Transcript Document

Care Transitions : Are You in the
Game?
Naomi Hauser RN, MPA
Director Care Transitions
Quality Insights of Pennsylvania
May 16, 2012
Welcome
 What we’ll cover today:
– Introduction of Care Transitions Program
– The Role of HCA in the Community
– Discuss Evidence Based Interventions to reduced
avoidable readmissions
– Share Lessons Learned form 3 Year Pilot
– Open Discussion
Why Are We Here?
 To learn about and
promote safe/effective
transitions of care as
patients navigate from
one provider setting to
another – or one
caregiver to another
 Develop partnerships
Integrated Care
For Populations and
Communities
GOAL
To promote safe/effective transitions of
care as patients navigate from one
provider setting to another – or one
caregiver to another
30 Day Readmissions:
The Problem
 Nationally – 17.6% of Medicare beneficiaries
discharged from the hospital are readmitted within
30 days.
 More than 85% of these re-hospitalizations are
unplanned.
 20-40% of re-hospitalizations are possibly
preventable.
 64% of Medicare beneficiaries who are readmitted
within 30 days do not receive any post-discharge
care before readmission.
Mrs. B’s Story
339 Days in the Life of Mrs. B
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Day 1 – New internal medicine physician, poorly controlled diabetes with neuropathy, HTN,
osteoporosis. To see physician q. 2 wks
Day 15 – Sees physician, fully functional, assists with care of grandchild and husband
Day 60 – Mrs. B falls on the ice, to ER, no fractures but abrasions. Referred to home health
Day 68 – Not feeling well
Day 69 – Hospitalized with Staph Septicemia, dehydration, ARF, CHF, A-Fib, PN and
uncontrolled diabetes
Day 82 – Transferred to SNF for short-term rehab and wound care
Day 182 – Discharged to home, depressed, abrasions healed, diabetes under good control
Day 183 – Nauseated, can’t find her teeth, dgt intends to call home health
Day 184 – Readmitted to the hospital for dehydration, CHF, A-Fib and diabetes
Day 191-337 – Admitted to in-pt rehab then to nursing home
Day 338 – Readmitted to hospital w/ ARF, CHF, ARF
Day 339 – Mrs. B dies
Timeline for payment penalty
for hospitals
 Beginning October 2012 Medicare will apply
penalties and will withhold payment for
avoidable 30 day acute care readmissions with
a progressively increasing scale for certain
DRGs.
July2008-August 2011
Pilot Project
14 QIOs with 14 Target Communities
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AL: Tuscaloosa
CO: Northwest Denver
FL: Miami
GA: Metro Atlanta East
IN: Evansville
LA: Baton Rouge
MI: Greater Lansing area
NE: Omaha
NJ: Southwestern NJ
NY: Upper capital
PA: Western PA
RI: Providence
TX: Harlingen HRR
WA: Whatcom county
Targeted Community
 Higher than state average re-admission rate
 Located in southwestern PA, in a community surrounding the southern
Pittsburgh metropolitan area
 Community spans most of Westmoreland County and small portions of
Allegheny, Washington, and Fayette counties
9th SOW Overview
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14 states
Community cross-setting
Transparent
Remove silos
 SWPA
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5 hospitals
8 home health agencies
15 nursing homes
2 AAAs
32 interventions
14% relative
improvement
Structure of the Project
 Cross-setting
 Community-based
 Collaborative
The Shift to…
 Chronic illness management
 Self-care management
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Empowerment
Responsibility
Accountability
Patient activation
Cross-Setting Goal
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Develop a practical, cross-setting approach
Unite providers from all settings
Share vision of improved health care quality
Equal voices
Identify provider strength
The Role of Agencies
•Home Health
•Hosicpe
Hospital Elements
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Leadership buy-in
Operational level leadership
Education
Silos
Bureaucracy/slow to change
Competitive
Non-transparent
Hospital Interventions
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Self reported readmission rate
Discharge process
Discharge instructions
End of life options
48-hour follow-up call
Schedule follow-up PCP visit
CTI-AAA
SNF Elements
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Education
Eager to learn
Eager to share
Share competence levels
Family
Physicians
Turnover
SNF Interventions
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SBAR
Communication transfer form
Chart reviews
End of life options/education
POLST/AD
Coach CTI
Home Health Elements
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Focus on ACH vs. readmissions
Medication management
Low referral rates
Educate on referral criteria
Coaching
Hands on in home care
Drivers of Hospital
Readmission
 Same for home care as other health care
providers:
– Patient activation
– Standard, known processes
– Transfer of information
Home Health Compare
 Top 20% for this measure has maintained an
unplanned hospitalization rate of 21% since last
quarter
 While stakeholders are focusing on reducing
unnecessary hospitalizations, the data tells us that we
still have work to do and…
– What about those 30-day readmissions?
– Low-hanging fruit for home care to determine root cause and
intervene in real-time—win-win for everyone
Home Health Compare
 The latest Home Health Compare (HHC) scores
were published on October 13th and reflect a
data collection period of July 2010 - June 2011.
