readmission rate deep dive: where your focus should be to optimize outcomes that impact your star...

Readmission Rate Deep Dive:Where Your Focus Should Be to Optimize Outcomes That Impact Your Star Rating

Barb Averyt, BSHAProgram Director, Care Coordination

Health Services Advisory Group (HSAG)June 2015

Objectives

2

Review the fiscal year (FY) 2015 CMS* hospital readmission criteria used to assess financial penalties on facilities falling below the acceptable criteria.

Identify the characteristics of patients that are readmitted to the hospital: timeframe, medication usage, follow-up care, etc.

List three definite red flags that put patients at high risk of being readmitted within 7 days of discharge from the hospital.

*Centers for Medicare & Medicaid Services (CMS)

Objective One

3

Review the fiscal year FY 2015 CMS hospital readmission criteria used to assess financial penalties on facilities falling below the acceptable criteria.

Identify the characteristics of patients that are readmitted to the hospital: timeframe, medication usage, follow-up care, etc.

List three definite red flags that put patients at high risk of readmitting within 7 days of discharge from the hospital

Hospital Readmission Penalty

• Age 65 or over • Discharged from non-federal acute-care

hospitals • Without an in-hospital death• Not transferred to another acute care facility • Enrolled in Part-A Medicare for the 12 months

prior to the date of the index admission

4

The Inclusion/Exclusion Algorithm

Source document: 2014 Measures Updates and Specifications ReportHospital-Wide All-Cause Unplanned Readmission – Version 3.0, CMS, March 2014

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National Impact: How Did Hospitals Fare?

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FY 2013Began Oct. 2012

FY 2014Began Oct. 2013

FY 2015Began Oct. 2014

Total hospitals penalized 2,217 2,225 2,610

Hospitals receiving maximum penalty 307 at 1% 154 at 1%

18 at 2% 39 at 3%

National average fine 0.42 0.38 0.63

$$ recouped by CMS $280 million $227 million $428 million

2015 Penalty—Began October 2014

• This is the third year for hospital penalties. • With a moving three-year baseline, hospital

readmissions improve every year, making it difficult to catch up if you were already behind.

• Only 129 hospitals of the 2,225 that were fined in FY 2014 avoided a fine in FY 2015.

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8

Arizona Impact: How Did Arizona Hospitals Fare?

2013 2014 20150

5

10

15

20

25

30

35

40

45

50

22

27

14

3134

43

5

032

02

No penalty< or =50%> or =51%Full penalty

What Is in Store For FY 2016?

• Based on claims data from July 1, 2011, to June 30, 2014 • Up to 3 percent financial penalty to all readmissions• The penalty determining diagnostic-related group (DRGs)

remain the big five: 1. Acute myocardial infarction (AMI)2. Pneumonia (PNE)3. Congestive heart failure (CHF)4. Chronic obstructive pulmonary disease (COPD)5. Total knee arthroplasty/total hip arthroplasty (TKA/THA)

• For FY 2017, coronary artery bypass graft (CABG) will be added

9Source Document: Federal Register / Vol. 80, No. 83 / Thursday, April 30, 2015 / Proposed Rules

Readmission Penalties Are Coming to Others

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!

Objective Two

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Review the FY 2015 CMS hospital readmission criteria used to assess financial penalties on facilities falling below the acceptable criteria

Identify the characteristics of patients that are readmitted to the hospital: timeframe, medication usage, follow-up care, etc.

List three definite red flags that put patients at high risk of readmitting within 7 days of discharge from the hospital

v

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The Deep Dive: West Valley, Phoenix 2013

Medicare Fee-For-Service Patient Activity in 2013

13

30-Day Readmissions by Volume—2013

14

15

All-Cause Readmissions To Another Hospital

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West Valley 2013: Five or More Emergency Department (ED) Visits

• 458 distinct Medicare beneficiaries (MBs); 3,532 ED visits annually

• Treat and release—not admitted• The top diagnoses for ED visits were due primarily to

causes such as abdominal pain, urinary-tract infections, headaches, and backaches

Diagnosis Code Description

789.09 Abdominal pain, other specified site599.0 Urinary tract infection, site not specified784.0 Headache789.00 Abdominal pain, unspecified site

724.5 Backache, unspecified

Hot-Spotting: 10 ZIP Codes, Three Hospitals,126 MBs, 751 Admissions/Readmissions

ZIP Code

# of MBs

Admissions Attributed

85310 3 1885027 13 7785382 15 8185381 9 5585373 8 4185351 29 16885345 19 12685308 10 6285306 13 8385053 7 40

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Then, What Happened?

