REDUCING HOSPITAL READMISSIONS BY TRANSFORMING CHRONIC CARE

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REDUCING HOSPITAL READMISSIONSBYTRANSFORMING
CHRONIC CARE

• Harold D. MillerStrategic Initiatives
  Consultant,Pittsburgh Regional Health Initiative
  (PRHI)November 2008

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What is PRHI?

• A non-profit agency dedicated to improving the
  safety and quality of health care in the
  Pittsburgh Region and nationally
• Board members include CEOs and senior staff from
  regional hospitals (e.g., UPMC, Jefferson),
  health insurers (e.g., Aetna, Highmark), and
  employers (Allegheny County, Duquesne Light,
  Medrad), and other civic leaders
• Funded by local corporations, foundations, health
  plans, and government contracts and grants
• Trains health care staff in Perfecting Patient
  Caresm, a quality improvement method based on the
  Toyota Production System
• Organizes and supports demonstration projects in
  hospital infection reduction, chronic care
  improvement, etc.

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Growing Focus on Hospitalizations For Improved
Value

• Biggest share of spending (37 of private
  insurance)
• Highest rate of increase in spending for private
  insurance (25 growth, 2003-2006)
• A significant share of MD costs are
  hospital-based
• Hospital costs are higher due to adverse events
• Hospital utilization higher due to poor
  prevention and weaknesses in primary care

MD/Outpatient Costs
Hospital Costs
RxCosts
COST
QUALITY
HOSPITALCARE
PoorPrevention
Hospital AdverseEvents
Poor CareCoordination
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Coming AttractionsOutcome-Based Payments

• For Hospitals
• Medicare is already reducing/eliminating payment
  for adverse events in hospitals other payers
  will likely follow suit
• Next step is likely to be financial disincentives
  or non-payment for hospital readmissions, as
  recommended by MedPAC
• For Physicians
• Most commercial payers now have some kind of P4P
  program based on process measures
• Medicares Physician Group Incentive Demo Program
  is paying physicians based on savings through
  reduced hospitalizations
• Direct payment incentives/disincentives based on
  preventable hospitalization rates will probably
  not be far away

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Pittsburgh Region Is 3rd Worst in Preventable
Admissions
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Biggest ROI in Short RunReducing Readmissions
COST
ReduceAdverseEvents
1 out of 50patients
1 out of 5patients
QUALITY
HOSPITALCARE
ReducePreventableReadmissions
ReduceInitialAdmissions
1 out of 1000patients
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Reducing Readmission RequiresThinking Across
Provider Lines
HOSPITAL
COMMUNITY
OUTCOME
PoorOutcome

CommunityPhysician
Admissionto Hospital
Treatment in Hospital
DischargePlanning
HospitalReadmit
Home Health
GoodOutcome
ModifiedTreatmentin Hospital?
ImprovedDischarge Planning?
ImprovedCommunityCare andSelf-Management?
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Chronic Diseases Are LargestCategories of
Readmissions
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Whats Needed to ImproveChronic Care?

• better use of non-physician team members,
• planned encounters,
• modern self-management support
• care management for high risk
• links to effective community resources
• guidelines integrated into care
• enhancements to information systems (registries)

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Challenge 1 Chronic Care Model Not Reimbursed
Today

• Key Services Not Billable/Reimbursable
• hiring additional non-physician personnel (e.g.,
  nurse care managers)
• patient contacts with physicians by phone or
  email (health insurance only pays for
  face-to-face visits)
• Insurers and Purchasers Reluctant to Pay for More
  Services and Increase Costs in the Short Run With
  No Guarantee of Reduced Hospital Admissions or
  Readmissions

