decreasing medicare readmissions › uploads › 2 › 4 › 0 › 6 › ... · the hospital use...
TRANSCRIPT
Marinka Bulic Jyothi Golkonda Diane Hunt Aziz Lalji Emad Osman
Decreasing Medicare Readmissions
1
1 Executive Summary ................................................................................................................. 3
2 Introduction ............................................................................................................................. 5
2.1 Background .........................................................................................................................5
2.2 Definition of the Problem and Impact ..................................................................................7 2.2.1 Financial Impact ....................................................................................................................................... 9 2.2.2 Clinical Impact ........................................................................................................................................ 10 2.2.3 Other Impact .......................................................................................................................................... 11
3 Goal ....................................................................................................................................... 11
4 Proposed Solutions ................................................................................................................ 12
4.1 Metrics ............................................................................................................................. 12 4.1.1 Role of Information Technology ............................................................................................................ 16
4.2 Clinical workflows and operations ..................................................................................... 16 4.2.1 Improve Discharge Medications Process ............................................................................................... 17 4.2.2 Optimize Transition Planning ................................................................................................................. 20 4.2.3 Care Coordination .................................................................................................................................. 24
4.3 Patient education .............................................................................................................. 25
4.4 Integration ........................................................................................................................ 27 4.4.1 Proposed Integrated System ................................................................................................................. 27 4.4.2 Privacy Issues ......................................................................................................................................... 29
4.5 Use Case Diagram .............................................................................................................. 30
5 Cost vs. Benefits Analysis ..................................................................................................... 31
6 Project Plan ............................................................................................................................ 33
6.1 Introduction ...................................................................................................................... 33
6.2 Project Governance ........................................................................................................... 34
6.3 Project Roles and Responsibilities ...................................................................................... 35
6.4 Project Assumptions, Constraints and Dependences .......................................................... 36 6.4.1 Assumptions .......................................................................................................................................... 36 6.4.2 Constraints / Limitations ........................................................................................................................ 37 6.4.3 Dependencies ........................................................................................................................................ 37
6.5 Quality Management Plan ................................................................................................. 38
6.6 Communications Management Plan .................................................................................. 38 6.6.1 General Guidelines ................................................................................................................................ 38 6.6.2 Key Groups ............................................................................................................................................ 39
6.7 Risk Management Plan ...................................................................................................... 39
6.8 High Level Functional Requirements .................................................................................. 40
6.9 High Level Workflow Requirements ................................................................................... 42
6.10 Metrics & Measurements .................................................................................................. 43
6.11 Testing .............................................................................................................................. 43
2
6.12 Training Plan ..................................................................................................................... 45
6.13 Deployment ...................................................................................................................... 46
6.14 Schedule ........................................................................................................................... 46
7 Conclusion ............................................................................................................................. 48
8 References ............................................................................................................................. 49
9 Appendices ............................................................................................................................ 51
9.1 Appendix A—Project Structure .......................................................................................... 51
9.2 Appendix B—Project Governance ...................................................................................... 52
9.3 Appendix C—Roles and Responsibilities ............................................................................. 53
9.4 Appendix D — Alternate solutions for Integrated systems .................................................. 62 9.4.1 CCDAs and Interfaces ............................................................................................................................. 62 9.4.2 Remote Access to all Systems ................................................................................................................ 63 9.4.3 One System for Entire Organization ...................................................................................................... 63 9.4.4 One Centralized Data Warehouse ......................................................................................................... 64
9.5 Appendix E—Annotated Bibliography ................................................................................ 66
Figure 1: Existing system diagram ................................................................................................................. 8 Figure 2: Use case for current workflow ....................................................................................................... 8 Figure 3: Proposed integrated system ........................................................................................................ 29 Figure 4: Use case for workflow in proposed integrated system ............................................................... 31
Table 1: Potential Losses ............................................................................................................................. 10 Table 2: University Hospital current LVF Scores ......................................................................................... 13 Table 3: University Hospital current ASA on Arrival Scores ........................................................................ 14 Table 4: University Hospital current Blood Culture Scores ......................................................................... 14 Table 5: Projected Return on Investment ................................................................................................... 32 Table 6: Project Roles and Responsibilities ................................................................................................. 36 Table 7: Project Dependencies ................................................................................................................... 38 Table 8: Project Key Groups ........................................................................................................................ 39 Table 9: Risk Management Plan .................................................................................................................. 40 Table 10: Schedule ...................................................................................................................................... 48
3
1 Executive Summary
University Hospital is concerned about Medicare-insured patients with diagnoses including
acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia, as those are
the diagnoses being targeted by the Hospital Readmissions Reduction Program (HRRP).
Without drastic improvements in these areas, the organization is set to lose close to $1 million
dollars over the next three years. University Hospital has set a goal to reduce Medicare
readmissions from 21% to 10% over the next two years; The Capstone Group has developed a
multi-faceted strategy to help University Hospital not only reach their goal, but also to improve
care provision while doing it. Pre-proposal analysis of the current system and workflows utilized
by University Hospital revealed opportunities for improvement in several areas, leading to the
following recommendations:
Improve hospital-wide performance on clinical quality measures, particularly as
they relate to the diagnoses of AMI, CHF, and pneumonia. This will be achieved
by utilizing currently-available technology to generate reports on quality
measures on a monthly basis, and by focusing re-education efforts as a result of
these reports. By enabling clinical leaders to focus on those providers/locations
that need re-education, we can better utilize available resources to encourage
improvements.
Streamline workflows within the hospital at transition of care points, specifically
at admission and discharge of acute care patients. This will be affected by
improving admission and discharge medication reconciliation processes through
detailed workflow analysis, evaluating patients at acute care admission for
4
readmission risk utilizing a BOOST score, and through the development of a
Transitional Care team to standardize movement of patients from inpatient to
outpatient care settings with necessary resources to ensure compliance with care
plans.
Develop improved interactive education modules to help patients demonstrate
understanding of clinical conditions and play a more informative role in their
care. This will take place primarily though development and increased utilization
of the Patient Portal.
Standardize current follow-up care modules within the organization, with
emphasis on primary care base, and home healthcare provisions. Through the
initiation of a primary care provider incentive program, which encourages
primary care providers to see discharged patients within 72 hours of discharge, in
addition to increased information sharing between the two care environments, this
objective will be obtained. In the future, the hospital will recoup these payments
through attainment of accountable care organization (ACO) quality of care
incentives.
Complete overhaul of currently disjointed information systems, leading to a more
robust, interactive, and available electronic health record (EHR) across the
organization. Primarily, we recommend developing interfaces to share basic
clinical information between the different electronic medical record (EMR)
systems utilized throughout the organization as well as a robust clinical data
warehouse to enable the tabulation of quality and other reporting information
from the system as a whole.
5
Additionally, University Hospital will be provided with a detailed project plan. The purpose
of this project plan is to clearly outline the scope of the project, assumptions made with the
generation of this proposal, and responsibilities necessary for both parties moving forward.
This proposal will save University Hospital approximately $516,000 in Medicare re-
admissions penalties over the next two years. Estimated cost for implementing the various
recommendations within this proposal is $470,000, which provides University Hospital with a
10% return on investment over the next two years.
2 Introduction
2.1 Background
University Hospital is a 500-bed facility with an Emergency Department, Intensive Care
Unit, and Cardiac Surgery Facility. In addition, University Hospital directly employs over 30
physicians in the local community encompassing a variety of specialties; however, the majority
of these physicians are primary care providers. The Capstone Group has been approached by the
administrative leadership at University Hospital to assist the organization in developing an
outline and implementing a plan to decrease hospital readmissions. The focus of project is on
not only readmissions, but also on improving the scope of care provided within the community.
As a major member in a local ACO, University Hospital understands and is committed to
improving care for its patients across the continuum of available services; this goal is aligned
with the hospital mission, which is “To provide quality healthcare services to our community”.
University Hospital wishes to utilize the experience and expertise of The Capstone Group to help
them meet their goals of improving the care provided to their patients in a timely and economical
6
manner. This proposal will outline the means by which The Capstone group will help University
Hospital meet and surpass these goals.
We wish to initiate this proposal with a review of the current state of medicine as it
relates to hospital readmissions in our country. In the United States, nearly 20% of all
hospitalized patients ages 65 and older are readmitted to an acute care facility within 30 days of
discharge (Gerhardt, 2013). Medicare attributes the costs of these readmissions to be over $17.5
billion annually, and they estimate that the gross majority of these readmissions are due to
preventable causes (Gerhardt, 2013). Given these astounding figures, which pose a great threat
not only to the stability of our healthcare system overall but also to the health of our at-risk
elderly population, the government determined that action was necessary to reduce hospital
readmissions across the country. In response, a portion of the Patient Protection and Affordable
Care Act (PPACA), which was signed into law in 2010, was dedicated to solving this particular
problem. Started on October 1, 2012, HRRP serves to essentially de-incentivize healthcare
organizations with above-average readmission rates for their Medicare patient base (Cloonan,
2013). Initially, the new rules are applicable to the following three diagnoses: AMI, CHF, and
pneumonia. Most health care professionals believe that this program will be expanded in coming
years to include more diagnoses. For 2013, the initial penalty for hospitals with higher
readmission rates than national average is 1% of total Medicare reimbursement; that will
increase to 2% in 2014 and 3% in 2015. Expected readmission rates for the country are
calculated by the Centers for Medicare & Medicaid Services (CMS), and adjusted for patient
age, gender, and co-morbid conditions. Penalties for 2013 will be levied on hospitals after it is
determined that their actual readmission rates exceed the expected readmission rates for a
particular time period (Joynt, 2013).
7
2.2 Definition of the Problem and Impact
University Hospital currently has higher-than-average readmission rates for Medicare
insured patients with diagnoses of AMI, CHF, and pneumonia. The Capstone Group performed
a root-cause analysis to help determine the causative factors leading to this problem. Some of
these factors include poor quality measure performance, inappropriate methods to track quality
measure indices, inadequate workflows, inappropriate follow-up, poor patient education
practices, and an insufficient Information Technology (IT) base.