• The community asked HSAG to conduct a focused data review on the patients that were readmitted within 7 days.

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Questions to Drive Analysis for 7-Day Readmissions• From what provider setting did the patient come? • How many of the patients readmitted within 7 days had

a physician follow-up visit?• How many of those who were readmitted within 7 days

were on high-risk medications, and which ones?• How many of those readmitted within 7 days died, and

when did they die? How many of those patients were on high-risk medications?

• What was the most frequent diagnosis for the patients who were readmitted within 7 days?

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Source of Readmissions Within 7 Days of Hospital Discharge

846; 60%204; 15%

11; 1%110; 8%

229; 16%

Readmitted from these care settings

HomeHHAHospiceOtherNH*

60 percent of patients readmitted within 7 days from hospital discharge had been discharged to home without home health agency (HHA).

20 *Nursing Home (NH)

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Physician Follow-Up Visit

• 846 (60 percent) patients were discharged to home without HHA.

• Less than one out of four (197 or 23 percent) had a physician follow-up visit within the first week of being home and before their readmission.

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Physician Follow-Up Visit (cont.)

• The data showed physician office visits only occurred for patients discharged to home without home health.

• Could it be that a home health visit provided enough social and medical support that the physician office visit was not essential for the first week?

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Physician Follow-Up Visit (cont.)

• 88 of those patients who saw their physician were readmitted the same day or within 24-hours of the physician office visit.

45%

High-Risk Medications

• How many of those readmitted within 7 days were on high-risk medications (anticoagulants, diabetic medications, opioids)? – Which high-risk medications? – Was one group of medications used more than

another (volume)?

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High-Risk Medications (cont.)

• 396 patients were on high-risk medications—more than one out of every four.

28%

Group Question

Which high-risk medication had the largest usage?A. AnticoagulantsB. Diabetic medicationsC. Opioids

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High-Risk Medications

• Readmissions’ drug category breakdown:– Anticoagulants =

80 patients

– Diabetic agents = 104 patients

– Opioids = 212 patients

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20%26%53%

How Many of the Patients Who Were on High-Risk Medications Expired?

• 156 of the 396 patients on high-risk medications expired within a year.

• More than 1 out of every 3.Expired Anticoagulants Diabetic Agents Opioid

Home without HHA 21 16 44

Home with HHA 4 5 16

NH 5 12 18

Other 3 5 7

Total 33 38 85

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Considerations

• Should all patients who are discharged to home on a high-risk medication always have a home health safety evaluation or be part of a care transition coach program?

Anticoagulants Diabetic Agent Opioid Total

Home without HHA 56 or 70% 55 or 53% 136 or 64% 247

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Deaths Among the Readmitted

• Of the 1,400 who were readmitted within 7 days, 554 expired within a year or more following the readmission.

• Only 9 of the 554 had been on hospice services from the hospital discharge.

40%

For the 554 7-Day Readmits Who Expired, When Did That Occur?

58; 11%

162; 30%

124; 23%

91; 17%

85; 16%

26; 5%

During readmission

Within 30 days

1–3 months

3–6 months

6 months–1 year

> 1 year

40%!

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Looking at Additional Geographic Areas

• Phoenix Metro Area• Southern Arizona• Northern Arizona• Data elements:

– 7-day readmission rate– Type of discharge disposition

(alone, with HHA, NH, etc.)– High-risk medication usage– Primary care physician (PCP) visit within 14 days– “Super users” by ZIP code

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Phoenix Metro 30-Day Readmission Rates, All Cause

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Phoenix Metro 7-Day Readmission Rates, All Cause

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Phoenix Metro 7-Day Readmission Rates by Settings

3194; 56%

984; 17%

40; 1%509; 9%

936; 17%Readmitted from these

care settings

HomeHHAHospiceOtherNH

Of those patients readmitted within 7 days, 56 percent were discharged from hospitals without HHA.

