy Literature
  • Schnipper et al
  • N 178 medical patients randomized
  • Intervention
  • Med reconciliation done at d/c by Pharmacist
  • Pharmacist counseling at d/c and 3day follow-up
    call
  • At d/c, pharmacist recommended med changes in 60
  • At 3d call, unexplainable discrepancies between
    d/c meds and reported home meds in 29
  • At 30d
  • Fewer preventable ADEs 1 vs. 11 (p0.01)
  • Fewer preventable med related ED visits 1 vs.
    8 (p0.03)
  • 49 had med discrepancies!
  • No difference in total ADEs, health care
    utilization, patient satisfaction, or med
    adherence

Arch Intern Med 2006166565-71
29
Pharmacists Work!
Arch Intern Med. 2009169(9)894-900
  • Swedish ward-based pharmacists
  • 16 reduction in hospital visits
  • 47 reduction in ER visits
  • Drug-related readmissions reduced 80
  • Intervention group cost lt control

30
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31
Project RED
  • RCT of 749 hospitalized adults
  • Intervention
  • Nurse Discharge Advocate
  • F/U appt, Medication Reconciliation
  • Patient education
  • Individualized instruction booklet
  • Pharmacist call 2-4 days post-discharge
  • Review medications
  • Limitations
  • Urban, academic, safety net hospital

32
Project RED Outcomes
p lt 0.05 p 0.09
33
Low-cost Intervention
JGIM 2008
  • user-friendly Patient Discharge Form
  • Telephone outreach from a nurse post-discharge
  • Improved outpatient follow-up
  • Reduced ER visits and rehospitalizations from
    historical controls

34
  • Med Rec by PharmD
  • RN Care Coordinator D/C Planning
  • Phone Follow-up
  • PHR, Supplemental Discharge Form
  • Reduced ER visits, Reduced Readmission

35
SHM Initiatives
  • Discharge Checklist Halasyamani L et al.
    Transition of care for hospitalized elderly
    patients --development of a discharge checklist
    for hospitalists. J of Hosp Med 2006354.
  • Resource Room
  • Safe STEPs
  • Project BOOST
  • Better Outcomes for Older adults through Safe
    Transitions
  • John A. Hartford Foundation 1.4 million


36
Safe STEPs
  • Safe and Successful Transitions for Elderly
    Patients
  • John A. Hartford Foundation Grant

37
Safe STEP Interventions
  • Medication reconciliation
  • Pharmacy reviews admission and d/c
  • Geriatric friendly medication forms
  • Education
  • Patients pre-d/c appointment
  • Providers geriatric hp
  • PCP communications
  • Fast facts

38
Safe STEPs
  • 237 elderly patients at three hospitals
  • Academic, community
  • 5 component intervention
  • Admission form with geriatric cues
  • Fax to PCP
  • Interdisciplinary worksheet
  • Pharmacist-physician medication reconciliation
  • Pre-discharge planning appointments
  • Reduced ED visits and readmissions by 1/3

39
Project BOOST Team
  • Janet Nagamine, MD
  • Dan Dressler, MD, MS
  • Kathleen Kerr
  • Greg Maynard, MD
  • Arpana Vidyarthi, MD
  • Tina Budnitz, MPH
  • Eric Coleman, MD, MPH
  • Jeff Greenwald, MD
  • Eric Howell, MD
  • Lakshmi Halasyamani, MD
  • Mark V. Williams, MD

40
Advisory Board
Chair Eric Coleman, MD, MPH Co-Chair Mark V.
Williams, MD with organizational representatives
from
  • Social work
  • Case management
  • Clinical pharmacy
  • Geriatric medicine
  • Geriatric nursing
  • Health IT
  • Blue Cross/Blue Shield
  • United Health
  • Health systems
  • NQF
  • AHRQ
  • TJC
  • CMS
  • National Consumers League
  • Other content experts

41
www.hospitalmedicine.org/BOOST
42
What is BOOST Today?
  • Intervention
  • Tailored clinical Tools
  • Comprehensive Risk Assessment
  • Team-based care
  • Patient centered discharge process
  • 72 Hour follow-up call for high-risk patients
  • Scheduled outpatient follow-up visits
  • Standardized PCP Communication
  • Tailored processes, work-flow
  • Project management tools

43
BOOST components (cont)
  • Technical Support
  • Mentors calls, email, resources
  • Teleconferencing across sites
  • Education (webinars, newsletters)
  • Enduring Materials (Teachback DVD)
  • Peer Support
  • Listserv
  • Document sharing
  • Moral support
  • Infrastructure Development
  • Train the trainer curricula
  • Mentor Guides
  • Mentor University

44
Teach Back
NEW CONCEPT Health information, advice,
instructions, or change in management
Assess patient comprehension / Ask patient to
demonstrate
Explain new concept / Demonstrate new skill
Clarify and tailor explanation
Patient recalls and comprehends / Demonstrates
skill mastery
Re-assess recall and comprehension / Ask
patient to demonstrate
Adherence / Error reduction
Modified from Schillinger, D. et al. Arch Intern
Med 200316383-90
45
Life-Cycle Project BOOST
Training Preparation
Individualized Mentoring
Implement intervention Keep stakeholders
informed Monitor core elements
Analyze data Adjust intervention
components Report to stakeholders Spread gains
Training-6months 6-9 months 9-12
months
46
BOOST Network
  • BOOST eNewsletter
  • Key milestones
  • BOOST updates
  • Site status reports, aggregate outcomes
  • Forum for sharing ideas, challenges, mini studies
  • BOOST Network
  • E-mail, call between sites
  • BOOST listserv

47
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50
End-Result
  • Network of Institutions using the guide and
    interventions
  • Understanding Impact of Interventions
  • Understanding Implementation facilitating factors
    and barriers

51
BOOST Mentor Sites
52
Projected Growth
  • Cohort 1 9/08 6 sites
  • Cohort 2 3/09 24 sites
  • MI Collaborative 5/10 14 sites
  • Tuition pilot 5/10 2 sites
  • CA Collaborative 20 sites
  • Fall 10 Tuition Cohort 15 sites

Online in 2010 81 sites
53
So what happens to readmission rates?
12/08
6/09
12/09
12/10
Hierarchical time series analysis of readmission
rates (one year prior to kick-off through one
year post kick-off) 12/10
Cohort 1 (n6) kickoff
Implementation Survey
Cohort 2 (n24) kickoff
54
Prelim Results
  • Across all sites overall readmission rates
    decreased from 13 to 11.
  • BOOST Intervention Units
  • 6 months post go live
  • Readmission rates rose in non-BOOST units by 2
  • Marked increased patient satisfaction at some
    sites.

55
A Hospital Nurse
  • Project BOOST brings me back to what I thought
    nursing was really about. BOOST helps patients
    and families understand what they need to do to
    go home. This is why I went into nursing.

56
THANKS!!!
  • The John A. Hartford Foundation
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