University Hospital is associated with a multi-site Accountable Care Organization
(ACO). University Hospital has adopted Centricity EHR for the past 18 years. The physicians in
the hospital use computerized physician order entry (CPOE) to electronically send prescription
orders to three different pharmacies that are part of the ACO. Pharmacies respond back to the
ordering physicians with the prescription fill data. Physicians also use CPOE to electronically
order lab tests and procedures to three different labs within the ACO. The labs with in the ACO
use different terms and different test combinations. This has been a major cause for confusion on
the receiving end and a potential patient safety issue. The labs have the capability to send test
results electronically to the ordering provider. The outpatient clinics in the ACO use Epic EMR
to electronically send and receive data from the pharmacies and the labs. Although University
Hospital can exchange data electronically with labs and pharmacies there is no electronic data
exchange between the Hospital and the outpatient clinics in the ACO. This has a major impact on
the transition of care when a patient is discharged from the hospital. Currently there is no
handoff during discharge process. The hospital has no control on the post discharge care of the
patient.
Figure 1 depicts the state of the current systems within the ACO.
8
Figure 1: Existing system diagram
Figure 2 captures the use case for the current workflow in the ACO. There is no transition of care
between the inpatient and outpatient care systems.
Figure 2: Use case for current workflow
Indicates areas of improved workflows; see future use case on page 31
9
The remainder of this proposal will touch on each of these concerns, and provide
University Hospital with methods to improve them.
2.2.1 Financial Impact
By careful calculation of the admissions and readmissions data for the calendar year 2012
provided by University Hospital to The Capstone Group, we have generated a potential loss
projection for the next three years based on current regulations. We want to make sure that the
administrative leadership at University Hospital understands that any solution enacted at this
point will alleviate projected losses for 2014, but that we will not be able to recoup losses already
in place to be levied for the 2013 calendar year. In 2012, University Hospital had a total of 7,500
Medicare admissions; this accounted for 5,100 novel patients. The overall 30-day readmission
rate for 2012 was approximately 21%. Of these, 60% occurred within 10 days of initial hospital
discharge; this information is critical to any project focusing on decreasing readmissions overall.
When analyzing admission diagnoses, The Capstone Group determined that 65% of the 30-day
readmissions were in patients with either one or a combination of AMI, CHF, and pneumonia.
When we look at comparable healthcare organizations, these figures show that University
Hospital is clearly within the Medicare penalty range for 2012 data.
The following table illustrates the projected financial burden that University Hospital will
endure, if corrective actions are not taken in a timely manner to reduce the rate of readmission
(Logue, 2013).
Year 2013 2014 2015
Penalty 1% 2% 3%
No. of Medicare admissions
7500 7500 7500
Average Medicare hospitalization rate in the service area
$13,387 $12,718 $13,119
10
Total Medicare payment per annum
$100,402,500 $95,382,375 $98,394,450
Medicare payment for readmissions
$21,419,200 $20,348,240 $20,990,816
Readmission payments for (AMI, CHF, and Pneumonia)
$13,922,480 $13,226,356 $13,644,030
Expected Medicare readmission penalty for the three diagnoses
$139,225 $264,527 $409,321
Table 1: Potential Losses
It is the goal of The Capstone Group to develop and implement a multi-faceted plan to
help University Hospital avoid Medicare repayment penalties of over $500,000 for 2014 and
2015 that are directly related to above-average 30-day readmission rates. University Hospital is
already predicted to lose almost $140,000 in Medicare payments due to the new requirements in
2013.
2.2.2 Clinical Impact
The Capstone Group believes that the clinical impacts presented by poor quality measure
performance and inadequate transitional workflows are of much greater potential harm than the
financial impacts. Currently, University Hospital is failing in its mission “To provide quality
healthcare services to our community”. Patients being cared for within the service lines provided
by University Hospital and its affiliates are not receiving the same standard of care expected at a
national level. This is directly impacting not only Medicare reimbursement, but also the trust
that your patients place in you as a healthcare organization. Poor quality measures are directly
related to readmission rates, as well as mortality rates and decreased quality of life indicators.
Without drastic changes in these measures, the future of University Hospital as a viable
healthcare option in the community is at risk.
11
2.2.3 Other Impact
At The Capstone Group, we want to make sure that our project meets your organization’s
mission. With that in mind, we would like for the leadership at University Hospital to understand
that our approach to reducing readmissions will not only result in a generous return on
investment financially, but also in terms of quality of care provided to the patients in your
community. Given University Hospital’s current involvement in a local ACO, this project will
supply the foundation from which you can realize benefits related to ACO payment models,
PCMH initiatives, Health Information Exchange (HIE) projects, and a variety of other
requirements as they relate to population health.
3 Goal
The goal of this project is to reduce readmissions in patients with the diagnoses of AMI,
pneumonia, and CHF; University Hospital’s stated goal is to reduce these readmission rates from
the current 21% to 10% over the next two years. This proposal will outline the multi-faceted
approach recommended by The Capstone Group to help University Hospital meet that goal. Our
proposal will outline solutions including:
Improvement of clinical quality measures and overall provision of care, with
reflection of these improvements in patient satisfaction surveys,
Development of standardized clinical workflows at transitions of care, with focus
on discharge process, primary care follow-up, and medication compliance,
Implementation of new patient education processes to better ensure that patients
participate and appropriately understand their own care,
12
Standardization of care coordination in the ambulatory settings, to allow for better
utilization of home health providers, and primary care physicians after discharge,
Recommendations for overhaul of the current disjointed IT solutions in the
hospital and affiliated practices in order to better streamline the flow of
information between care locations
We believe that a multi-faceted approach, addressing the majority of the concerns revealed
by the root cause analysis will help University Hospital to not only avoid further financial
penalties as they are related to Medicare readmission rates, but also to drastically improve the
quality of care provided within the organization.
4 Proposed Solutions
4.1 Metrics
The focus on quality measures defined by CMS is a system in place to reduce patient
readmissions within 30 days of being discharged. The CMS program, HRRP, will collect data on
quality measures involving CHF, AMI, and pneumonia (CMS, 2013). If the data show that a
hospital has a higher than expected 30-day readmission rate for these diseases, penalties will be
applied against their total Medicare payments. This financial incentive has been proven to
improve readmission rates in hospitals for those diseases.
We have identified initial measures within University Hospital for each condition with a
low score that needs to be improved. A low percentage (under 95%) of a measure score is costly
in two ways:
1. Penalties in Medicare payments hurt the overall bottom line of the hospital
13
2. These measures are proven to reduce readmission rates with a direct correlation between
higher score with lower readmission rates.
CHF
• In the United States, there are more than 700,000 hospitalizations due to heart failure
annually; University Hospital had 1,900 admissions due to heart failure last year (Good
Shepard, 2013).
LVF Assessment – Left Ventricular Systolic Function Assessment
“This score shows the percentage of patients who had the left side of their heart assessed during
their hospital stay at University Hospital The left side of the heart is where the main pumping
chamber is located. By assessing it, doctors can tell how well it is pumping and what type of
treatment is needed” (Memorial Health, 2013).
University Hospital Quality Measure Score - LVF
2010 Total 2011 Total 2012 Total YTD 2013 Total Projected 2014
75.6% 78.4% 84.9% 87.3% 96.7%
Table 2: University Hospital current LVF Scores
AMI
• Approximately 1.1 million patients have an acute myocardial infarction in the United States
annually; there were approximately 2,000 patients with a heart attack at University Hospital last
year (Good Shepard, 2013).
• Of those patients who have an AMI, almost 2/3 do not completely recover (Good Shepard,
2013).
• Patients who do survive the initial stages of an AMI have an increased chance of co-morbid
disease and ultimately death that is 2-9 times increased over non-AMI afflicted peers (Good
Shepard, 2013).
14
ASA on Arrival – Aspirin on Arrival
“This score shows the percentage of heart attack patients who received aspirin within 24 hours
of arriving at Memorial University Medical Center. Aspirin can help break up blood clots and
prevent new ones from forming. It may reduce the severity of a heart attack” (Memorial Health,
2013).
University Hospital Quality Measure Score – ASA on Arrival
2010 Total 2011 Total 2012 Total YTD 2013 Total Projected 2014
66.5% 72.5% 79.5% 83.6% 95.1%
Table 3: University Hospital current ASA on Arrival Scores
Pneumonia
• The 5th leading causes of death in the nation for patients age 65 and over are pneumonia and
influenza; they are 4th for the University Hospital patient population (Good Shepard, 2013).
• More than 90% of deaths due to pneumonia occur in patients aged 65 and older (Good Shepard,
2013).
Blood Culture
“This score shows the percentage of pneumonia patients at Memorial University Medical Center
who had a blood sample studied before receiving any medication. By analyzing the blood,
doctors can see what type of pneumonia is present and which type of antibiotic will treat it”
(Memorial Health, 2013).
University Hospital Quality Measure Score – Blood Cultures
2010 Total 2011 Total 2012 Total YTD 2013 Total Projected 2014
73.7% 81.2% 89.4% 90.4% 98.2%
Table 4: University Hospital current Blood Culture Scores
15
In order for these CMS quality measures to be implemented with the most effectiveness, the
hospital must identify its own risks by using one of the following:
Influenza vaccine status
Patient Survey: Hospital Consumer Assessment of Healthcare Providers and Systems
scores
Core measures for CHF, AMI and pneumonia
Readmission rates
Utilization of resources
Cost of care per case
A review of the above results should be performed monthly in order to adjust the system and
improve the performance of the hospital. Analyzing the quality measures and identifying lapses
in performance can help the hospital adjust and reduce its risk for readmissions
Patient Survey
The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
Survey is a survey that has been standardized and used to help hospitals determine how patients
feel about the care provided to them (HCAHPS Survey, 2013). HCAPHS has provided a method
to standardize a practice employed by many hospitals across the nation, as well as a means to
determine performance compared to other organizations. This survey has three goals, according
to the originators: to produce comparable data on based on a patient perspective of care that
allow comparisons amongst peer hospitals, to publicly report results of the survey so that
consumers are aware of them and there is increased transparency, and to create incentives for
16
hospitals that provide improved quality of care (HCAHPS Survey, 2013). All data generated
through the use of the HCAHPS survey is provided to the public.
The following topics are addressed in the current HCAHPS patient survey, and are of
particular concern to University Hospital (HCAHPS Survey, 2013):
• Communication About Medicines
• Discharge Information
• Overall Rating of Hospital
The improvement of patient satisfaction survey metrics in the above areas is addressed
through recommendations in this proposal. The initiation of improved workflows as they relate
to these metrics will undoubtedly lead to increased patient satisfaction. Addressing these issues
through this will lead to a decrease in University Hospital’s readmission rate as well as a
healthier bottom line.