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Phoenix Metro 7-Day Readmissions Discharged Home Alone = 3,194

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Total Phoenix Metro 7-day readmission rate from all

settings

3,1945,693

Total Phoenix Metro 7-day readmission

rate from home alone

Southern AZ30-Day Readmission Rates, All Cause

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Southern AZ 7-Day Readmission Rates, All Cause

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Southern AZ 7-Day Readmission Rates by Settings

1; 20%

1; 20%

1; 20%

1; 20%

1; 20%Readmitted from these

care settings

HomeHHAHospiceOtherNH

Data Pending

Of those patients readmitted within 7 days, XX percent were discharged from hospitals without HHA.

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Northern AZ30-Day Readmission Rates, All Cause

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Northern AZ 7-Day Readmission Rates, All Cause

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Northern AZ 7-Day Readmission Rates by Settings

1; 20%

1; 20%

1; 20%

1; 20%

1; 20%Readmitted from these

care settings

HomeHHAHospiceOtherNH

Data Pending

Of those patients readmitted within 7 days, XX percent had been discharged from hospitals without HHA.

42

7-Day Readmissions Who Discharged Home Alone and Had Physician Office Visits Prior

• Phoenix Metro– Home alone 7-day readmission = 3,194 – Saw their physician before readmission = 633 • 20%– Were readmitted within 24 hours = 187 • 29%

• Northern AZ– Home alone 7-day readmission = 444 – Saw their physician before readmission = 90 • 20%– Were readmitted within 24 hours = 24 • 27%

• Southern AZ – Home alone 7-day readmission = 874 – Saw their physician before readmission = 185 • 21% – Were readmitted within 24 hours = 70 • 38%

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7-Day Readmissions: Home Alone and High-Risk Medications

• How many of those readmitted within 7 days, who were discharged home alone, were on high-risk medications (anticoagulants, diabetic medications, opioids)?

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7-Day Readmissions: Home Alone and High-Risk Medications (cont.)

46

7-Day Readmissions: Home Alone, on High-Risk Medications, by Drug Category

Opioids significantly

higher

Super Users—Northern ArizonaZIP Codes 86301 and 86313

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5 or More ED Visits Per Year

ZIP Code Number of Medicare beneficiaries

Total ED visits attributed to these beneficiaries

86301

86313

3 or More Admissions/Readmissions Per Year

ZIP Code Number of Medicare beneficiaries

Total admissions/ readmissions attributed to these beneficiaries

86301

86313

Super Users—Southern ArizonaZIP Codes 85741 and 85704

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5 or More ED Visits Per Year

ZIP Code Number of Medicare beneficiaries

Total ED visits attributed to these beneficiaries

85741

85704

3 or More Admissions/Readmissions Per Year

ZIP Code Number of Medicare beneficiaries

Total admissions/ readmissions attributed to these beneficiaries

85741

85704

Objective Three

49

Review the FY 2015 CMS hospital readmission criteria used to assess financial penalties on facilities falling below the acceptable criteria

Identify the characteristics of patients that are readmitted to the hospital: timeframe, medication usage, follow-up care, etc.

List three definite red flags that put patients at high risk of being readmitted within 7 days of discharge from the hospital.

Red Flags

• Senior and discharged home alone and on an opioid

• Senior and discharged home alone and on a diabetic medication

• Senior and discharged home alone and on an anticoagulant

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Touch-Points and Follow-Up

• Patients who have a touch-point within the first week of hospital discharge, regardless of physician follow-up visit, are less inclined to be readmitted than those that do not have a touch-point.

• Patients who are discharged to home with no follow-up resources such as home health or a care transition coach/intervention are more inclined to be readmitted than any other group.

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Where Do We Go From Here?

Given this information:• What needs to be done so patients are not

readmitted and can be managed at home?• What conversations need to be had and with

whom?• What would be shared? What data can you

provide, share, or ask for that motivates action?

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Start With Common Agreements

• Start with the premise that no one wants a readmission.

• Patients heal better when in their own familiar surroundings.

• Hospitals are not necessarily safe (e.g., healthcare associated infections [HAIs], falls, medication errors, etc.).

• With these agreements, what action can be done that bridges the patient during that vulnerable care transition period?

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Final Goal: Collaboration, for the Patient's Sake

“If you want to go quickly, go alone.

If you want to go far, go together.”

— African proverb

Questions?Thank you!

Barb Averyt, BSHAbaveryt@hsag.com

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, 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 No. AZ-11SOW-C.3-06192015-01

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