Preventing Readmissions

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Preventing Readmissions

• Esteban Ramirez, D.O., F.A.C.O.I
• Hospitalist Department
• Indiana Univ. Health Arnett

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Objectives

• Why is reducing readmissions so important
• CMS definition of a readmission
• Definition of Value Based Purchasing
• Become familiar with the measures that CMS is
  looking at this year
• Familiarize yourself with the Projects available
  to assist with minimizing readmissions.

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Why look at Readmissions

• Deficit Reduction Act 2005 mandated the
  Secretary of Health and Human Services include
  measures of hospital outcomes and efficiency in
  the Hospital Inpatient Quality Reporting (IQR)
  program.
• Affordable Care Act in 2010, Section 10303(a) of
  this Act directed the Secretary of Health and
  Human Services to develop additional outcome
  measures focused on the five most
  resource-intensive conditions as well as primary
  and preventive care.

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Why look at readmissions?

• The NEJM in 2009 and the Medicare Payment
  Advisory Commission (MedPAC) 2005 reported that
  18-20 of Medicare patients are readmitted in 30
  days.
• MedPAC estimated that 30 day readmissions cost
  Medicare 15 Billion dollars
• 78 of readmissions are thought to have been
  preventable.
• For example, gt50 of pts readmitted within 30
  days did not have on record a post
  hospitalization visit (NEJM 2009)

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What is a readmission per CMS

• ANY diagnoses after being discharged within 30
  days.
• Common misconception is that it has to be the
  same as the discharge diagnosis
• Could be an admission to another hospital
• Observation visits , ED visits, and same day
  readmissions (to the discharging hospital) do not
  count as a readmission
• AMI Exception Planned PTCA, CABG within 30 days
  of discharge
• CMS has chosen to focus on 3 diagnoses at first
  to start penalizing hospitals for higher than
  expected readmission rates.
• Pneumonia
• Heart failure
• Myocardial Infarction

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Value Based Purchasing

• CMS is using its purchasing power to drive up
  the quality of healthcare.
• DRG payments for Fiscal Year 2013 will be based
  on the organizations Total Performance Score
• Items included in the calculation are
• 17 processes of care in
• Pneumonia,
• Heart Failure,
• Acute myocardial infarction,
• Healthcare associated infections,
• Surgical care improvement
• 8 measures in HCAHPS
• In following years, it is expected that the
  number of measures will increase

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Value Based Purchasing

• Funding to these institutions will be reduced by
  1 2013.
• In further years, it will be increased
• Money can be earned back by improving your
  overall performance on the above measures

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How do we currently compare?

• Using the data from Medicare claims over the last
  3 years CMS has determined the national average
  of readmissions per diagnosis.
• Rates of readmission vary by state which has led
  Medicare to surmise that readmission rates can be
  decreased by the lower performing hospitals.
• States with lower readmission rates
• Idaho (13.3), Oregon (15.7), Utah (14.2)
• States with higher readmission rates
• Illinois (21.7), Louisiana (21.9), New Jersey
  (21.9)

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How do we compare?

• Using the above data, the hospitals are being
  compared on 30 day readmission rates for
  pneumonia, myocardial infarction and heart
  failure
• Better than US national rate of readmissions
• No different than US national rate of
  readmissions
• IUH Arnett and St. Elizabeth Hospitals
• Worse than US national rate of readmissions
• This group will have 1 withheld from their DRG
  payment

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How do we compare?

• This data is available now on the HOSPITAL
  COMPARE public website
• This site is managed by the Department of Health
  and Human Services.
• http//www.hospitalcompare.hhs.gov/

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How do we compare?

• Recently released Hospital Compare data (7/2012)
• Better than national average for readmissions
• Citrus Memorial Hospital, in Inverness, FL and
  Sarasota Memorial Hospital, in Sarasota, FL.
• Worse than national average
• 1. Beth Israel Deaconess in Boston, MA 2.
  Florida Hospital, Orlando, FL3. Franciscan St.
  James Health, Olympia Fields, IL4. Henry Ford
  Hospital in Detroit, MI5. Mount Sinai Hospital,
  NY, NY 6. Olympia Medical Center, Los Angeles,
  CA7. Tampa VA Medical Center, Tampa, FL8. San
  Juan VA Medical Center, San Juan, Puerto Rico

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Preventing Readmissions

• Multiple organizations/groups have initiatives to
  address this
• Institute for Healthcare Improvement (STAAR) and
  American College of Cardiology (H2H)
• INTERACT and Community Based Transition Programs
  from CMS
• National Priorities Partnership
• Hartford Foundation
• Project RED- RED Re-Engineered Discharge
• Designed by researchers at Boston Univ. and
  Boston Medical Center
• funded by Agency for Healthcare Research and
  Quality (AHRQ) and National Institutes of Health
  (NIH)
• Showed significant decrease in utilization of ED
  visits and Hospital Utilization. Trended toward
  reducing readmissions
• Project BOOST- Better Outcomes for Older Adults
  through Safe Transitions-
• led by the Society of Hospital Medicine and
  includes Joint Commission, CMS, CDC, IHI, Blue
  Cross and Blue Shield, AHRQ, Kaiser Permanente
• 6 sites that have utilized this have produced 21
  reduction in readmissions

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Project red
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Project RED

• Education about the diagnosis
• Make the follow up appointment for the patient
  using input from the patient
• Give purpose for visit
• Coordinate with needed labs and studies
• Review transportation to appointment and if
  needed set it up for the patient
• Discuss test results and if any are pending who
  is responsible for following up on these

15
Project RED

• Organize post discharge services
• Confirm medication plan
• Reconcile discharge plan and medications with
  national guidelines (heart failure, acute MI,
  etc)
• Review what should be done if a problem arises
  (redevelop chest pain, increased fevers, etc.)

