Transcript Slide 1

Partnership for Patients:
Readmission Reduction
Presented by:
Rachel Cicerchi, MPH
Program Manager, Texas Center for Quality & Patient Safety
Texas Hospital Association
Phone: 512/465-1016
Fax: 512/857-0808
Email: [email protected]
Mailing: P.O. Box 679010, Austin, Texas 78767-9010
Physical: 1108 Lavaca, Suite 700, Austin, Texas 78701
April, 2012
Today’s Agenda
I.
The Need to Reduce Readmissions
II. Introduction to Project RED
III. Readmission Reduction Tools & Resources
IV. Data Metrics & Collection
V. Developing an Action Plan
VI. Teach Back
VII. Next Steps, Timeline of Events, Questions
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Readmission Statistics
 Almost 1 in 5 patients are readmitted
within 30 days of discharge.
– 34% are rehospitalized within 90 days.
 90% of rehospitalizations within 30 days appear
to be unplanned and approximately 75% are
considered avoidable.
 Only half of patients rehospitalized within 30
days had a physician visit before readmission.
Source: S. F. Jencks, M. V. Williams, and E. A. Coleman, “Rehospitalizations Among Patients in the Medicare Fee-for-Service
Program,” New England Journal of Medicine, April 2, 2009 360(14):1418–28.
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Readmission Statistics (cont.)
 CMS estimates the cost of
avoidable readmissions at more than $17
billion a year, 20 percent of all Medicare
payments.
 There is enormous variation in
readmission rates across states. Ranging
from a low in Idaho of 13.3% to a high in
Maryland of 22%.
Source: S. F. Jencks, M. V. Williams, and E. A. Coleman, “Rehospitalizations Among Patients in the Medicare Fee-for-Service
Program,” New England Journal of Medicine, April 2, 2009 360(14):1418–28.
4
Readmission Rates by State
Source: S. F. Jencks, M. V. Williams, and E. A. Coleman, “Rehospitalizations Among Patients in the Medicare Feefor-Service Program,” New England Journal of Medicine, April 2, 2009 360(14):1418–28.
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Dartmouth Atlas Findings
 Little change in readmission rates
from 2004 to 2009.
– Surgical 30-day readmission rates were 12.7% in
2004 and 2009
– Medical 30-day readmission rates rose slightly from
15.9% in 2004 to 16.1% in 2009.
Source: Dartmouth Institute for Health Policy & Clinical Practice
Medical Discharges
Number of Patients in
Cohort
2004
2009
Texas
244,883
217,015
United
States
3,632,811 3,250,574
Percent
readmitted
within 30 days
of discharge
2004
2009
Percent seeing a
primary care
clinician within
14 days of
discharge to
home
2004
2009
Percent having
an emergency
room visit within
30 days of
discharge
2004
2009
16.0
16.0
42.1
40.1
17.0
18.9
15.9
16.1
43.9
42.9
17.0
18.9
Source: Dartmouth Institute for Health Policy & Clinical Practice
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Surgical Discharges
Number of Patients in
Cohort
Percent
readmitted
within 30 days
of discharge
Percent seeing
a primary care
clinician within
14 days of
discharge to
home
Percent having an
emergency room
visit within 30 days
of discharge
2004
2009
2004
2009
2004
2009
2004
2009
Texas
138,030
126,092
12.6
12.1
21.5
19.5
13.2
14.4
United
States
2,013,795
1,809,343 12.7
12.7
22.6
21.8
13.7
15.2
Source: Dartmouth Institute for Health Policy & Clinical Practice
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National Trends by Cause of Initial Hospitalization
Condition
% Readmission
2004
2009
Relative
Change (%)
Absolute
Change (%)
Medical
15.9
16.1
1.2
<0.5
CHF
20.9
21.2
1.4
<0.5
AMI
19.4
18.5
-4.6
-0.9
Pneumonia
15.1
15.3
1.7
<0.5
Hip Fracture
14.3
14.5
1.4
<0.5
Surgical
12.7
12.7
<0.5
<0.5
Source: Dartmouth Institute for Health Policy & Clinical Practice
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National Trends by Post-Discharge Location
Condition
% Discharged to
home
% Discharged to
facility-based
rehabilitation
% Discharges to
other location
2004
2009
2004
2009
2004
2009
Medical
73.6
72.6
22.6
24.8
3.8
2.7
CHF
78.0
76.9
19.0
21.0
3.0
2.1
AMI
74.7
76.0
22.5
22.4
2.8
1.6
Pneumonia
69.1
70.1
26.6
26.6
4.4
3.2
Hip Fracture 8.6
8.6
86.5
89.8
5.0
1.6
Surgical
68.7
28.4
30.5
2.1
0.8
69.5
Source: Dartmouth Institute for Health Policy & Clinical Practice
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Why do readmissions occur?