Overall, the results have improved.
 Hospitalization result has had a setback
– Hospitalization worsened from 26% last quarter to
27%
www.Fazzi.com
Intervention HHA
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Communication transfer sheet
Front load visits
Telehealth
Phone monitoring
Life line
Chronic care education
Coaching/partnering
Depression screening
Chart reviews
Best Practices
 Home Health Quality Improvement National Campaign Best
Practice Intervention Packages (BPIPs)
 Focus on reducing ACH, improving management of oral
medications and cross-setting collaboration
– Simplified approach to use packages
– Standardized steps to follow for each publication
– Flexible for HHA implementation
 BPIPs free to download at:
http://www.homehealthquality.org/hh/default.aspx
BPIPs Include
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Hospitalization Risk Assessment
Emergency Care Planning
Medication Management
Fall Prevention
Care Transitions
Coaching
Patient Self-Management
Disease Management
Telehealth
Introduction to new ideas/topics: Patient Centered Medical Home;
Accountable Care Organizations and others
Learn more…Coach/HH nurse
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Coaching and home health service
Increase Medicare HH referrals
Oasis takes time
Coach non-clinical
Different role
Medication review… patient driven
Complementary/respectful
Lessons Learned
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Community focus
Root cause analysis
Communication
Transparency
Leadership buy-in
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Collaboration
Patient-centered
Ongoing monitoring
Community outreach
Sustainability
Lessons Learned
 Re-Engineers the discharge
process (Project Red, Project
Boost, Medication
reconciliation)
 Increase community
outreach (Collaboration with
community resources,
Handover)
 Change the paradigm of
patient education (Teach
Back)
 Increase post discharge
process and support (PHR,
Medication management,
PCP f/u appointment and
coaching)
 Improve information transfer
(Cross setting transfer form)
August 2011-July 2014
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10
SOW
AIMS and Goals
Strategic Aims
“What will be done”
 Integrate Care for Populations
• Care Transitions that reduce re-admissions by 20%
within 3 years.
CMS 10th SOW for QIOs
 Form a community coalition to ensure communitywide adoption of improved practices in care transitions
 Assist communities in applying for the CMS 3026
CCTP funding opportunity
 Form a Learning and Action Network (LAN) and
provide evidence-based interventions associated with
known drivers of hospital readmissions (Jan. 26, 2012)
 Host quarterly LAN sessions; one in-person each year
CMS 10th SOW for QIOs
 Provide the community with a template for coalition
charters to help the partners formalize structure and
procedures
 Assist the community with root cause analysis to
identify community-specific causes for poor
transitions and develop data reports to monitor
progress
 Assist in the selection of the most appropriate
evidence-based interventions
The Importance of Communities
to Improve Health Care
Integrating Care for Populations and
Communities
CMS Defines a Community
 Defined by contiguous zip codes
– Medicare beneficiaries that live in those zip codes
– Committed providers and stakeholders
Community Essentials
 Developed around collaborative care delivery
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Shared vision
Shared mission
Shared resources
Shared decision making
Environment of trust
A Community
 Social network analysis for Medicare
beneficiaries in 2009
– Allows visualization of relationships between
providers through network diagrams
– Shows flow of transitions among providers
– Senders, receivers, provider type and strength of
relationship
4 Recruited Communities
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Western Pennsylvania
Lehigh Valley
York
Chester County
Building Community
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Leaders reach to other leaders
Expand the circle of support
Grow more resources
Develop/sustain commitment
Recruit people
The more volunteers or members who find
purpose in the community -the more they will
commit resources that you may never have
known existed.
Community Development
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CMS suggested communities
Hospitals in contiguous Zip Codes
Overlap of beneficiaries/penetration
Desire to reduce re-admission rates
Agree to collaboration/relationship
Transparency
Downstream Providers
Provider Responsibilities
 Leadership commitment
 Active involvement of provider teams including
leadership in meetings, conference calls, webinars and
coalition activities
 Implement improvement strategies using rapid cycle
testing
 Create new strategies that maximize improvement for
all participants
 Track, monitor and share real time data
Stakeholder Support
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Are the cornerstone for the community
Learn from the community
Inform members of CT strategies
Support/provide community education sessions
Participate in quarterly calls
Provide publications via newsletter
Post information/links of CT on Web sites
Expand the Circle of Support…
Motivating Call to Action
Community
Intervention Selection
Standard/Known Process
– BOOST (Better Outcomes for Older
adults through Safe Transitions)
– TCM (Transitional Care Model)
– F/U appointment made at discharge
– Pharmacy
– Telephone F/U
– Document standardization
Drivers of Readmissions
Based on discharges from 2007. Clinical Classification Software (CCS) 2008 downloadable from http://www.ahrq.gov/data/hcup/ .