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Project RED

• Expedite the discharge summary
• Components to DC summary
• Reason for hospitalization/diagnosis
• Significant findings
• Procedures performed
• Condition at discharge
• Comprehensive medication list including allergies
• Pending tests/labs and medical issues that
  require follow up
• Assess understanding of the above
• May require a translator, different literacy
  level, involving caregivers

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Project RED

• Provide hard copy of the discharge plan when
  leaving
• Provide telephone reinforcement at 2-3 days.
• Re-assess understanding
• Intent on following up with appointments
• Assess need for second call by
• Pharmacist and/or
• Nurse and/or
• Physician

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Project BOOST
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Project BOOST

• Geared primarily to patients greater than 65 year
  of age.
• Encourages identifying high-risk patients and
  providing the intervention solely to this
  population
• TARGET tool to assess risk
• Includes GAP (General Assessment for
  Preparedness)-assess potential barriers
• 8P tool done at admission
• Problem medications warfarin, digoxin, aspirin,
  insulin in combination with clopidogrel
• Hx of psychiatric disorders
• Problem Diagnoses COPD, heart failure, cancer,
  stroke, diabetes/glycemic complication
• Polypharmacy (gt5 medications)
• Poor health literacy
• Poor social support
• Prior (unplanned) hospitalizations in the last 6
  months
• Has been identified as the single most predictive
  risk factor of readmissions (NEJM 2009)
• Palliative Care

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Project BOOST

• Educating patients on their conditions and
  possible side effects of medication- Utilization
  of the Teach Back Method
• Scheduling follow-up physician appointments
  within 7 days
• Medication reconciliation at discharge to ensure
  that drugs prescribed at discharge don't
  harmfully interact with previously prescribed
  drugs
• Discharge instructions should be in at least 14
  font. Avoid all capitals and jargon.
• Include diagnoses, possible side effects from
  medications, what to look for to get further
  care/ER visit, list of appts.
• Discharge summary to PCP lt48 hours
• Direct communication with PCP for these high risk
  patients.
• Telephone contact with patient within 72 hours
• There is a training and mentoring program
  available for this project

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Take Home Points

• Communicate better with our patients
• May require repetition or discharge instructions
  in a different language/interpreter or
  involvement of family/caregivers
• Communicate better between inpatient to
  outpatient providers
• Quick turn around of DC summaries lt48hrs
• Better quality DC summaries that include pending
  tests/labs
• Phone calls to PCPs office for high risk patients
• Make appointments for patients before DC
• Provide follow up phone call to patient 2-4 days
  to ensure understanding and address unexpected
  issues
• Must use a multidisciplinary approach

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Readmission Risk Calculators

• Center for Outcomes Research and Evaluation
  (CORE) has an application that is free that could
  be downloaded on iPhone.

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What will the future look like

• Improved electronic discharge process that
  incorporates EBM check off lists that must be
  completed prior to DC
• More availability for quicker turn around on DC
  summaries (including weekends and holidays)
• Improved access to post hospitalization care
  within 7 days
• Medical Home Model (e.g. extended hours, weekend
  avail.)
• Use of physician extenders and/or
• Semi-retired physicians
• Improved collaboration between inpatient,
  outpatient and SNF/ECF healthcare workers
• Gather representatives from each area
• Analyze the process
• Inpatient to outpatient, inpatient to SNF/ECF,
  SNF/ECF to Outpatient
• LEAN methodology
• Projects are currently under way to address
  specifically the high readmissions for Heart
  Failure, Pnemonia and Acute Myocardial Infarction
• Perhaps a future lecture series on these?
• Champions for each?

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• Questions or Comments?

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References

• Readmission Measures Overview. www.QualityNet.org
  (established by CMS)
• Jencks S, Williams M, Coleman E.
  Rehospitalizations among Patients in the Medicare
  Fee-for-Service Program. N Engl J Med 2009
  3601418-1428
• Medicare Payment Advisory Commission (MedPAC).
  Promoting greater efficiency in Medicare. June
  2007.
• Project Boost Website www.hospitalmedicine.org/BO
  OST/
• Project RED website https//www.bu.edu/fammed/proj
  ectred/
• Voss R, Gardner R, Baier R, Butterfield K,
  Lehrman S, Gravenstein S. The care transitions
  intervention translating from efficacy to
  effectiveness. Arch Intern Med. Jul 25
  2011171(14)1232-1237.