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Chronic Care/Preventable Admission Initiative
ReducingHospital Readmissions
LowerHospitalReadmissionsProvides ROIfor
ChronicCare Investment
ReducingHospitalReadmissionsRequires
ImprovedCommunity Care
ImplementingWagnerChronicCare Model
ReformingPayment forChronicCare
Chronic Care RequiresHigher/DifferentPayment
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Initial Focus COPD is 4th Highest Volume Rate
of Readmissions
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Plus, 40 of Pneumonia Readmits Are COPD Patients
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70 of COPD Patients Under 65, 33 of Admissions
Under 65
Readmission Rate Similar for All Ages
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Adapted from Global Initiative for COPD
www.goldcopd.org
? At Risk Normal lung function with or
without Chronic symptoms
Clinical PracticeGuidelines Exist
? Mild COPD Abnormal lung function with or
without Chronic symptoms
Long-Term Treatment for Stable COPD ?Avoidance
of Risk Factors Influenza Vaccination ?Add
Rapid-Acting Bronchodilator when indicated ?Add
Short or Long-acting Bronchodilators and
Pulmonary Rehabilitation ? Add medium to
high-dose inhaled or oral glucocorticosteroids or
antibiotics when indicated ? Add long-term
oxygen consider surgical referral
?Moderate COPD Chronic symptoms Shortness of
breath on exertion
? Severe COPD Shortness of breath
worsens Exacerbations common
Increasing Severity
?Very Severe COPD Quality of life
impaired Exacerbations may be Life threatening
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Research Shows Dramatic Impact From Simple
Interventions

• 39.8 reduction in admissions from improved
  patient education and self-management
• case managers (nurses or respiratory therapists)
• 1 hour/week of teaching at home for 7-8 weeks,
  including exercise
• weekly follow-up phone calls for 8 weeks, monthly
  calls beyond
• 37.3 reduction in admissions from education,
  training on medications, action plan for
  worsening symptoms
• 30 - 50 reductions in admissions from influenza
  vaccination
• Significant reduction in hospital admissions from
  smoking cessation

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A Key Element May Be Inhaler Training
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Some Have 3 Different Inhalers, All Work
Completely Differently
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Multiple Inhalers ComplicateTraining and Reduce
Success
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Opportunities to Use Hospital Stay As A
Teachable Moment

• Inhalers
• COPD patients use inhalers to prevent/manage
  exacerbations
• Neither PCP nor pharmacy trains patient on
  inhaler technique (only 20 know how to use it
  properly)
• Failure to use inhalers properly may result in
  hospitalization
• Hospital staff only trains patients if the
  inhaler is newly prescribed
• Patients in hospital typically treated with
  nebulizers, instead of the inhalers they will use
  after discharge, so limited opportunity for
  training
• Hospital may learn of barriers to patient use of
  medications (affordability, convenience, etc.),
  but dont address them
• Smoking Cessation
• Smokers are, by definition, in forced smoking
  cessation during hospital stay, but its not
  systematically treated as an opportunity for
  initiation of ongoing smoking cessation therapy

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3 Key Elements for COPD Readmission Reduction
Guidelines for Physician Diagnosis/Treatment of
COPD
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A More Detailed Viewof the Intervention Concept
HOSPITAL
Admission
Treat Exacerbation
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A More Detailed Viewof the Intervention Concept
HOSPITAL
COPD PROTOCOL
Admission
Identify asCOPD Patient
ImprovedDischargePlanning
Treat Exacerbation
Address Root Causes -medication skills -smoking
cessation-other
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A More Detailed Viewof the Intervention Concept
HOSPITAL
COPD PROTOCOL
Admission
Identify asCOPD Patient
ImprovedDischargePlanning
Treat Exacerbation
Discharge
Address Root Causes -medication skills -smoking
cessation-other
COMMUNITY CARE
MD Treatment
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A More Detailed Viewof the Intervention Concept
HOSPITAL
COPD PROTOCOL
Admission
Identify asCOPD Patient
ImprovedDischargePlanning
Treat Exacerbation
Discharge
Address Root Causes -medication skills -smoking
cessation-other
X
Readmission
COMMUNITY CARE
CARE PROTOCOL
MD Treatment
Prompt Responseto Exacerbations - 24/7 Phone
Support - Home Visit?
PromptFollow-up AfterDischarge - Home Visit?

