Reducing Unnecessary Hospitalizations:

Focus on Transitions

Amy Boutwell MD MPP IHI-CMWF Reducing Re-hospitalizations Initiative Institute for Healthcare Improvement

“The $15 Billion Dollar U-Turn”

• 17.6% of Medicare admissions are readmissions within 30 days – Accounting for $15 B in spending • Not all re-hospitalizations are potentially preventable, not all avoidable, but many are (accounting for $12B in Medicare spending) – HF, Pna, COPD, AMI lead the medical conditions – CABG, PTCA, other vascular lead surgical conditions • Disparities exist along racial and “burden of illness” lines • Individual delivery systems and health services researchers have demonstrated dramatic (40-85%) reduction of 30-day readmission rates for certain patient populations (esp. CHF)

Why Readmissions? Why Now?

• MedPac June 2007 report highlights avoidable hospitalizations as an area of high-cost, low-quality; recommends hospital-specific re-hospitalization data be collected and publically reported – Exploration of aligning payment to stimulate improvement in performance on avoidable re-hospitalization rates – – Some health care systems want to “get out ahead” on this issue Some states are looking for immediate “wins” and cost savings • CMS announcement of Care Transitions focus in the 9 th SOW – Approx. 12 -18 QIOs will be selected to identify *communities* in which to coordinate care and improve transitions with the *specific aim* to reduce re-hospitalizations (August 1, 2008)

Why Readmissions? Why Now?

• MedPAC June 2008 report outlines steps toward delivery system reform that focuses on overcoming limitations of current FFS payments – Vision of moving toward payment for care across provider types and time • MedPAC June 2008 recommendations: 1. Confidentially report to hospitals and physicians readmission and resource utilization rates to allow risk-adjusted performance comparison with peers for 2 years and then make data publically available 2. Reduce payment to hospitals with high readmission rates for a set of conditions; allow hospitals and physicians to share in savings gained from improved processes (gainsharing, or shared accountability) 3. Conduct a voluntary pilot to test bundled payments for hospitalizations for a set of conditions

What can be done, and how?

• There exist a wealth of approaches to reduce unnecessary readmissions that have been locally successful

Which are high leverage? Which can go to scale?

• Success requires engaging clinicians, providers across organizational and service delivery types, patients, payers, and policy makers

How to align incentives? How to catalyze coordinated effort?

Opportunities: Avoidable Hospitalizations

• Potentially preventable hospitalizations – Ambulatory care sensitive conditions • Hospitalizations occurring as a result of these conditions may have been prevented by either timely access to quality outpatient care or adoption of healthy behaviors – Re-hospitalizations • Process of discharge aims to establish care in a new setting • Unplanned re-hospitalization usually signals failure of that process • Methods exist to define “potentially preventable” re-hospitalizations

Prevalence and Drivers of Re-hospitalizations

• Preliminary 2007 Medicare data analysis finds: – – – 20% beneficiaries are re-hospitalized at 30 days 35% are re-hospitalized at 90 days 67% are re-hospitalized or deceased at 1 year • Among medical patients re-hospitalized at 30 days: – 50% no bill for MD service between discharge and re-hospitalization • Among surgical patients re-hospitalized at 30 days: – 70% were re-hospitalized with a medical DRG Source: Jencks, Williams, Coleman preliminary data pending peer-review

Evidence: Reducing Re-hospitalizations

• – – – – – Growing evidence of the effectiveness of following: – – – – High quality in-patient care Manage medical co-morbidities (in medical and surgical inpatients) Early assessment of discharge needs Enhanced patient and caregiver self-management engagement Early post-acute follow up with MD or RN (home visit, phone call) Hospital-based post-acute follow-up (phone calls, nurse visit) Appropriate referral for home care services Appropriate patient centered end of life/palliative care discussions Remote monitoring – Improved transfer processes between acute hospitals and post-acute facilities

Improving Care for Patients with Chronic Illness: Evidence: Re-hospitalizations

• • 81% of patients requiring assistance with basic functional needs failed to have a home care referral 64% said no one at the hospital talked to them about managing their care at home Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices. Marblehead, MA: HCPro, Inc.; 2006. 9

Evidence: Reducing Re-hospitalizations

• Excellent research and experience of innovators highlight the effectiveness of enhanced care delivery during transitions: – – – Transition coaching (Coleman) Advanced NP coordination roles (Naylor) Guided care model (Bolt) – Nurses that “wrap around” primary care for high –risk populations (CMS demonstrations) – – Enhanced primary care coordination with home health (NYVNA) IHI Transforming Care at the Bedside (Ideal Transition Home for HF)

High-Leverage Opportunities for Action

1. Improved Transitions for All Patients

a) Transitions “out” of the hospital b) Reception “in” to home (activated home health, office practice) c) Reception “in” to skilled nursing (activated post-acute rehab, NH)

2. Proactively address the needs of “high risk” patients

a) Create inventory of evidence-based “wrap around” or enhanced services b) State-specific assessment of plausibility of financing

3. Engage population in being active, informed consumers

a) Web-based tool, AARP campaign (medications), Partnership for Healthcare Excellence campaign (consumer activation) b) Consider focus on patients and families/caregivers in disease-specific advocacy organizations to promote self-management, proactive role in care, esp at transitions

Conditions to Support Systemic Improvement

• • • • • • • Create incentives to work across traditional settings of care Create incentives to coordinate between providers Create incentives to communicate with patients/caregivers (HCAHPS) Encourage efficiencies in coordination and communication (electronic records, email and phone interactions, group mgt) Decrease barriers to change (“carrot,” gainsharing) Implement catalyst to change (“stick,” transparency, payment reduction) Finance low-cost community / outpatient services to avoid expensive hospitalizations

Opportunities to Improve Care at Transitions

In-hospital

Evidence-based care (e.g. for CHF) Adverse-event free

Transition out of Hospital

Enhanced assessment Enhanced communication Comprh. care (e.g. medical management comorbidities) Timely follow up appointments/ check-in

Reception to SNF/NH

Timely Complete (clinically relevant) Medication management

Reception Home

Timely Complete (clinically relevant) Medication management

Patients/ Caregivers

Enhanced self management Coaching / navigating Enhanced clinical support in new setting End of life care planning/ referral Transfer advanced directives End of life planning/ Transfer info.

End of life planning / transfer info Proactive, informative counseling