4.1.1 Role of Information Technology
Dash boards can be used to display all the above metrics to providers and administrators
alike. Dash boards provide graphical display of the key performance indicators for readmission
rates and support drill down of the key performance indicators to lower levels to examine critical
drivers of performance. They help track and manage readmission rates by providing at a glance
display for management and department heads. The analytic reports provide details of the
performance drivers that affect readmission rates. (HIMMS, 2012)
4.2 Clinical workflows and operations
The arena of clinical workflows, in particular, presents an opportunity for standardization
across the organization. We seek to help University Hospital optimize the processes related to
post-discharge medication planning, the transition process, and care coordination. We
17
recommend a Lean Six Sigma approach to improve the medication reconciliation processes to
help standardize and streamline these workflows. Our black-belt certified Lean Six Sigma team
will work directly with appropriate stakeholders within the organization to map out not only the
inadequate current processes, but also a desired future state that will ensure error-free medication
reconciliation at all transitions of care. Our team will work with your stakeholders to analyze the
entire process including clinical caregiver workflows, current EMR functionality, and caregiver
to patient communication. The final stage of this project will be implementation of the future
state within all patient care areas in the hospital, led by our Lean Six Sigma consultants.
4.2.1 Improve Discharge Medications Process
The next step in the plan to reduce hospital readmissions at University Hospital is to improve
the patient’s ability to understand and adhere with medication regimens prescribed at discharge.
Studies have repeatedly shown that patients who adhere to their prescribed medication regimens
have lower readmission rates than those patients who are noncompliant with their medications
(Stewart, 1999). At the current time, we have identified three areas of concern as they relate to
the discharge medications process at University Hospital: medication reconciliation, e-
prescribing, and compliance verification. Our plan to improve processes in these three areas will
lead to increased medication compliance in patients after discharge, and reduced readmission
rates overall.
In our initial analysis, we determined that medication reconciliation is a process that is
fragmented and poorly defined; in particular, we determined that last year over 75% of
University Hospital’s admitted patients had medication reconciliations performed incorrectly at
either admission or discharge. Additionally, The Capstone Group has identified that over half of
18
these mistakes occurred during the admission medication reconciliation process, which then led
to carry-over errors in the discharge medication reconciliation process.
In addition to the concerns about medication reconciliation, The Capstone Group
determined that University Hospital’s e-prescribing rate at hospital discharge is far below the
requirement for attainment of Meaningful Use. Improvement in this particular area will not only
help University Hospital to recoup some of those Meaningful Use dollars, it will also help to
improve patient compliance with discharge medication instructions. Upon initial investigation, it
was determined that providers at University Hospital cited inconvenience as the main reason
why they were not e-prescribing discharge medications consistently. We have identified an
inadequate current state that requires providers to order prescriptions individually based on how
they should be routed (controlled substances routed to the printer, non-controlled substances to
the pharmacy); this is very inconvenient and time-consuming for your providers. The next
solution we propose is that The Capstone Group work directly with Centricity’s e-prescribing
team in conjunction with University Hospital’s appropriate stakeholders to alter the current state
so that prescriptions route automatically without physician direction. This is functionality
currently available in the Centricity EMR, so we do not anticipate any difficulties with this
project. Once this phase of the project is complete, we will work directly with your providers to
educate them about the improved process. With this project, we aim to increase provider e-
prescribing at hospital discharge to more than 80% of appropriate medications, which is the
current requirement to meet Meaningful Use Stage One.
The final piece we recommend to improve discharge medication compliance is the
development of a communication channel between outpatient pharmacies and primary care
providers, with inclusion of the patient via the Patient Portal. We believe it is this phase of the
19
discharge medications project that will have the greatest impact on readmissions overall. When
we evaluated compliance with discharge medications, The Capstone Group determined that
fewer than 50% of discharged patients received all of the medications prescribed for them at
release from the hospital. We will work directly with representatives from University Hospitals’
informatics team, local pharmacy representatives, and personnel from Centricity and Epic to
develop electronic workflows to allow outpatient pharmacies to inform primary care physicians
when medications are not filled by the patient. The first step in this process is to include the
primary care physician, who was identified at the time of hospital admission, on any e-
prescriptions sent at the time of discharge. This allows the local pharmacists to determine who
the appropriate following provider is for any particular patient. The next step in this process is to
work directly with the local pharmacies to take their current “refill request” process and modify
it slightly to become a “prescriptions unfilled” notification. In projects with previous clients, we
have found local pharmacies to be very willing to work with us on this communication, because
it results in increased revenue for them through higher percentages of prescriptions filled.
Additionally, this requires very little work for them to perform. These notifications will come
into the outpatient EMR, Epic, directly through the message center, just as refill requests come to
the providers or designated staff today. Once this process is in place, our team will work to
educate the primary care physician base in the community about these notifications. In
particular, we will focus on the employed primary care physicians with education about how to
respond to these notifications and identify those patients who are noncompliant at the time of
discharge. By placing that information in the hands of the primary care providers, we believe
that we can improve the ability of these providers to help recently discharged patients better
comply with medication instructions by facilitating dialogue that should elucidate reasons why
20
particular medications were not filled. Once they are aware of barriers facing an individual
patient, the primary care provider can involve necessary resources to help patients comply with
discharge orders.
4.2.2 Optimize Transition Planning
Another particularly important facet of this project proposal is the transition from not only
the inpatient to outpatient care setting, but also the transition from outpatient to inpatient. The
Capstone group will help University Hospital to streamline the processes surrounding care in
both the acute care and ambulatory settings, so that the end result will be reduced readmission
rates throughout the University Hospital organization. On initial evaluation of these processes at
University Hospital, we have determined that these processes are not standardized at all. Patients
are currently at the mercy of an extremely varied system that may or may not utilize social
workers, home healthcare resources, and primary care providers to facilitate necessary post-
discharge care.
The first step in this portion of the proposal is to look at what happens when a patient is
admitted to University Hospital. We will start by focusing on identifying patients who are
particularly at risk for readmission based on certain factors present upon admission for acute
care. While there are several disease-based scoring systems available for use in the inpatient
care realm, we recommend using a more global approach to stratifying patients according to risk
scores; in this way we are more likely to reduce readmissions for our patient base overall and not
just for those disease states identified by the measurement tools. Additionally, we simplify the
admission process for the support staff, ensuring that all patients receive the same risk
assessment, regardless of diagnosis at the time of admission. Although many risk-predictive
models have not been proven to effectively reduce readmission rates in randomized controlled
21
studies to date, we feel that the benefits of improved targeted care and relatively low cost of such
measures make the practice ultimately useful (Kansagara, 2011). In evaluating options for patient
risk stratification at admission, we have determined that the BOOST Model has shown the most
initial promise in reducing readmissions in the short-term. The BOOST model will allow the
clinical staff to calculate a readmission risk score for all patients over the age of 65 at the time of
admission, and includes alterations in care based on the following (The Society of Hospital
Medicine, 2013):
The presence of problem medications
The presence of psychological symptoms
The principal diagnosis at the time of admission
The presence of polypharmacy
Poor health literacy on the part of the patient
The presence or absence of patient support
Prior hospitalizations in the last six months
Palliative care
The Capstone Group will work with University Hospital’s informatics team to develop a
form within the inpatient Centricity system that is completed by nursing staff at the time of
admission on all patients over the age of 65. This form will trigger an alert identifying a patient
as high-risk for readmission if they have the presence of risk factors in 1 or more of the above
categories. This alert will be visible to all care providers on the patient’s banner bar within the
Centricity EMR, and reminds them that appropriate care should be taken with the transition from
acute to outpatient wherever possible. Additionally, we recommend that this alert also trigger a
task within the Centricity system that places the patient onto a list for social work and/or a
22
transitional care team for further resources. By effectively utilizing the BOOST tool as a clinical
decision support within the EMR, we have standardized a process to best stratify those patients
who are high-risk for readmission at the time of presentation.
Finally, The Capstone Group recommends the development of a Transitional Care Team to
help smooth the movement of high-risk patients from acute inpatient care to ambulatory care
provision. Traditional models show Transitional Care Teams led by a nurse practitioner in
conjunction with a managing medical director, with staffing provided by a combination of
nurses, home healthcare providers, and social workers. The recommended team size for
University Hospital at this time is 6. This recommendation is based on initial analysis which
showed that approximately 20% of the inpatient population at University Hospital is over the age
of 65, and that half of those patients qualify as high-risk utilizing the BOOST scoring method;
this translates to an approximate case load of 50 at any given time. The medical director should
be available on a part-time basis for consultation and organizational decisions, while the
remainder of the positions should be full-time. It is this team that will help patients move across
the gap between acute and ambulatory care; these care providers will provide the full spectrum
of care for patients as they navigate that 30 day transition. Potential services offered by this
team include follow-up in home evaluation post-discharge, arrangement of home care,
housekeeping, and financial support to help patients meet medical needs (prescriptions, durable
medical equipment, dietary changes, Meals on Wheels, etc.), facilitation of transportation,
education about diagnoses and expectations, and scheduling of appointments with follow-up
providers after discharge. While development of this team does require additional resources at
the hospital level, we have seen that the benefits of this team far exceed the cost. The Capstone
Group has seen marked success with the transitional care model across the country to date, and
23
nationally, readmission rates have decreased anywhere from 2-10% for certain diagnoses thanks
to the initiation of this type of program (Stauffer, 2012). Additionally, with the implementation
of the clinical decision support-aided BOOST score, we can automatically assign patients to the
Transitional Care Team based on risk. It is the task of the Transitional Care Team to act as
facilitators to work directly with patients during the move from hospitalization to home; the
development of this team will help patients to utilize the extensive outpatient support system
offered in the community, and will help them to avoid expensive Emergency Department and
Inpatient care unless it is absolutely necessary.
Our final recommendation regarding the transition of care from inpatient to outpatient is
the involvement of the Home Healthcare providers. While the local Home Healthcare agency is
not currently affiliated with University Hospital, we believe a partnership between the two would
be greatly advantageous to both entities. Home Healthcare can play a vital role in improving
patients’ quality of life, outcomes, and unnecessary readmissions (Fleming, 2013). With the
recommendation to include Home Healthcare providers on the Transitional Care Team, we allow
for both entities to provide necessary services after the time of discharge. Additionally, because
Home Healthcare services are reimbursable, while Transitional Care Services are not, the
utilization of Home Healthcare agencies creates a symbiotic relationship for both entities as well
as for the patient. Home Healthcare intervention can start within 24-48 hours after discharge
with a visit by a registered nurse (RN) to the patient’s house. The intervention continues for up to
sixty days from the date of discharge and can continue for subsequent sixty day episodes until
the patient completely recovers. During a patient’s stay with home healthcare, additional services
such as physical, occupational and speech therapy, home health aide and social worker services
are also provided. These services are provided on a weekly basis or as needed.
