David G. Schulke Vice President, Research Health Research and Educational Trust

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Improving Transitions from Hospital to Community
Care Models that Work

• David G. SchulkeVice President, Research Health
  Research and Educational Trust
• dschulke_at_aha.org
• [phone]
• October 18, 2011

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The Health Research and Educational Trust (HRET)

• HRETs mission is to transform health care
  through research and education.
• AHRQ has retained HRET to support state-based
  Learning Networks with trainings for providers
  that wish to use AHRQs patient safety tools.
• Primary tools supported include Project RED
  (readmissions reduction), HCAHPS (patient
  satisfaction), VTE prevention, ED flow management.

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Overview of Presentation

• Review research behind new financial incentives
  to reduce readmissions in the Patient Protection
  and Affordable Care Act (ACA).
• Examine the importance of patient centered care
  and the relationship between hospitals and other
  providers in the community.
• Describe proven strategies hospitals use to
  improve care and protect against financial
  penalties, focusing on Project RED.

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The Discharge Process and Post-hospital Care
Influence Rehospitalization Rates

• 19 of Medicare inpatients are readmitted by 30
  days.
• Only half of the patients re-hospitalized within
  30 days saw their doctor before their
  readmission.
• As many as 90 of rehospitalizations within 30
  days appear to be unplanned.
• Cost to Medicare estimated at 17 Billion/year.
• Source Jencks et al N Engl J Med
  20093601418-28

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How Many Readmissions Should be Prevented?

• What proportion of readmissions are truly
  preventable, with good care? No one knows.
• Evidence suggests many rehospitalizations result
  from poor practices and are preventable--
• Many rehospitalized before seeing a physician
• High inter-hospital and inter-state variation
• Randomized clinical trials testing interventions
  achieve 30 reduction in readmissions

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Business Case for Hospital Action on Readmissions

• ALOS for rehospitalized patients is 0.6 day
  (13.2) longer than the stay for patients in the
  same DRG who were not hospitalized in the
  previous 6 months
• Medicare payment for rehospitalizations is 4
  lower than for index hospitalization
• For hospitals with excess readmissions Penalty
  of 1 of all Medicare PPS payments in FY 13
  (rising to 3 in FY15)
• Value-based purchasing penalty of 1 of all PPS
  payments (grows to 2 in future years)
• If your system has competitive pricing pressure
  these are all inefficiencies others are driving
  out of their systems

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Federal Penalties for Avoidable Readmissions

• Penalties on hospitals with readmissions above
  expected rates for targeted conditions (AMI, CAP,
  CHF), starting October 1, 2012
• Penalties will reduce hospital payments by at
  least 7 Billion over 10 years
• Exempt Sole community hospitals,
  Medicare-dependent rural hospitals, low volume
  conditions
• CMS proposes more conditions for 2014
• Chronic Obstructive Lung Disease
• Coronary Artery Bypass Graft surgery
• Percutaneous Coronary Interventions
• Vascular Procedures

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Potential Financial Impact of Readmissions
Penalty at a Small Community Hospital

• Laurens County Health System (76 acute, 14 SNF
  beds) and SCHA modeled potential annual effect of
  penalties

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Financial IncentivesMedicare Hospital Value
Based Purchasing

• Medicare VBP program pays hospitals for actual
  performance on quality measures, not just
  reporting measures, beginning FY13
• The VBP program will apply to all acute-care PPS
  hospitals (VBP demonstration for CAHs)
• Funded by reducing all Medicare DRG payments by
  1, redistributed to best performers
• A hospital that meets or exceeds the performance
  standards will be eligible to earn back the
  initially withheld money (or more if others
  perform poorly)

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Value Based Purchasing Higher Scores with Strong
Discharge and Follow up Processes

• H-CAHPS accounts for 30 of hospital VBP score
• Four patient perceptions measured by H-CAHPS are
  better predictors of readmissions than core
  clinical measures
• During this hospital stay, did doctors, nurses
  or other hospital staff talk with you about
  whether you would have the help you needed when
  you left the hospital? and
• During this hospital stay, did you get
  information in writing about what symptoms or
  health problems to look out for after you left
  the hospital?
• How do you rate the hospital overall?
• Would you recommend the hospital to friends and
  family?