RN Care Manager
Medication Access
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Similar Approach Likely Applicable to Other
Chronic Diseases
Other Chronic DiseaseReadmission/ Admission Redu
ction
COPDReadmissionReduction
AsthmaAdmission Reduction
COPDAdmission Reduction
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Initial Demonstration Sites
DEMONSTRATION SITE 1
UPMC St. MargaretHospital
Renaissance Family Practice
Other MD Practices
DEMONSTRATION SITE 2
ForbesRegionalHospital
Premier Medical Associates
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Higher COPD Readmission Rate at St. Margaret than
Other Hosp.
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Forbes COPD Readmission Rate Average, But Higher
Than Others
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Forbes Has High Readmissions for
Complications/Infections
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Two Stages to Designing Improved Care

• What can be done differently in the hospital to
  reduce the chances of readmission after discharge
• Why focus on the hospital first?
• Patients have demonstrated risk of
  hospitalization
• Patients are captive for several days
• Staff and treatment resources already exist
• What can be done differently in the community to
  reduce the chances of readmission after discharge
  (and ultimately preventing initial admission)
• Bigger challenges to be addressed
• Challenge 1 Lack of payment mechanisms for care
  management
• Challenge 2 Many small physician practices

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Process for Improving Hospital Care at UPMC St.
Margaret

• Formation of Physician Leadership Team
• Pulmonologist and 2 PCPs, along with key hospital
  dept. heads
• Meeting monthly since December
• Formation of Staff Task Force
• Over 20 staff from multiple departments (Care
  Management, Home Care, Nursing, Nursing
  Education, Pharmacy, Respiratory Therapy, Social
  Work)
• Creation of Draft Protocol for Improved Treatment
• Based on national/international guidelines
• Customized by pulmonologist from Physician
  Leadership Team
• 3-Day Toyota/PPC Workshop to Reinvent Processes
• Facilitated by Healthcare Performance Partners
  and PRHI/PPC staff
• 13 hospital staff participated
• Recommendations endorsed by hospital management
  and physicians

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Phases of Care for a Hospitalized COPD Patient
PHASE IVDischargeto OutpatientCare
PHASE IArrival Assessmentin Hospital
PHASE IIStabilization Initial Treatmentof
Exacerbationor Pneumonia
PHASE IIITransitionto Post-DischargeMeds/Care
PHASE VContinuingOutpatientCare
COPD PatientHas Exacerbationor Pneumonia
Diagnosis Initial Treatmentin Emerg.Dept.
Treatment onHospitalMed/SurgUnit
Patient ReturnsHome or toLTC Facility
MD/ CareMgt/Home Care
3 Hours
1-7 Days
1-6 Weeks
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PHASE IIITransition to Post-Discharge Meds/Care
Treatment on Hospital Med/Surg Unit
No Transition toInhaler Before Discharge
Respiratory Therapy Administers Nebulizer
MDOrders
CURRENT STATE
RN Administers MDI Inhalers
Little or No Patient Training on Inhaler
RN Administers All Other Medications
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PHASE IIITransition to Post-Discharge Meds/Care
Treatment on Hospital Med/Surg Unit
No Transition toInhaler Before Discharge
Respiratory Therapy Administers Nebulizer
MDOrders
CURRENT STATE
RN Administers MDI Inhalers
Little or No Patient Training on Inhaler
RN Administers All Other Medications
Resp. Therapy RecommendsWhen Transition to
Inhaler Occurs
Respiratory TherapyAdministers Nebulizer
Resp. Therapy AdministersMDI Inhaler until
Discharge
MDOrders
RECOMMENDATION
Resp. Therapy Trains Patient onPlacebo MDI As
Early As Possible
RN Administers All Other Medications
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November 15, 2009
IMPROVED SMOKING CESSATION INTERVENTION PROCESS
Tobacco Use Identified Later?
PATIENT ADMITTED
No Further Action
NO
NO
NO
YES
AdmissionAssessment
Tobacco User?
Automatic Order to Respiratory
Trained RTGoes to Patient Room
30 Minute 5 A Intervention
Agrees to Try Quitting?
YES
YES
Training in How to Ask Tobacco Question
Within 24 Hours
Standing Order/ Guidelines for Patch?
Nurse Removes Patch
Repeat Cessation Intervention
Willing to Try Again?
No Further Action
NO
YES
YES
ContinueAdministeringPatch
Get MD Order for Nicotine Patch
RT or RN Applies Patch
Smokes in Hospital?
Outpatient Pharmacy
Notify Care Mgt to Add to Discharge Plan
Schedule Outpatient Clinic Visit

• DISCHARGE PROTOCOL
• 2-7 Day Patch Supply
• PCP Appointment
• Rx for Smoking Cessation Clinic
• Outpatient Pulmonary Rehab