24
Home Healthcare agencies have an incentive to provide better care to patients. Early
discharge from Home Healthcare with less than five skilled services provided to patient can
result in reduction of payment to the agency. Home Healthcare agencies can also be penalized
for re-hospitalizations and not meeting the required quality metrics. Home Healthcare provides
the following services that can help reduce unnecessary readmissions (Logue, 2013):
Providing information and education to patients about their health conditions,
how to identify red flags and self-monitoring.
Help create up to date medication list by doing medication reconciliation.
Reminding patients and caregivers about physician follow-up.
Providing plan of care for timely recovery of patients
Assess and help patient in getting other community resources
The combination of the Transitional Care Team and the Home Healthcare providers will help to
better coordinate patient care before and after discharge. The teams together will act as a liaison
between the hospital, patient, and primary care physician and will help smooth the transition of
care as it occurs (Fleming, 2013).
4.2.3 Care Coordination
In addition to standardizing the discharge medications process and the transition of care,
the coordination of care between the acute care providers and the primary care providers is
another critical piece of this proposal. This coordination of care is necessary to keep patients out
of the hospital. Currently, patients discharged from University Hospital have less than a 50%
chance of seeing a primary care physician within 14 days of discharge. However, we know that
patients who are not seen within 72 hours of discharge have a markedly increased risk of
readmission (Cloonan, 2013). The primary care physician base in the community must be
25
involved in this project, or it is doomed to fail. We believe that it is essential for University
Hospital to set up an incentive program for the employed primary care physicians, to get them
invested in the project. As the hospital’s involvement in the ACO program evolves, those
payments related to decreased readmission rates could be utilized to fund the primary care
physician incentive program. A whole re-evaluation of the current payment model for these
physicians is likely necessary, as many organizations are moving away from a production-based
incentive program and towards a quality-based incentive program. However, for the purposes of
this proposal, the recommendation at this time is to develop an incentive program for the
employed primary care physicians of the hospital. This program should reward physicians who
consistently get discharged patients into the office to be seen within 72 hours of discharge and
who meet outpatient quality metrics set by Meaningful Use requirements. Because we know that
improvements in these two areas are directly related to decreased readmission rates, this program
will pay for itself in time. Additionally, given University Hospital’s ACO involvement, this will
help reduce per-patient expenditures and lower costs overall. A program that rewards primary
care physicians for improving quality of care provided, while also reducing costs of providing
that care is critical to the financial health of University Hospital moving forward. These steps in
improving coordination of care, in addition to recommendations elsewhere in this proposal to
streamline information flow between care providers, will help facilitate improved care for
patients within the organization overall.
4.3 Patient education
One key element in reducing the admissions of patients and increasing their satisfaction is
in them getting the proper education regarding how to take their medicine and when to make
follow-up appointments. Patients who receive education on these factors are “30 percent less
26
likely to be readmitted or visit the emergency department than patients who lack this
information” according to a study funded by the Agency for Healthcare Research and Quality
(Jack, 2013).
One program that has shown signs of success has been Project RED, the Re-Engineered
Hospital Discharge Program considered to be a leading project in care coordination. This
program is put into place to help “nurses to help patients arrange follow-up appointments,
confirm medication routines, and understand their diagnoses using a personalized instruction
booklet” (Jack, 2013). The next step after the nurse interaction is for a pharmacist to contact the
patient up to 4 days after being discharged from the hospital in an effort to “reinforce the
medication place and answer any follow up questions” (Krames, 2013). The preliminary results
of the testing of Project Red showed that after 30 days after their hospital discharge, the 370
patients who participated in the RED program had 30% fewer subsequent emergency visits and
early readmissions than the 368 patients who did not. 94% of the patients who participated left
the hospital with a follow-up appointment with their primary care physician, compared to 35%
for patients who did not participate. 91% of participants had their discharge information sent to
their primary care physician within 24 hours of leaving the hospital (Krames, 2013).
We would like to emulate this program at University Hospital. We will utilize the
inpatient EMR to suggest diagnosis-specific patient education at the time of discharge, and will
build out a reporting tool for University Hospital to use to determine which nurses are not
providing this education at hospital discharge. Additionally, we recommend utilizing the
Transitional Care Team to function as the pharmacist in the Project RED scenario above, to call
the patient 2-3 days post discharge to verify the patient is taking medications and following care
plans as directed.
27
Finally, patient portals help to drive patient engagement and support patients while they
make health-related decisions and manage their own personal health information. Patient portals
can also serve as a communication channel between the patient and the physicians (physicians
who attended the patient during hospitalization and physician responsible for the follow-up care
after discharge). The portal can be used to share patient specific educational resources. Patients
can access clinical summaries online through the portal. Physicians can also choose to use the
patient portal to post the labs results with a brief message explaining the results. We recommend
optimizing the Portal currently used by University Hospital to include this functionality, and to
enhance the workflows outlined above.
4.4 Integration
4.4.1 Proposed Integrated System
The Capstone Group recommends the following steps to integrate the hospitals, outpatient
clinics, pharmacies and labs in the ACO.
1. University Hospital uses Centricity EHR. The outpatient clinics use Epic EMR. There is
no electronic communication between the Hospital and outpatient clinics. This is a major
hurdle for transition of care between University Hospital and the primary care physician
or the home healthcare providers. Capstone Group recommends using CCDAs to bridge
the gap between the inpatient system and the outpatient systems and allow patient data to
flow across the continuum of care.
2. University Hospital is already using CPOE to electronically send and receive data from
labs, pharmacy, and radiology. But during our investigation it was observed that the labs
use different terms and test combinations. This causes confusion on the receiving end
(both inpatient systems and outpatient systems). Capstone group recommends using the
28
standards recommended by CMS in all labs. Use CPT codes for procedures and LOINC
codes for lab tests. Units of measure on the reported results must follow CMS
recommendation.
3. Capstone group recommends creating a centralized data warehouse and feed data from
all clinical systems (inpatient, outpatient, lab, pharmacy, radiology, etc.), financial
systems, operational systems and human resource (HR) systems. The data warehouse
could be used to generate metrics on patient care and provide possible recommendations
to the providers. Data can also be used for retrospective analysis for continuous quality
improvement.
Figure 3 depicts the proposed integrated system. Advantages of the proposed system
An integrated system provides access to complete patient record from anywhere
anytime.
Potential data loss or incomplete patient record, due to manual consolidation of
patient data is eliminated.
Allows seamless data flow between the systems.
Addresses patient safety issues due to lost communication
Facilitates dashboard development to track readmission rates
Provides the necessary infrastructure for Inpatient clinical reports, Outpatient clinical
reports, Patient experience reports and Cross functional reports
Track patient outcome with respect to financial impact
Track patient outcome with respect to operational and staff changes
29
Figure 3: Proposed integrated system
4.4.2 Privacy Issues
With the implementation of new workflows, CMS quality measures, and technology changes, the
personal health information (PHI) of patients cared for by providers at University Hospital is at
risk. In particular, University Hospital must be cognizant to remain compliant with the
regulations included in the Health Information Portability and Accountability Act (HIPAA).
With the addition of a data warehouse to the current information technology infrastructure at
University Hospital, an agreement must be developed between the hospital and the Health
Information Organization (HIO). While a HIO is not a covered entity, it is a business associate,
under the HIPAA rules (45 C.F.R. §§ 164.502(e), 164.504(e)) (Department of Health & Human
30
Services, 2009). Therefore, University Hospital will need to engage legal counsel in order to
draft and enforce appropriate business associate agreements with the HIO managing and storing
the personal health information for the organization. This is outside of the scope of the proposal
presented by The Capstone Group and must be arranged by the hospital separate to this project.
Additionally, University Hospital must be cognizant of potential weaknesses in the
network that may compromise personal health information. As data is sent between physicians
and other care providers within the organization, it becomes more likely to be compromised.
Evaluation of network security is another element not provided by The Capstone Group, but is
necessary to remain HIPAA compliant. Considerations for the organization, as recommended by
The Department of Health and Human Services include utilizing unique and secure ID’s for all
users of the network, automatic log-out protocol, encryption and decryption of data, and
emergency access procedures (Department of Health & Human Services, 2009). All of these are
considerations for University Hospital as they work to improve their information system to
reduce readmissions.
4.5 Use Case Diagram
Figure 4 depicts the use case diagram with Capstone Group’s proposed solution. Use cases in
yellow represents modification to the existing use case (using additional tools to improve care
and changes to the care delivery and discharge process). Use cases in green represent a new use
case added as a result of the proposed solution to improve patient care across the continuum of
care and reduce readmissions.
31
Figure 4: Use case for workflow in proposed integrated system
5 Cost vs. Benefits Analysis
The benefit of implementing the proposed solutions will not only reduce the overall Medicare
readmission rate from 21% to 10%, but will also help University Hospital save $516,618 or 64%
in readmission penalties.
Year 2013 2014 2015 Total for 3-
years
Penalty 1% 2% 3%
32
No. of Medicare
admissions
7500 7500 7500
Average Medicare
hospitalization rate
in the service area
$13,387 $12,718 $13,119
Total Medicare
payment per annum
$100,402,500 $95,382,375 $98,394,450 $294,179,325
Medicare payment
for readmissions
$21,419,200 $9,538,238 $9,839,445 $40,796,883
Readmission
payments for (AMI,
Heart Failure and
Pneumonia)
$13,922,480 $3,433,766 $2,951,834 $20,308,079
Penalties after
implementation of
proposed solutions
$139,225 $68,675 $88,555 $296,455
Penalties before
implementation of
proposed solutions
$139,225 $264,527 $409,321 $813,073
Savings in penalties
due to
implementation of
proposed solutions
$0 $195,852 $320,766 $516,618
Estimated cost of
proposed solutions
($188,000) ($211,500) ($70,500) ($470,000)
Return on
investments ($188,000) ($15,648) $250,266 $46,618
Table 5: Projected Return on Investment
Before the implementation of the proposed solutions 65% of the readmissions were
patients with either one or a combination of AMI, CHF, and pneumonia. After implementation of
the proposed solutions the readmissions of patients with the three diagnoses will be 33%.