Factors include:
– Quality of downstream providers (nursing
homes, home health agencies, and downstream
providers)
– Patient characteristics that lead to admissions
also lead to readmissions

Behavioral comorbidities
– Big Picture Factors: social support, community
demographics, hospital staff communication and
processes.
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Common process breakdowns leading to
readmissions
 Poor communication between staff
and patient
– Lack of patient understanding of how to take
medications post-discharge
– Patient doesn’t recognized warning signs of
complications, and what to do if a problem arises
 Poor transfer of information to post-discharge
providers
– Between hospital staff and nursing home staff or
PCP
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Common process breakdowns leading to
readmissions (cont.)
 Lack of timely visit with PCP
post-discharge
– Patient doesn’t have a PCP/Lack of PCPs in area
– Issues with patient transportation to appointments
 Patient confusion over how, when, and why
to take medications
– Financial issues in obtaining medications
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Project RED
 What is Project RED?
 The Re-Engineered Hospital Discharge Intervention (Project RED) is
a patient safety initiative that has been demonstrated to create a more
efficient discharge process and consequently decrease hospital
readmissions.
 Developed by Boston Medical Center, Project RED is the product of
five years of work with more than $7.5 million from the Agency for
Health Research and Quality, and the National Heart, Lung and Blood
Institute.
 Consists of 3 main components:
– The Discharge Advocate
– The After Hospital Care Plan
– A follow-up phone call
Project RED
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Principles of Project RED
1. Explicit delineation of roles and
responsibilities
2. Discharge process initiation upon admission
3. Patient education throughout hospitalization
4. Timely accurate information flow:
–
From PCP > Among Hospital team > Back to PCP
5. Complete patient discharge summary prior to
discharge
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Principles of Project RED (cont.)
6. Comprehensive written discharge
plan provided to patient prior to discharge
7. Discharge information in patient’s language
and literacy level
8. Reinforcement of plan with patient after
discharge
9. Availability of case management staff
outside of limited daytime hours
10. Continuous quality improvement of
discharge process
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3 Central Components of the RED Model:
1. The Discharge Advocate
–
Each patient is assigned a Discharge Advocate (DA)
who acts as a central resource for the patient during
and after his/her hospital stay. During the hospital
stay the DA explains all aspects of the patient’s care
from diagnosis.
–
The DA follows an 11-item checklist which includes
making follow-up appointments, reviewing the
medication plan, and conducting patient education.
–
The DA role is often filled by a nurse or case
manager.
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Discharge Advocate
 Is notified when patients in target
population are admitted/diagnosed
 Initiates 11-step checklist
 Educates patient and family on diagnosis,
medications, and post-discharge plans
 Reviews After Hospital Care Plan with patient
and family
 Collects process and outcome data specific
to project and patient population
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11-Item Checklist
1.
Educate the patient about his her
diagnosis throughout the hospital stay.
2.
Make appointments for clinician follow-up and postdischarge testing.
–
Make appointments with input from the patient regarding the
best time & date of the appointment.
–
Coordinate appointments with physicians, testing, and other
services.
–
Discuss reason for and importance of physician appointments.
–
Confirm that the patient knows where to go, has a plan about
how to get to the appointment; review transportation options
and other barriers to keeping these appointments.
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11-Item Checklist (cont.)
3.
Discuss with the patient any tests or
studies that have not been completed in
the hospital and discuss who will be responsible for
following up with the results.
4.
Organize post-discharge services (e.g. PT, OT, SLT).
–
Be sure patient understands the importance of such services.
–
Make appointments that the patient can keep.
–
Discuss the details about how to receive each service
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11-Item Checklist (cont.)
Confirm the medication plan.
5.
–
Reconcile the discharge medication regimen with those taken before the
hospitalization.
–
Explain what medications to take, emphasizing any changes in the regimen.
–
Review each medication’s purpose, how to take each medication correctly, and
important side effects to watch out for.
–
Be sure patient has a realistic plan about how to get the medications.
6.
Reconcile the discharge plan with national guidelines and critical
pathways.
7.
Review with the patient appropriate steps of what to do if a
problem arises.
–
Instruct on a specific plan of how to contact the PCP (or coverage) by providing
contact numbers for evenings and weekends.