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Discharge Process Must Address Breakdowns Leading
to Avoidable Readmissions

• Breakdowns include
• Inadequate communication with primary care
  physicians
• Inadequate education of patient
• Drug therapy
• Poor coordination with other community providers

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Process Breakdown Poor Transfer of Information
to Primary Care Physician

• 25 pts require additional outpt work-ups 1/3
  incomplete (Source Archives of Internal
  Medicine. 2007 167 1305-11)
• 41 inpatients discharged w/ pending test result
• 2/3 of physicians unaware of results
• 37 of tests actionable and 13 urgent
• (Source Annals of Internal Medicine. 2005
  143(2) 121-8)
• Discharge summary not readily available
• Only 12-34 at first post-discharge appt 51-77
  at 4 weeks
• Discharge summary lacking key components
• Hospital course (7-22)
• Discharge medications (2-40)
• Test results (33-63)
• Pending tests (65)
• Follow-up plans (2-43)
• (Source JAMA 2007 297(8) 831-41)

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Process Breakdowns Poor Pre-discharge Patient
Education

• Poor transfer of information to patient
• 37 able to state purpose of all medications
• 14 knew the common side effects
• 42 able to state their diagnosis
• Result
• Poor patient understanding of how to use
  medications after hospital discharge
• Patient doesnt understand warning signs that
  warrant an emergency call to their physician
• Lack of clarity on patients end of life care
  preferences lead to unwanted rehospitalization
• Source Courtesy of Michael Paasche-Orlow, MD,
  Mayo Clinic Proceedings. August 2005
  80(8)991-994

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Adverse Drug Events in the Transition from
Hospital to Home

• Studied 400 consecutive hospital patients
  discharged home.
• 19 of patients had an adverse event (AE) within
  3 weeks of discharge home.
• 66 of AEs were adverse drug events
• Most ADEs were preventable or ameliorable, unlike
  other Adverse Events.
• Clinical process improvements suggested by the
  authors
• Identify unresolved problems at discharge
• Patient education re treatment plan
• Post-discharge monitoring and follow up
• (Source Forster et al, Annals Int Medicine, Feb
  2003)

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Rates of Rehospitalization within 30 days after
Hospital Discharge
Source Jencks SF, et al. N Engl J Med
20093601418-1428
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Hospital Admissions Vary for Ambulatory Sensitive
Conditions
2007 Medicare SAF data
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Hospital Admissions of Short Stay Nursing Home
Residents
2006 Medpar Data
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Hospital Admissions of Home Health Patients
OASIS data in 2008 AHRQ National Healthcare
Quality Report
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Implications

• Nursing home, home health agency, hospice,
  pharmacy, and physician practices influence your
  hospital admission rates
• Coordinating with these providers can help your
  hospital escape penalties for patient care
  breakdowns
• Reducing readmissions cannot be done as
  effectively with interventions only within the
  hospitals walls
• Hospitals should improve their discharge process,
  but also talk with referral partners to see how
  to work better together

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Help for Hospitals in Reducing Avoidable
Readmissions
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Mathematica Study of Effective Care Coordination
(March 2009)

• Most claims of high impact care coordination
  interventions are unproven
• Mathematica concluded 3 types of change packages
  are proven effective
• Transitional care interventions (Naylor and
  Coleman)
• Self-management education interventions (Lorig
  and Wheeler)
• Coordinated care interventions (a few sites from
  the Medicare Coordinated Care Demonstration)

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Mathematica Study Key Components of Effective
Transitional Care

• Engage patients early in hospitalization
• Give patients comprehensive post-discharge
  instructions on medications, self-care, and
  symptom recognition and management
• Assist patients in setting up and keeping
  follow-up physician appointments
• Follow patients post-discharge

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Reengineered Hospital Discharge Program (Annals
of Internal Medicine, Feb. 2009)
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Impact of Project RED on Hospital Use
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Impact of Project RED Reengineering the
Hospital Discharge

• RED reduced health spending vs. control group
• More patients reported seeing their PCP
• Inpatient and ED care reduced by 30
• Net Saved 412/patient (19/month)
• Three key components in Project RED
• Discharge Advocate educates hospital patient
• Give After Hospital Care Plan to patient, PCP
• Pharmacist calls patients 2-4 days post-discharge
  (most hospitals struggle to arrange pharmacist
  calls)

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RED 11-point Checklist

• RED has eleven mutually reinforcing components
• Medication reconciliation
• Patient education
• Follow-up appointments
• Outstanding tests
• Post-discharge services
• Reconcile discharge plan with national guidelines
• What to do if problem arises
• Written discharge plan
• Assess patient understanding
• Discharge summary sent to PCP
• Telephone reinforcement

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RED Component 1 Reconcile the Medications

• Reconcile the patients home medication list upon
  admission to the hospital
• Review each medication make sure that the
  patient knows why they take it
• Discuss new medications each day with medical
  team and with patient

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RED Component 2 Educate the Patient

• Educate patient throughout the hospital stay
• The Project RED intervention starts within 24
  hours of the patients admission to the hospital
  and continues daily until completion of the
  post-discharge telephone follow up call to the
  patient

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RED Component 3 Reconcile Discharge Plan with
National Guidelines

• Example Discharge medication orders for
  ACEIs/ARBs for Heart Failure patients
• Communicate with medical team each day about the
  discharge plan
• Recommend actions that should be taken for each
  patient under a given diagnosis

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RED Component 4 Make appointments for clinician
follow-up and post-discharge testing