The estimated costs of implementing the proposed solutions will be $470,000. Majority
of the estimated costs will be utilized for upgrading and integrating the infrastructure, training,
consultancy and other expenses.
In the next two years, the proposed solutions will help University Hospital gain 10%
Return on Investment (ROI).
33
6 Project Plan
6.1 Introduction
The implementation approach proposed for the solution will take on a multi-phased approach
over the course of a (12) month timeline beginning in January 2014. Core groups of work that
will be concentrated on are as follows 1) Project Management, 2) Infrastructure, 3) Application
Solution, 4) Testing, 5) Training, 6) Operations and Communications. The work will be broken
out in the following project phases or milestones:
Planning
Design
Build
Testing
Deploy and Close
Capstone consulting project plan aims to clearly manage goals, strong communications, realistic
schedules, a cost – schedule – quality equilibrium supported by detailed plans. The Project Plan
and associated work breakdown structure will become the working documents of the project and
updated throughout the life of the project.
Project success factors:
Agreement among the project team, customer, and management on the goals of the
project.
A plan that shows an overall path and clear responsibilities, which is also used to measure
progress during the project.
Constant, effective communication between everyone involved in the project.
34
A controlled scope.
Management support.
6.2 Project Governance
Project governance is illustrated in (2) ways for the Medicare Readmission Reduction (MRR)
project. Both diagrams are submitted as addendums (A & B).
Overall Project Governance – The overall project governance reflects the organizational
governance structure w/ respect to the MRR. As illustrated in addendum A, the project itself will
run up through the Chief Operations Officer at University Health. Other key decisionmakers and
business/clinical unit representation will be a part of the MRR Oversight committee. These key
members will represent:
Information Technology
Physician stake holders
Nursing Stakeholders
Revenue Cycle / Finance
Patient Care Services
Additionally, the responsibilities of the project leaders vary from direction on the
tactical/operational approach of the project, as well as execution, and overall organizational
strategy. As the MRR project is not just focused on technology, and financial goals, there is also
clinical representation both at execution and steering committee.
ITS Project Team Governance – An additional governance chart (addendum B) has been
supplemented to highlight the governance structure with respect to the actual project execution.
35
As you review you will notice the different teams that will comprise the overall project team and
their roles with:
Design / Build / Testing
Training Development
Training Delivery
Implementation / Operations
Please note that the steering committee will work in coordination with the patient care service
team, and the overall EMR leadership team with ultimate reporting up to the MRR oversight
committee as highlighted in the overall project governance chart.
6.3 Project Roles and Responsibilities
Below are the project team members that will be involved with project execution and a brief
review of their responsibility. A full review of roles by responsibilities has been submitted as
addendum C.
Role Responsibilities
Clinical Adoption
Mgr.
Participate and/or lead design sessions to ensure that system
design and workflows support clinical care & departmental
processes
MRR Clinical
Analysts
Development of business process solutions and requirements with
support from application support
MRR Educators Conduct training sessions following predefined standards
MRR Oversight Resolve and/or Escalate to project concerns/issues to Executive
Sponsor as needed
MRR Training Lead Lead team to design enterprise-focused learning objectives,
course outlines, assessments, storyboards, instructor manuals, and
participant materials
Dept. Business
Owner
Oversee identification, review, modification and creation of
clinical policies and procedures and discharge instructions.
Education Liaison Develop and maintain training plan and training work breakdown
36
Role Responsibilities
structure
Executive Sponsor Provide overall strategic leadership to the project
MRR Design Lead Business solutions & requirements: Lead gathering and
documentation
Project Director Resolve issues escalated from Project Manager, Accountant, and
Architect
Project Manager Provide project tracking for each affected system and process
within the project scope
Resource Manager Work with the Project Manager to staff the project appropriately
so timelines and targets can be achieved Table 6: Project Roles and Responsibilities
6.4 Project Assumptions, Constraints and Dependences
6.4.1 Assumptions
Accurate and Timely Documentation – One key design feature of the MRR project will
be its ability to mine discreet patient data that is deemed critical to identifying the high
risk patient population. To be effective, the data in the patient record will need to be
wholly, accurate and timely.
Decision Support - Another key feature of the MRR project will be its ability to provide
clinicians with evidence based patient care instructions. For the project to be effective
the care instructions developed as part of the MRR initiative will need to be reviewed and
executed accordingly.
Scope- While the MRR project will focus on (3) core measures, the project understands
there are other core measures that can adversely affect organizational readmission
statistics. This project assumes no more than a moderate (+/-3%) deviation in the core
measures outside of the scope of this project in order to drive down the whole
organizational readmission population.
37
Integration – In order to observe the benefits of fully integrated patient data across the
whole care team and both University Health EMR’s (Centricity/Epic) this project
assumes significant investment in integration and interoperability efforts between both
systems and standardization of data standards
6.4.2 Constraints / Limitations
<Data Standards>– In the current state the University Health existing architecture hosts
(2) separate EMR’s. This is identified as a limitation to this project with regards to the
lack of standardization of data across both EMR’s.
o To counter this constraint we propose significant work be invested in identifying
organizational data standards with respect to patient data being documented by
provider and exchanged from system to system
<Data Sources>– Again, with the existing architecture and use of (2) separate EMR’s,
clinicians application workflow, data mining/reporting will be constrained.
o To counter this constraint, the project proposes significant investment and time
into the development of future state workflows and development ofclear policies
and procedures for use of both EMR’s.
6.4.3 Dependencies
Below is a list of project dependencies for the MRR project. Meaningful Use Stage 2 project
will impact the future state integration architecture and standards for University Health.
Additionally, the ICD-10 implementation will have significant impact on billing / reimbursement
as well as documentation standards in the future state.
38
Description Status Owner Escalation
Date
Due Date
Meaningful use stage 2 Open MU PM 1/1/2014 6/30/2014
ICD -10 Open ICD 10 PM 1/1/2014 10/1/2014 Table 7: Project Dependencies
6.5 Quality Management Plan The MRR project will utilize the following tools to monitor and control the progress, project
objectives, quality, and risk with regards to the project. Capstone consulting believes monitoring
and controlling affects all other phases of the project life cycle.
Risks / Issues – Will be documented in a Microsoft SharePoint site designed uniquely for the
project. Risks and issues documented will be communicated to the project manager as well as
the lead for the particular phase of the project (i.e. design/training, implementation) for tracking
and escalation purposes.
Time Tracking –Will be documented and managed utilizing Microsoft Project Server. Time
tracking will be assessed by phase and project activity by the team member responsible for the
work. Time tracking will assist the project leadership with future phase cost and resource
planning.
Project Progress – Will be documented by the Project Manager in Microsoft Project will be
integrated to project server.
6.6 Communications Management Plan
6.6.1 General Guidelines
Capstone consulting has developed thefollowing guidelines for all project communications --
Communicate with all affected parties.
Every message should be audience-specific.
Set appropriate expectations.
39
Provide regular, unbiased reporting of project progress.
Communicate with other people before they need to know the information.
Provide time to assimilate the information.
6.6.2 Key Groups
Below is a list of the key groups of people with whom the project manager and/or project team
will communicate with during the project.
Groups Members
Project Sponsor(s) Chief Operation Officer (University Health)
Project Team Clinical Adoption Mgr
MRR Clinical Analysts
MRR Educators
MRR Training Lead
Department Business Owners (Department Managers)
Educator Liaison
MRR Design Lead
Project Director
Project Manager
Department
Stakeholders Ambulatory Medical Directors
Acute Care Medical Directors
ICU Managers
ED Managers
Ambulatory Clinic Managers
Cardiology Managers / Directors
Director of Pharmacy
Director of Lab Operations
Director of Radiology
Home Health Managers
ClinApps Project
Management Office
(PMO)
Project director / Project Manager
Resource Managers Resource Managers Table 8: Project Key Groups
6.7 Risk Management Plan
40
The following risks have been identified by Capstone consulting and are evaluated based on
Likelihood
Impact
Severity
Risk Likelihood Severity Impact Mitigation
Project Resources –
With so many
regulatory projects in
2014 such as ICD-10
and Meaningful Use
there is a risk of
recruiting and retaining
project resources
Highly
Likely
HIGH HIGH impact
to timeline
Contracting staff
Clinical Adoption –
Additional Decision
support functionality if
improperly designed
and trained can impact
adoption and impede
clinical workflow
Likely High Significant
impact to
project goals
Training
Assessment
Post-Go Live
Monitoring
and assessment
of log files
Qualitiative
post-
production
surveys by
users
ICD-10 – The ICD-10
project poses
significant risk to
reimbursement as well
as documentation
standards for providers.
High High Significant Add ICD-10
validation
checkpoint as
part of
requirement
acceptance Table 9: Risk Management Plan
6.8 High Level Functional Requirements
General
Integrates with existing Centricity and EPIC EMR architecture
Integration
41
Development of additional system to system integrations with adherence to CCDA
standards
Full integration ability with all ancillary systems
o Lab
o Radiology
o Pharmacy
o Home Health
o Primary Care providers portals
Decision Support
Alert Functionality - must identify patient data with respect to the following 3 measures and alert
based on reference range violation developed as part of application design efforts (see core
measures above in section 4.1)
Congestive Heart Failure
Acute Myocardial Infarction
Pneumonia
Decision Support Functionality – Based on identification of high risk alerts and patient
identification, system will provide detailed plan of care instructions to providers with respect to:
Discharge Summary
Follow-Up visits
Communication to entire patient care team
Patient Triage
Coordinated provider hand-off
42
Tailored medication reconciliation
STAT routing for all lab
Documentation of Vitals
Tailored assessment instructions
Tailored communication and follow up messaging thru Patient Portal
Printing
Patient Discharge Summary out of both EMR’s in addition to patient portal
Add new printing devices (as needed)
Workflow
Complies with ICD-10 documentation requirements
Complies with MU requirements
Reports
Ability to assess increase / decrease of readmission within core measure population
Hardware
Servers
6.9 High Level Workflow Requirements Based on development of policies and procedures new workflow requirements will need ability
to tailor the following to high risk protocols created as part of the MRR project -
Discharge Summary
Follow-Up visits
Communication to entire patient care team
Patient Triage
Coordinated provider hand-off
43
Tailored medication reconciliation
STAT routing for all lab
Documentation of Vitals
Tailored assessment instructions
Future Orders
6.10 Metrics & Measurements
Measurements of readmission volume will be completed every (3) months. The following teams
and responsibilities have been highlighted for providing the metrics and measuring of them –
Operations – Will provide figures on the number of readmissions broken out by 1) chief
complaint 2) primary diagnosis. Operations will also provide figures and input on qualitative
surveys completed by patients as well as users of the system for continuous process improvement
IT – Will provide data figures on the amount of alerts triggered, appropriateness and adoption of
decision support steps provided
RevenueCycle – Will provide figures on the amount of reimbursement and subsequent additional
cost of readmission
6.11 Testing
Capstone consulting will also complete a detailed testing assessment as part of the project
implementation plan. A multi-phased testing approach will be utilized.