–
Instruct on what constitutes an emergency and what to do in cases of
emergency.
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11-Item Checklist (cont.)
Expedite transmission of the discharge
summary to clinicians accepting responsibility for the
patient’s care after discharge that includes:
8.
–
Reason for hospitalization with specific principal diagnosis
–
Significant findings
–
Procedures performed and care, treatment, and services provided to
the patient
–
The patient’s condition at discharge
–
A comprehensive and reconciled medication list (including allergies).
–
A list of acute medical issues, tests, and studies for which confirmed
results are pending at the time of discharge and require follow-up.
–
Information regarding input from consultative services, including
rehabilitation therapy.
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11-Item Checklist (cont.)
Assess the patient’s understanding of this plan.
9.
–
May require removal of language and literacy barriers by utilizing professional
interpreters.
–
May require contacting family members who will share in the care-giving
responsibilities.
10. Give the patient the discharge plan which includes:
–
Reason for hospitalization.
–
Discharge medications including what medications to take, how to take them,
and how to obtain the medication.
–
Instructions on what to do if their condition changes.
–
Coordination & planning for follow-up appointments that the patient can keep.
–
Coordination & planning for follow-up of tests and studies for which confirmed
results are not available at the time of discharge.
11. Call the patient within 72 hours of discharge to reinforce the
discharge plan and help with problem solving.
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3 Central Components of the RED Model:
2. The After Hospital Care Plan
(AHCP)
– A hardcopy of the AHCP is presented to the
patient upon discharge and includes detailed
instructions on medication administration, all postdischarge appointments with physicians, testing,
and other services, and contact information for the
DA and providers.
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After Hospital Care Plan
• Template from AHRQ
• Free, downloadable, fill-able PDF form
• Store on your server for easy access by DA
• Integrate with your current systems as able
• Hard copies available from AHRQ
•
Provided by TCQPS for Project RED participants
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3 Central Components of the RED Model:
3. The Follow-Up Phone Call
– Preferably a clinical pharmacist, but more commonly the DA,
follows up with the patient within 72 hours of discharge to ensure
the patient understands when and how to take all medications
and answers any questions the patient may have.
– Questions include:
 Does the patient feel that he/she knows how and when to take each
medication?
 Does the patient feel that he/she was able to follow discharge instructions
when at home?
 Does the patient understand the importance of follow-up with a physician/clinic
post-discharge?
 Does the patient feel he/she received all the answers to any questions prior to
leaving the hospital?
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Project RED Introductory Webinars
Module 1: Preparing to Redesign your Discharge Program
Tuesday, May 8th at 10:00 CT
Module 2: The Re-Designed Discharge Process – Patient Admission and
Care & Treatment Education
Tuesday, May 15th at 10:00 CT
Module 3: The Re-Designed Discharge Process – Patient Discharge &
Follow-Up Care
Tuesday, May 22nd at 10:00 CT
Module 4: Re-Engineering Discharge: The Hospital Launch
Tuesday, May 29th 10:00 CT
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Readmission Reduction Tools &
Resources
 The 11-Step Checklist
 Example of an Education Plan
 Discharge Advocate Documentation Forms
 Patient Discharge Survey
 Project RED Patient Tracking Tool
 CHF Survival Kit
 Follow-Up Phone Call Script
– General and CHF specific
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Readmission Reduction Tools &
Resources
 All of the tools mentioned here,
plus many, many more can be found on the
Healthcare Communities website.
http://www.healthcarecommunities.org/
Communities > My Communities > TCQPS
HEN > Browse Community Documents >
Readmissions Resources
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Data Metrics and Collection
 Data Dictionary
– 1 outcome metric
– 1 process metric
 How do you currently monitor hospital
readmissions?
 TCQPS PfP Data Portal
http://pfp.texashospitalquality.org
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Action Planning
 Refer to Action Planning
worksheet in your
packet.
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Next Steps
 Mark your calendar for Project RED Implementation Webinars &
watch your email for dial-in information
– Tuesday, May 8th at 10:00 CT
– Tuesday, May 15th at 10:00 CT
– Tuesday, May 22nd at 10:00 CT
– Tuesday, May 29th at 10:00 CT

Register on www.healthcarecommunities.org to gain access to
Readmission Resources

Gather baseline data for 30-day readmission rates. 2010-2011
monthly data is ideal, but we are willing to work with what you
have available (i.e. quarterly, or shorter duration).
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Questions?
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Serving Texas Hospitals/Health Systems
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