• Schedule PCP appointment for the patient, to
  occur within 2 weeks after discharge
• Review, with the patient, the providers
  location, transportation and plan to get to
  appointment
• Consult with patient regarding best day and time
  for appointments
• Discuss, with the patient, the reasons for and
  importance of all follow-up appointments and
  testing

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RED Component 5 Discuss with Patient Pending
Tests/studies and Who will Follow up

• Explain tests and studies done while in the
  hospital and tell the patient which clinician is
  responsible for reviewing the results
• Encourage the patient to discuss tests his/her
  PCP
• Let the patient know that this information will
  be listed on the AHCP

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RED Component 6 Organize Post-discharge
Services

• Collaborate with case manager and social worker
  about patient needs and post-discharge services
• Provide patient with contact information for
  these services (phone number, name of company,
  etc.)

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RED Component 7 Give the Patient a Written
Discharge Plan Before Discharge

• The After Hospital Care Plan (AHCP) should
  include, in plain language understandable to the
  patient
• 1) Principal discharge diagnosis
• 2) Discharge medication instructions
• 3) Follow-up appointments with contact
• information
• 4) Pending test results
• 5) Tests that require follow up

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RED Component 8 Review with the Patient Steps
to Take if a Problem Arises

• Review with the patient
• Whats an emergency vs. a common problem
• What to do if a question or a problem arises
• Where in After Hospital Care Plan to find contact
  information for the discharge advocate and PCP to
  answer questions after discharge
• HCAHPS questions about the discharge process
• Q 19 During this hospital stay, did doctors,
  nurses or other hospital staff talk with you
  about whether you would have the help you needed
  when you left the hospital?
• Q 20 During this hospital stay, did you get
  information in writing about what symptoms or
  health problems to look out for after you left
  the hospital?

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RED Component 9 Teach the Patient the AHCP, and
ask the Patient to Tell You the Details of the
Plan

• Explain post hospital care and post-discharge
  medications in a way the patient understands,
  including how to take the meds and how and where
  prescription can be filled 
• Communicate this information to the accepting
  physician
• Deliver information to reach those with a low
  health literacy level
• Include caregivers when appropriate
• Utilize professional interpreters as needed

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RED Component 10 Expedite Transmission of the
Discharge Summary to the PCP

• Fax the discharge summary and AHCP to PCP within
  24 hours after discharge
• National Quality Forum Safe Practice SP-15
• Reliable information from the primary care
  physician (PCP) or caregiver on admission, to the
  hospital caregivers, and back to the PCP, after
  discharge, using standardized communication
  methods
• A discharge summary must be provided to the
  ambulatory clinical provider who accepts the
  patients care after hospital discharge.

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RED Component 11 Telephone Reinforcement of the
After Hospital Care Plan after Discharge

• RED intervention calls for a pharmacist to call
  the patient within 72 hours after discharge
• If pharmacist unavailable, have pharmacist help
  with script and available for back up
• Why? Because most patients leave with drug
  therapy, most post-discharge adverse events are
  drug problems, and 2/3 of adverse drug events are
  preventable or ameliorable
• Assess patient status
• Review medication plan
• Review follow-up appointments
• Take appropriate actions to resolve problems

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Compare Your Discharge Process with RED Checklist
to find Improvement Opportunities

• Sample Current State Process
• ?Discharge order
• ?Discharge Instruction Form
• ?Discharge teaching on day of discharge
• ?No Discharge Advocate
• ?No appt scheduled
• ?No post DC phone call
• ?No PCP DC Summary
• Source JCR
• Project RED components
• ?Med Reconciliation
• ?National guideline used
• ?Follow up Appointment
• ?Outstanding Tests
• ?Post DC services
• ?Written DC Care Plan

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AHRQs Consumer Version of the Project RED
After Hospital Care Plan"

• Project RED research team created this tool to
  help--
• Keep track of medications
• Patients talk with hospital staff and primary
  care doctor
• Family assist patients
• Get it free from AHRQ http//www.ahrq.gov/qual/go
  inghomeguide.pdf

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Health Care Leader Action Guide

• Provides strategies for you to
• Examine your hospitals current rate of
  readmissions
• Assess and prioritize your improvement
  opportunities
• Develop an action plan of strategies to implement
  
• Monitor your hospitals progress
• Get it free at www.hret.org/resources

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Other AHRQ and CMS-funded Tools to Help Reduce
Avoidable Readmissions (continued)

• TeamSTEPPS, a method for improving team
  communication and patient safety culture among
  hospital staff
• Care Transitions Toolkitfree resources at QIO
  site http//www.cfmc.org/integratingcare/
• QIO program Home Health Quality Improvement
  projects patient risk assessment tool for Home
  Health Agencies http//www.homehealthquality.org/
  hh/ed_resources/interventionpackages/hra.aspx
• QIO program originated toolkit for nursing homes
  Interact2.net

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• Thank you!
• Your Questions and Comments are Welcome!