The objectives of testing for the University Health Readmission Reduction projectare to:
Document that the system reliably and repeatedly performs as designed.
Ensure regulatory documentation standards are met.
Verify business and system requirements are satisfied.
44
Capture discrepancies (problems) to eliminate defects.
Establish testing documentation that can be reused for system maintenance.
Provide information to assess go-live readiness.
Practice a dress rehearsal build and testing
Key testing milestones and purpose will include –
Unit Testing
Unit testing will focus on application components (i.e. a unit of functionality) as they are built.
For a specific list of units that will be tested, please refer to high level requirements section
(above). Unit testing verifies basic application components work as designed during the build
process.
Application / Functional Testing
Application Testing confirms that the component functions of the product/application perform to
meet the business and technical design requirements. Focus is on software defects. This testing
will confirm correct configuration of the infrastructure as well. The application testing will
focus on the full system requirements and how they flow together, beginning with the alert and
on to the decision support guidance and full system integration and communication to the full
patient care team.
Regression / Performance
Performance Testing validates the ability of the application to function under maximum volumes
and peak transaction loads.
Also serves to validate the technical environment supporting the application under normal and
stressed conditions.
45
Stress Testing attempts to find system defects exposed by overloading its resources in a
short span of time. An example of this method of testing is for multiple users to open a
flow sheet at the exact same time.
Volume Testing determines the system’s general ability to handle heavy volumes of data.
This is exemplified when many users are using a variety of applications simultaneously.
Focus is on response time and system performance.
Integration Testing
Integration Testing validates the ability of the application of the MRR system, to communicate
and exchange data between BOTH EMR’s in the normal or proposed course of a clinical
encounter. It also verifies that processes between all ancillary systems to behave as expected,
whether a new anticipated process change or continuance of an existing one. Additionally,
integration testing will assess the systems ability to successfully operate thru use cases, similar to
one illustrated as part of this project proposal.
6.12 Training Plan
Training Plan - A detailed evaluation for training will be incorporated into the projects
implementation plan. The training strategy will have two core focuses:
Curriculum Development
Education
The curriculum development aspect will begin by assessing the content that will be delivered, ,
all resources for content. The key exercise in curriculum development will be the stakeholder
analysis as the project will look to identify what individuals will be impacted most by the
projects solution, the level of impact. Additionally, an assessment into their existing experience
46
in both EMR’s as well as any prerequisite knowledge needed and preferred method of training.
Content will ultimately be driven by both the workflow and application requirements designed
by the subject matter experts from the departments and the clinical analysts designing the
system.
The education aspect will focus on the execution of training, the coordination, logistics and
methods for delivering the content. Recommended options for training are as follows:
Classroom
Online
Self Study
Job Aids
Blended solution of classroom and online
6.13 Deployment
Capstone consulting recommends a big bang approach of implementing ALL functionality at
once, commonly known as a big bang approach. The deployment will have one centralized
command center that will be staffed by the project team and any additional resources. The
deployment coverage will focus on at the elbow support for the end-users as well as a team
responsible for triage of service requests, troubleshooting, testing and education needed.
6.14 Schedule
Major Milestones Target Completion
Date
Pre-Planning
Project Approval 12/1/2013
Planning
47
Project kick-off meeting 1/6/2014
Initial Work Breakdown Structure (WBS)
approval
1/13/2014
Technical Environment Planning 1/20/2014
Project Charter Sign-off 1/27/2014
Project Plan Sign-off 1/27/2014
MRR QA Checkpoint #1 - Planning 1/31/2014
Design
Design workshops complete 4/25/2014
Initial design review complete 5/2/2014
MRR QA Checkpoint #2 – Design 5/9/2014
Build
Test cases identified/scripts written 7/25/2014
Build Complete 8/1/2014
MRR QA Checkpoint #3 – Build 8/8/2014
Testing
First round of integrated testing complete 8/29/2014
Second round of integrated testing complete 9/26/2014
MRR QA Checkpoint #4 – Testing 10/3/2014
Production Readiness
Hardware installed and printing configuration
complete
11/3/2014
Curriculum development & training preparation
complete
10/3/2014
Training for first site complete 11//28/2014
Go-live prep activities for first facility complete 11//28/2014
Go No Go Decision for site #1 approved 10/3/2014
Go Live
48
Site 1 Implementation 12/3/2014
Project Close
Post Implementation Review 3/31/2015
Project Close-out Report complete 5/1/2015
Table 10: Schedule
7 Conclusion
We have found that the current system has limitations, hindering the quality of care
delivered and hurting the hospital financially. The project proposal is intended to bring new
technology and processes that will reduce University Hospital’s 30-day readmission rate, but
also improve the bottom line. Upfront the cost may seem daunting, but the return on the
investment is set to be at 10%. Going forward, the benefits come not only from meeting CMS
measures, but also from the trust developed with the community. As hospital operations become
more transparent, readmission data will be a large variable that the community uses to decide
what hospital to receive treatment. Having an improved system in place allows for better quality
of care provided to patients allowing for closer ties between the community and hospital. Our
proposal not only provides a plan to improve the current state of the hospitals readmissions, but
also becomes a solid foundation for future improvements. As the healthcare system transitions to
a more modernized and integrated one, University Hospital will be ready for the future of
healthcare.
49
8 References
Centers for Medicare & Medicaid Services. (2013). Quality Measures. Retrieved November 26,
2013 from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/QualityMeasures/Downloads/Hospitals-and-CAH-2014-Proposed-EHR-Incentive-
Program-CQM.pdf
Cloonan, P., Wood, J., & Riley, J. B. (2013, July/August). Reducing 30-Day Readmissions
[Journal]. The Journal of Nursing Administration, 43(7/8), 382-387.
http://dx.doi.org/10.1097/NNA.0b013e31829d6082. Retrieved on November 04, 2013
Department of Health and Human Services. (2009). Security 101 for Covered Entities.
Retrieved December 4, 2013 from:
http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/security101.pdf
Fleming, M., Haney, T. (2013). Improving patient outcomes with better care transitions: The role
for home health. Cleveland Clinic Journal of Medicine, 80(e-Suppl 1), e-S2.
Retrieved on October 9, 2013 from http://www.ccjm.org/content/80/e-Suppl_1/e-S2.full
Gerhardt, G., Yemane, A., Hickman, P., Oelschlaeger, A., Rollins, E., Brennan, N. (2013).
Medicare Readmission Rates Showed Meaningful Decline in 2012. Medicare and Medicaid
Research Review, 3(2), E1-E12.
Good Shepard Medical Center. (2013). Quality: What are Core Measures? Retrieved December
7, 2013 from: http://www.gsmc.org/quality/.
HIMMS (2012). Reducing Readmissions -Top Ways Information Technology Can Help
Retrieved October 13, 2013 from:
http://www.himss.org/files/HIMSSorg/content/files/ControlReadmissionsTechnology.pdf
Jack, B., Passche-Orlow, M., Mitchell, S., Forsythe, S., Martin, J. (2013). Re-Engineered
Discharge (RED) Toolkit. Agency for Healthcare Research and Quality. Retrieved October 14,
2013 from: http://www.ahrq.gov/professionals/systems/hospital/toolkit/redtool1.html#
Joynt, K., Jha, A. (2013). A Path Forward on Medicare Readmissions. New England Journal of
Medicine, 368(13), 1175-1177. Retrieved on October 24, 2013 from:
http://www.nejm.org/doi/full/10.1056/NEJMp1300122
Kansagara, D., Englander, H., Salanitro, A., Kagen, D., Theobald, C., Freeman, M. (2011). Risk
Prediction Models for Hospital Readmission, A Systematic Review. Journal of the American
Medical Association; 306(15): 1688-1698.
Krames Patient Education. (2013). Reducing Hospital Admissions With Enhanced Patient
Education. Retrieved October 14, 2013 from:
http://www.bu.edu/fammed/projectred/publications/news/krames_dec_final.pdf
50
Logue, M., Drago, J. (2013). Evaluation of a modified community based care transitions model
to reduce costs and improve outcomes [Magazine]. BMC Geriatrics, 13(94), 1-11.
http://dx.doi.org/10.1186/1471-2318-13-94. Retrieved on October 24, 2013
Memorial Health. (2013). Quality Data. Patient Satisfaction. Retrieved November 26, 2013,
from https://www.memorialhealth.com/quality-data.aspx
The Society of Hospital Medicine (2013). Risk Assessment Tool: The 8 P’s. Retrieved
November 3, 2013 from:
http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/html_CC/06Boo
st/03_Assessment.cfm
Stewart,S., Marley, J., Horowitz, J. (1999). Effects of a Multidisciplinary, Home-based
Intervention on Planned Readmissions and Survival Among Patients with Chronic Congestive
Heart Failure: A Randomized Controlled Study. Lancet; 354(9184): 1077-1083.
Stauffer, B., Fullerton, C., Fleming, N., Ogola, G., Herrin, J., Martin, S. (2011). Effectiveness
and Cost of a Transitional Care Program for Heart Failure. Journal of the American Medical
Association Internal Medicine; 171(14): 1238-1243.
