Transcript 3026 - TMIT
Lessons from the Care Transitions Theme
Jane Brock, MD, MSPH Alicia Goroski, MPH This material was prepared by CFMC (PM-4010-070 CO 2010), the Medicare Quality Improvement Organization for Colorado, 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.
Objectives
• • • Methods used by QIOs for analyzing root causes of readmissions Drivers of readmission How to plan for success
14 QIOs with 14 Target Communities
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Community Names
• Tuscaloosa AL • NW Denver CO Miami FL Metro Atlanta East GA Evansville IN Baton Rouge LA East Lansing MI • Omaha NE • Southwest NJ • Upper Capital Region NY • Western PA • Providence RI • Harlingen TX • Whatcom County WA 3
Results*: CY 2007 compared to CY 2009
Measure
14 Care Transitions Communities vs. the Nation % readmitted Readmissions/1000 Admissions/1000 CT Theme (National) Absolute Change -0.08% (+0.05%) -2.96/1000 (-1.93/1000) -15.23/1000 (-11.8/1000) CT Theme (National) Relative Change -0.39% (+0.24%) -4.75% (-3.34%) -4.59% (-3.77%)
*Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.
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Root Cause Analyses
• • • Medical record review – First hospitalization discharge – Other services provided – Readmission admission Process assessment – Direct observation – Process owner interviews Group discussion
Why do hospitals have unwanted readmissions?
Provider-Patient interface unmanaged condition worsening, use of suboptimal medication regimens, return to an emergency department Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers
Why
do hospitals have unwanted readmissions?
Provider-Patient interface unmanaged condition worsening, use of suboptimal medication regimens, return to an emergency department Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers
No Community infrastructure for achieving common goals
Why
do hospitals have unwanted readmissions?
Provider-Patient interface unmanaged condition worsening, use of suboptimal medication regimens, return to an emergency department Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers
No Community infrastructure for achieving common goals
Handing Over Medical Responsibility
Real time communication to PCPs
<20% at time of discharge 33% unaware of discharge
SNF needs functional status
High refusal rates 3-day stay rule
Communication to HHAs
No direct conversation Need signature from PCP
Discharge Summaries
86% in 48 hours 33% prior to follow up visit 9
CMS’s Table of Interventions
http://www.cfmc.org/caretransitions/files/Care_Transition_Article_Remington_Report_Jan_2010.pdf
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Building Community-ness:
Four Models of Community Engagement Multi-representative steering committee Aggregate providers vertically in clusters, then merge Aggregate providers by setting then vertically integrate Individual improvement projects, with information and data-broker Make it visibly a community effort
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Where a motivated community could start
Figure out who you share patients with – Forum for routine exchange/discussion Utilization – Quality – Routine discussion of readmission cases among all involved providers Multi-institution ‘transitional care’ rounds Review hospice/palliative care providers/utilization/referral processes
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Where a motivated community could start
– Require routine cross site visits – Include CEOs – – Map/create handover management processes with your partners Form a ‘receiver’s group’ Form receiver’s coalitions Call/visit your AAA to see what they can do for you Value/promote informal social networking