Lessons Learned
Key drivers of 30 day readmission
Low patient activation
Lack of standard processes
Inadequate transfer of information across care settings
Key strategies for 30 day readmission reduction
Community organization
Patient activation
Multi-provider process improvement
End of Life
 Of discharges of CT residents from the five targeted
hospitals that result in a 30-day readmission to any
acute care hospital during the last six months of life
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35% are discharges to a SNF
33% are discharges to home under the care of a HHA
23% are discharges to home or self-care
28% of all readmissions occur during the last six months of
life
Root Cause Analysis
 Simply stated RCA is a process designed to
help identify not only
– What and how BUT
– Why
 Leads to interventions selection and ongoing
identification of gaps in care delivery across
settings.
Intervention Selection
 Derived from root cause findings
 Monitor & Measure
– Process Measures
• System Components
– Outcome Measures
• Effect of change on patient
Intervention
Selection by Driver
 Patient Activation
 Standard/Known Process
 Transfer of Information
PROJECT RED
(ReEngineered Discharge)
 Evidenced based toolkit.
 Developed by Boston University Medical
Center
 Addresses key factors identified in RCA
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Delayed Transfer of Discharge Summary
Unknown Test Results
Patients Failure to Follow-up
Medication Interactions and Adverse Events
Transfer of Information
–Communication Re-design
–HIT
–SBAR
–Beneficiary and community
outreach
Patient Activation
– INTERACT
– RED (Re-engineered Discharge)
– Medication Reconciliation
– Coaching
– Teach-Back
Coming together is a beginning.
Keeping together is progress.
Working together is success.
~Henry Ford
Community Care Transitions
Program
The Community–based Care Transitions Program
(CCTP)
 The CCTP, mandated by section 3026 of the Affordable Care
Act, provides funding to test models for improving care
transitions for high risk Medicare beneficiaries.
 •Increasing rates of avoidable hospital readmissions will result
in negative health outcomes for Medicare beneficiaries
impacting their levels of safety and quality of care.
 •The CCTP seeks to correct these deficiencies by encouraging
communities to come together and work together to improve
quality, reduce cost, and improve patient experience.
CCTP: Program Goals
 Improve transitions of beneficiaries from the
inpatient hospital setting to other care settings
 •Improve quality of care
 •Reduce readmissions for high risk
beneficiaries
 •Document measureable savings to the
Medicare program
Eligible Applicants
 Are statutorily defined as: Acute Care Hospitals
with high readmission rates in partnership with
a community based organization
 Community-based organizations (CBOs) that
provide care transition services
 •There must be a partnership between the acute
care hospitals and the CBO
CCTP: Definition of CBO
 Community-based organizations that provide
care transition services across the continuum of
care through arrangements with subsection (d)
hospitals−Whose governing bodies include
sufficient representation of multiple health care
stakeholders, including consumers
CCTP: Key Points
 CBOs will use care transition services to effectively
manage transitions and report process and outcome
measures on their results.
 •Applicants will not be compensated for services
already required through the discharge planning
process under the Social Security Act and stipulated in
the CMS Conditions of Participation.
 •Applicants will be required to participate in ongoing
learning collaboratives
CCTP: Application Guidance
 Applicants are required to complete a root
cause analysis
 The proposals must specify how the root causes
will be addressed
 The proposal will describe how they will work
with accountable care organizations and
medical homes if applicable
 The proposal will describe how they will align
their care transition programs
CCTP: Conclusion
 The program solicitation was announced in the
Federal Register and is now available at:
http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313
 The program will run for 5 years with the
possibility of expansion beyond 2015
 If community progress is not occurring within 2
years of receiving funding, funding will be
stopped
 Please direct CCTP questions to:
http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313
CCTP Website
 Visit the program website for daily updates on
program status at
http://www.cms.gov/DemoProjectsEvalRpts/M
D/itemdetail.asp?itemID=CMS1239313
Do not forget to note Frequently-Asked Questions
On the Site
What Actions Can You Take?
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Look at your process
What do you already have in place?
What strength do you bring to the community?
Be a good team player
How can you collaborate to
– Improve care delivery across the continuum
– Reduce errors and avoidable re-admissions
– Share resources and reduce cost
– Improve communication and information transfer
– Improve Care Transitions
10th Scope of Work:
The Opportunity for You….
 Communities are developing
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Position yourselves
Promote cross setting best practices you have implemented
Integrate with upstream and downstream providers
Be part of the discussion and strategic planning
Let everyone know the role of home care and the services
are critical to decreasing the rate of 30-day readmissions
– Be part of the solution!
QIO Technical Assistance
 Learning and Action Networks (LAN) on a
state-wide level
 Webinars provided and recorded
 Connect to downstream providers
 Provide current Medicare data to providers
Resource Sharing
 Upcoming conferences or meetings
 E-newsletters
– Share with us/success stories
– Or how can we share an article with you?
 Contact Krista Davis at [email protected] or
[email protected]
 www.qipa.org
You must be the
change you wish to
see in the world
MahatmasGandhi
This material was prepared by Quality Insights of Delaware, the Medicare Quality Improvement Organization for
Delaware, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department
of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number
10SOW-DE-ICP-KD-010612A. App. 1/12.