The HCAHPS Survery. (2013). The HCAHPS Survey: Frequently Asked Questions. Retrieved
December 8, 2013 from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/HospitalQualityInits/downloads/HospitalHCAHPSFactSheet201007.pdf
51
9 Appendices
9.1 Appendix A—Project Structure
52
9.2 Appendix B—Project Governance
MRR Project GovernanceUniversity Health COO
MRR Oversight Commitee
MRR Operational
Leadership
Team
MRR Project Mgt Team
Project Team/s
CMOs
CMIO
Clinical Adoption
Mgr
- University Health CIO,
Chairman
- Medical Director
- CNO
- Revenue Cycle Director
- ITS Medical Director
- Director of Pharmacy
Services
Organization
Communication
Lead
Benefits & Metrics
Coordinator
HR
Support
Strategic Governance
Project Execution
Tactical / Operations Governance
Responsibility Key
ITS Liaison /
PCIS Director
Assoc
Administrators
PCS
Clinical Governance
ITS Governance
Physician Lead
ITS Program
Director
ITS ClinApps
Project Director
MRR Clinical
Advisory Team
53
9.3 Appendix C—Roles and Responsibilities
Role Responsibility
Clinical
Adoption Mgr
Acceptance: Responsible for working with clinical areas on usability and
acceptance testing
Clinical
Adoption Mgr
Business solutions & requirements: Facilitate clinical input and
documentation of requirements
Clinical
Adoption Mgr
Business solutions & requirements: Manage changes to clinical processes
and workflow related to implementation
Clinical
Adoption Mgr
Communications: Coordinate with Project Management Office
Communications Coordinator
Clinical
Adoption Mgr
Communications: Develop communications content for distribution to
nursing and essential service departments
Clinical
Adoption Mgr
Communications: Liaison to HR regarding role changes for clinical staff
Clinical
Adoption Mgr
Communications: Provide communications to corporate communications for
distribution
Clinical
Adoption Mgr
Communications: Serve as single point of contact for nursing and essential
service department leadership to provide clinical input into the MRR project.
Clinical
Adoption Mgr
Communications: Manage the communications Medical Center Leadership &
Department stakeholders
Clinical
Adoption Mgr
Communications: To clinical leadership on system requirements and change
management
Clinical
Adoption Mgr
Concerns & Issues: Escalate to Project Manager or Project Leadership
Team
Clinical
Adoption Mgr
Design: Lead development of workflow crosswalk documentation to support
process changes
Clinical
Adoption Mgr
Design: Participate and/or lead design sessions to ensure that system design
and workflows support clinical care & departmental processes
Clinical
Adoption Mgr
Device: Assist Device Specialist in developing the device planning
Clinical
Adoption Mgr
Education: Participate in MRR vendor led application training to gain
understanding of MRR functionality and product features/capabilities as they
relate to future-state workflows & system design
Clinical
Adoption Mgr
Implementation plans & support: Develops with Site Managers and project
leadership
Clinical
Adoption Mgr
Implementation plans & support: Develop and direct EMR unit experts in
performing clinical department readiness assessments for MRR
Clinical
Adoption Mgr
Implementation plans & support: Working together with the EMR Site
Mangers, develop a deployment plan that supports providers, nurses and
other clinicians
Clinical
Adoption Mgr
Leadership: Escalate critical issues to senior leadership providing
recommended solutions
Clinical
Adoption Mgr
Leadership: Provide monthly updates both oral and written to University
Health Senior Leadership on the project’s progress especially around
54
potential clinical impacts.
Clinical
Adoption Mgr
Leadership: Represent University Health Senior Leadership in project
activities
Clinical
Adoption Mgr
Leadership: Together with MD Lead, co-chair MRR Leadership Team
Clinical
Adoption Mgr
Leadership: Recruit & supervise assigned clinical experts (subject matter
experts) during system deployment
Clinical
Adoption Mgr
Membership: MRR Leadership, MRR EMR Governing, MRR Global
Decisions Group
Clinical
Adoption Mgr
P&P: Oversee identification, review, modification and creation of clinical
policies and procedures and discharge instructions.
Clinical
Adoption Mgr
Quality: Ensure system supports quality initiatives
Clinical
Adoption Mgr
Quality: Lead clinical workgroups to gather input, feedback, and resolve
issues
Clinical
Adoption Mgr
Quality: Liaison to existing quality groups to determine benefits and metrics
measurements
Clinical
Adoption Mgr
Quality: Maintain an expert knowledge or JCAHO and other hospital
regulations
Clinical
Adoption Mgr
Quality: Participate in deployment reviews
Clinical
Adoption Mgr
Quality: Participate in project QA reviews
Clinical
Adoption Mgr
Quality: Provide project feedback at regular intervals to the Project
Management Office and EMR Project Manager
Clinical
Adoption Mgr
Quality: Serve as the MRR liaison to existing clinical committees
Clinical
Adoption Mgr
Training : Act on evaluation data as needed
Clinical
Adoption Mgr
Training: Assist with development of resource estimations
Clinical
Adoption Mgr
Training: Identify audience for training
Clinical
Adoption Mgr
Training: Participate in creation of the EMR Training Request & MRR
Project Training Plan
Clinical
Adoption Mgr
Training: Participate in curriculum design sessions
Clinical
Adoption Mgr
Training: Provide input and feedback on all deliverables from the EMR
Education team
Clinical
Adoption Mgr
Training: Work with MRR Training Lead to ensure clinical expert users &
project team support staff are adequately prepared to support the MRR
deployment (training & materials)
Clinical
Adoption Mgr
Training: Ensure that the MRR education program supports clinical training
needs
Clinical
Adoption Mgr
Workflow: Manage the catalog of future state workflows for clinical
departments
55
MRR Clinical
Analysts
Business solutions & requirements: develop together with application
support and other team members.
MRR Clinical
Analysts
Business solutions & requirements: Responsible for documenting business
process solutions and requirements
MRR Clinical
Analysts
Business solutions & requirements: Work with project team members
assisting in their understanding of technical, customer and business process
requirements.
MRR Clinical
Analysts
Concerns & Issues: Raise issues and concerns to the project manager and
project leadership team, where appropriate.
MRR Clinical
Analysts
Coordinate with SMEs and application support Team throughout project
MRR Clinical
Analysts
Deadlines: Work to meet project deliverable deadlines
MRR Clinical
Analysts
Devices - Develop of business process solutions and requirements with
support from application support
MRR Clinical
Analysts
Implementation plans & support: Participates in deployment and support
plan development and implementation
MRR Clinical
Analysts
EMR: Completes and maintains Spec documentation (data collection tools)
MRR Clinical
Analysts
PM: Assist in the development and refinement of the high-level project
plans.
MRR Clinical
Analysts
Status Reports: Complete status reports
MRR Clinical
Analysts
Test Plans & Objectives - Assist with development
MRR Clinical
Analysts
Time Tracking: Participate in time tracking activities per procedure
MRR Clinical
Analysts
Workflow: Responsible for completing current and future workflow
documents
MRR Clinical
Analysts
Workflows: Responsible for understanding vendor solutions and how they
can be best utilized in clinical workflows.
MRR Educators Time Tracking: Participate in time tracking activities per procedure
MRR Educators Training: Analyze, design, and develop, and review training outlines and
materials as needed following predefined standards
MRR Educators Training: Conduct training sessions following predefined standards
MRR Educators Training: Gather evaluation data and distribute it to Site Managers and
Training PM
MRR Educators Training: Provide input and updates to the Education Liaison on tasks
completed or in progress
MRR Educators Training: Provide input and updates to the Lead Educator and/or Site
Education Coordinator on tasks completed or in progress
MRR Educators Training: Provide input to Lead Educator or Site Education Coordinator for
status reports
MRR Educators Training: Train staff and physicians
MRR Educators Training: Curriculum and training materials development
MRR Oversight Acceptance Criteria: Approve
56
Team
MRR Oversight
Team
Communications: To hospital clinical leadership
MRR Oversight
Team
Concerns & Issues: Escalate to Executive Sponsor as needed
MRR Oversight
Team
Concerns & Issues: Resolve issues escalated from the Project Leadership
Team
MRR Oversight
Team
Implementation plans & support: Lead the development of the
implementation strategy
MRR Oversight
Team
Leadership: Review & approve key project documents
MRR Oversight
Team
Leadership: Review and approve requirements & design decisions
MRR Oversight
Team
Leadership: Provide vision, oversight, and guidance to the Project Leadership
Team
MRR Oversight
Team
Membership: Member of the MRR Steering Team
MRR Oversight
Team
QA: Participate and approve QA checkpoint results as appropriate
MRR Oversight
Team
Training: Approve training content
MRR Oversight
Team
Training: Review and sign-off on training plan
MRR Training
Lead
Communications: Attend project meetings and report decisions, action
items, and project elements impacting training back to the EMR Education
Teams,
MRR Training
Lead
Communications: Execute communication plan as defined in the 400 EMR
Training Plan document working with Communication Lead
MRR Training
Lead
Communications: Provide input and updates to the Training Project Manager
on tasks completed or in progress
MRR Training
Lead
Coordinate: Coordinate clinicians (Nursing, Physicians, Pharmacy, etc.) to
review training curriculum
MRR Training
Lead
Coordinate: Coordinate efforts the EMR Educators, TEACH/TRAIN
Domain Administrator, Training Ops/Scheduling Coordinator and Project
Management Teams
MRR Training
Lead
Coordinate: Coordinate with the MRR EMR Training Project Manager,
MRR EMR Project Manager and the MRR EMR Project Management Team
MRR Training
Lead
Deadlines: Work to meet project deliverable deadlines
MRR Training
Lead
Deadlines: Work to meet project deliverable deadlines
MRR Training
Lead
Implementation plans & Support: Participate in conversion support
MRR Training
Lead
Issues & Concerns: Bring forward departmental related training issues to
Project Manager/s) documenting in bugzilla.