Alert MDsand Nurses
RepeatPositive Reinforcement
Positive Reinforcement
Training and Reinforcement with Family
PatientEducation Materials
Follow-Up Home Visit/Callby Outpatient Care Mgr
PATIENT AT HOME
Inpatient Pulm. Rehab (If Available)
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Next Step Creating a Community Care Manager

• Goals
• Integral member of primary care team
• Focus on patients with COPD (initially) with
  ability to expand to other patients with high
  rates of readmission in the future
• Sufficient number of cases at risk of
  hospitalization to justify expense of a new
  position

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Challenge 1 Paying for Community Care
Management
Guidelines for Physician Diagnosis/Treatment of
COPD
NOT CURRENTLY PAID FOR!
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Challenge 1a EstablishingThe Business Case
Reduction in Hospital Payments from Reduced
Readmissions
Costs of Interventions(Community Care Mgrs, etc.)
-
gtgt0
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Significant Savings Exceeds Cost of Care
Management
CURRENT
Admissions/Year
500
25
Readmitted(lt30 Days)
5,400
/Admission(Medicare/No Complic.)
Cost of Readmissions
675,000
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Savings Potential Exceeds Cost of Care Management
CURRENT
40 REDUCTION
Admissions/Year
500
500
Readmitted(lt30 Days)
25
15
/Admission(Medicare/No Complic.)
5,400
5,400
Cost of Readmissions
675,000
405,000
Savings
270,000
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Challenge 2 Care Delivered by Many Small MD
Practices
Largest Practice
18 MD Practices to get 60 of patients 36 MD
Practices to get 90 of patients 63 MD Practices
to get 96 of patients
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Next Step Creating a Community Care Manager

• Goals
• Integral member of primary care team
• Focus on patients with COPD (initially) with
  ability to expand to other patients with high
  rates of readmission in the future
• Sufficient number of cases at risk of
  hospitalization to justify expense of a new
  position
• Options
• Employee in physician practice
• works only for large practices

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Next Step Creating a Community Care Manager

• Goals
• Integral member of primary care team
• Focus on patients with COPD (initially) with
  ability to expand to other patients with high
  rates of readmission in the future
• Sufficient number of cases at risk of
  hospitalization to justify expense of a new
  position
• Options
• Employee in physician practice
• works only for large practices
• Shared employee among physician practices
• Expanded Pharmacy function
• Expanded Urgent Care Center function
• Hospital-based employee (covering multiple small
  practices)
• Contract for services with home health agency

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Outpatient Protocol/Care ManagerStarting w/
Largest Practices
MD Office
MD Office
MD Office
Multi-PracticeRN Care ManagerBased at
Hospital
MD Office
HOSPITAL
InpatientCareProtocol
OutpatientCareProtocol
MD Office
MD Office
MD Office
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Other Challenges in ImprovingOutpatient Care

• No financial reward to MDs for reducing
  readmissions
• Spending time redesigning care processes creates
  a financial penalty by reducing billable time
  with patients
• Most physician practices do not have spirometers
  to properly assess the stage of COPD, which is
  needed to prescribe medications appropriately
• Most physician practices do not have patient
  registries or EHRs to enable tracking of patient
  care

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Challenge 3 Addressing Other Needs,
Particularly Depression

• Depression/Anxiety
• More than 60 of people with COPD also have
  depression or anxiety
• Depression is a significant factor affecting
  medication adherence
• In one study, healthcare providers recognized
  fewer than 40 of depressive or anxiety disorders
  in patients with COPD, and only 31 were being
  treated
• Other Comorbidities
• CHF (similar symptoms, drug interactions)
• Diabetes, Hypertension (may be triggered by
  steroids)

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Creating a Continuous Improvement Process

• Monthly Reports Generated by the Hospital on
  Readmissions
• PHC4 data indicate that for these hospitals,
  80-90 of readmissions return to the same
  hospital
• Special Questionnaire Administered in Hospital to
  All Readmitted COPD Patients
• Hospital identifies patients who are readmissions
  within 24 hours of admission
• Nurses administer detailed questionnaire to
  patients probing for factors contributing to
  readmission
• Modifications can then be made to both inpatient
  and outpatient care

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For More InformationHarold D. MillerStrategic
Initiatives ConsultantPittsburgh Regional Health
Initiative(412) 803-3650Miller.Harold_at_GMail.com