MRR Training Lead: Monitor work of MRR Education Team
57
Lead
MRR Training
Lead
Lead: Serve as liaison between project team and EMR Education Team/s) –
to include all sites within the project scope
MRR Training
Lead
Leadership: Serve as a role model for Educators, TEACH/TRAIN Domain
Administrator, Training Ops/Scheduling Coordinator and expert users
MRR Training
Lead
Membership: Participate in ongoing project meetings
MRR Training
Lead
PM: Contribute to the development of the Implementation Management Plan
MRR Training
Lead
PM: Provide input to the Training Project Manager for the training work
breakdown structure (WBS)
MRR Training
Lead
PM: Provide regular status reports to project manager
MRR Training
Lead
PM: Develop status update reports and submit them to the MRR EMR
Project Managers
MRR Training
Lead
Time Tracking: Participate in time tracking activities per procedure
MRR Training
Lead
Training: Lead one or more curriculum design and development teams
MRR Training
Lead
Training: Assign and monitor Educators to complete training task analysis
based on delta between current and future state workflows
MRR Training
Lead
Training: Assign Educators to specific functional (system oriented) or role-
based (job oriented) teams
MRR Training
Lead
Training: Assign Educators, TEACH/TRAIN Domain Administrator, and
Training Ops/Scheduling Coordinator to specific tasks per the MRR EMR
Training WBS and various teams as appropriate and provide oversight
MRR Training
Lead
Training: Conduct and support the training class evaluation and feedback
requirements
MRR Training
Lead
Training: Develop and document training schedule requirements and
resource needs with input from the Site Education Coordinators and/or
Education Team Members
MRR Training
Lead
Training: Lead team in identifying how to sequence training content
MRR Training
Lead
Training: Lead team to design enterprise-focused learning objectives, course
outlines, assessments, storyboards, instructor manuals, and participant
materials
MRR Training
Lead
Training: Monitor work of Education Team to achieve project tasks
MRR Training
Lead
Training: Organize and facilitate tasks and schedules for expert users /
subject matter experts participating in design, review, and delivery of training
and education
MRR Training
Lead
Training: Participate in reviews of the current and future state workflows
MRR Training
Lead
Training: Participate in the gathering and documentation of the current state
training materials
MRR Training Training: Perform Quality Assurance function / review of all curriculum
58
Lead (learning objectives, course outlines, storyboards, instructor manuals, and
participant materials) to ensure consistency and alignment with EMR
Education standards
MRR Training
Lead
Training: Perform Quality Assurance function on training task analysis
MRR Training
Lead
Training: Perform Quality Assurance function regarding current and future
state workflows
MRR Training
Lead
Training: Proctor training courses
MRR Training
Lead
Training: Provide content to the Clinical Applications Communication Lead
and/or Site Managers for department specific communications regarding
training and education as needed
MRR Training
Lead
Training: Provide MRR EMR training for users in all disciplines, applying
knowledge of health care environment and clinical practice as the operational
training lead
MRR Training
Lead
Training: Provide feedback regarding ongoing issues or concerns with
curriculum design via Bugzilla
MRR Training
Lead
Training: Provide input into development and refinement of the detailed
training project plans
MRR Training
Lead
Training: Provide Trainer/Super User training - this may include classroom
and one-on-one instruction
MRR Training
Lead
Training: Lead team to develop interactive training materials (includes
instructor and participant materials, including competency assessments) to
support the most appropriate use of clinical applications
Department
Business Owners
(Department
Managers)
Acceptance: Responsible for working with clinical areas on usability and
acceptance testing
Department
Business Owners
(Department
Managers)
Business solutions & requirements: Facilitate clinical input and
documentation of requirements
Department
Business Owners
(Department
Managers)
Business solutions & requirements: Manage changes to clinical processes
and workflow related to implementation
Department
Business Owners
(Department
Managers)
Communicate: To clinical leadership on system requirements and change
management
Department
Business Owners
(Department
Managers)
Concerns & Issues: Escalate to Project Manager or Project Leadership
Team
Department
Business Owners
Membership: Member of Department Project Leadership Team and/or
Steering Team
59
(Department
Managers)
Department
Business Owners
(Department
Managers)
P&P: Oversee identification, review, modification and creation of clinical
policies and procedures and discharge instructions.
Department
Business Owners
(Department
Managers)
Training : Act on evaluation data as needed
Department
Business Owners
(Department
Managers)
Training: Assist with development of resource estimations
Department
Business Owners
(Department
Managers)
Training: Identify audience for training
Department
Business Owners
(Department
Managers)
Training: Provide input and feedback on all deliverables from the EMR
Departmentucation team
Educator Liaison Member: Project Team
Educator Liaison Time Tracking: Participate in time tracking activities per procedure
Educator Liaison Training: Develop and maintain training plan and training work breakdown
structure
Educator Liaison Training: Provide communications between user-educator-build/project
team.
Educator Liaison Training: Communicate status of training work back to the project team /
project manager.
Educator Liaison Training: Coordinate EMR Education team members to complete tasks
Educator Liaison Training: Develop resource estimates
Educator Liaison Training: Serve as liaison between project team and EMR Education Team
Executive
Sponsor
Concerns & Issues: Address issues & decisions that can not be resolved by
Steering Committee
Executive
Sponsor
Leadership: Provide overall strategic leadership to the project
Executive
Sponsor
PM: Perform final sign-off on key project documents
MRR Design
Lead
Business solutions & requirements: Lead gathering and documentation
MRR Design
Lead
Communication: Provides project communication to the CA Team
MRR Design
Lead
Coordinate: Creation of functional and detail design documents
MRR Design Deadlines: Work to meet project deliverable deadlines
60
Lead
MRR Design
Lead
Design: Develop current & future state design standards and enforce their
use
MRR Design
Lead
Design: Develop process for documentation of current and future state
MRR Design
Lead
Design: Develop with Application Build Lead standardized specification
document tools
MRR Design
Lead
Leadership: Direct work of Clinical Analysts monitoring progress & quality
MRR Design
Lead
Leadership: Enforce standardized documentation of issues in Bugzilla by
MRR Clinical analyst Team
MRR Design
Lead
Leadership: Escalate critical issues to project manager & MRR Leadership
Team
MRR Design
Lead
Meetings: Lead Work Status Meetings/Interviews
MRR Design
Lead
Membership: MRR EMR Governing & MRR Global Decisions Group
MRR Design
Lead
Membership: Represents application support on the EMR MRR Governing
Team & Global Decision Team
MRR Design
Lead
PM: Assist in the development and refinement of the high-level project
plans.
MRR Design
Lead
PM: Completes tasks as assigned in project plan
MRR Design
Lead
PM: Contribute to the development of the Implementation Management Plan
MRR Design
Lead
PM: Provide regular status reports to project manager
Project Director Concerns & Issues: Escalate to Program Director or MRR Steering
committee.
Project Director Concerns & Issues: Resolve issues escalated from Project Manager,
Accountant, and Architect.
Project Director Coordinate: Scheduling project management activities and tasks across EMR
projects.
Project Director Enforce use of standards
Project Director PM: Review and approves project documentation.
Project Director Vendor Management: EMR project level management of vendor relationship
across all sub-projects.
Project Director Vendor Management: Enforce compliance with terms and conditions of
contract amendments and agreement letters.
Project Manager Acceptance Criteria: Develop initial high-level acceptance criteria
Project Manager Communications: Provide project plan and schedule updates to project team
Project Manager Meetings: Lead Project Team Meetings
Project Manager PM: Provide project tracking for each affected system and process within
the project scope.
Project Manager PM: Monitor domain management
61
Project Manager PM: Monitor time tracking
Project Manager PM: Support and monitors issue management
Project Manager PM: Support IT Production Readiness process
Project Manager PM: Ensure timely completion of project milestones
Project Manager PM: Maintain project work breakdown structure
Project Manager PM: Maintain the project plan
Project Manager PM: Produce IT Project Deliverables
Project Manager Resources: Work with the project operational owner and/or managers of the
effected systems and processes to ensure resource availability
Project Manager Status Reports: Create
Project Manager Technical Requirements - Assist with development
Project Manager Training: Attend high-level staff training
Resource
Managers
Concerns & Issues: Escalate resource concerns to Project Manager and
Project Director
Resource
Managers
Design: Participate in project change decisions from an organization
perspective
Resource
Managers
Resources: Re-enforce time tracking requirements and other team
responsibilities with their staff
Resource
Managers
Resources: Work with the Project Manager to staff the project appropriately
so timelines and targets can be achieved
62
9.4 Appendix D — Alternate solutions for Integrated systems
Other possible solutions to integrate inpatient, outpatient, pharmacy, labs, radiology etc..
Access to data from all systems through CCDAs and Interfaces
Remote access to all systems
One system for entire organization
One centralized data warehouse (data flows from all information systems)
9.4.1 CCDAs and Interfaces
Build two way interfaces between the inpatient, outpatient, pharmacy, labs, radiology etc.
to receive and send patient data electronically from different systems and save the complete
patient record locally within the inpatient and outpatient systems. Similarly patient data may
also be exchanged between systems through CCDAs.
Advantages:
Complete patient record on the local system.
No manual consolidation of patient information and potential loss of data or
incomplete information.
Seamless data flow between the systems.
Addresses patient safety issues due to lost communication
Disadvantages:
Patient data duplicated in all systems.
New interfaces have to be built every time a new lab, pharmacy or a new practice is
added to the organization
IT staff to maintain all interfaces. Adds cost to maintenance.
63
Rework required on interfaces during any upgrade to the existing systems. CCDAs to
some extent will avoid such rework, but might be impacted by version changes to CCDA
specifications.
9.4.2 Remote Access to all Systems
Providers must be able to remotely connect to all systems (inpatient, outpatient, lab,
pharmacy, radiology…) within the organization to access patient information.
Advantages:
Access to all patient information at any time.
No loss of data since data from all systems in saved in one location.
Disadvantages:
Providers must learn to navigate in the various systems to extract relevant patient
information.
No one location/system for complete patient information.
Management of patient data is cumbersome.
Chances of missing some patient data during patient evaluation and potential patient
safety issue.
9.4.3 One System for Entire Organization
Use one enterprise solution for all departments inpatient, outpatient, pharmacy, lab,
radiology.. etc. All patient data is saved in one system for easy retrieval and analysis.
Advantages:
All data available on one system.
No duplication of patient data.
One source data for data analysis and analytics.
64
Disadvantages:
Cost of implementation is high to move all departments on to one system.
Disruption to patient services is high to move all departments on to an enterprise solution.
The user experience ranking for one enterprise solution for all departments may be lower
when compared to the usability of best of the breed product for individual departments.
Complete dependency on one vendor for all problems. Could be advantageous or
disadvantageous depending on level of customer support from the vendor.
9.4.4 One Centralized Data Warehouse
Having one centralized data warehouse with information flowing from all clinical systems
and financial systems that includes operational and HR data. Research indicates that dashboards
and analytic reports help healthcare organizations focus, track and manage re-admission rates. A
centralized data warehouse provides the necessary infrastructure for such dashboards and reports.
Advantages:
Dashboard to track readmission rates
Inpatient clinical reports
Outpatient clinical reports
Patient experience reports
Cross functional reports
Track patient outcome with respect to financial impact
Track patient outcome with respect to operational and staff changes
Disadvantages:
65
Additional overhead costs to maintain the data warehouse. Expense may be justified if
used not only to track readmission rates but also for disease management of chronic
conditions and other research purposes.
66
9.5 Appendix E—Annotated Bibliography
American Hospital Association. (2011). Examining the Drivers of Readmission and
Reducing Unnecessary Readmissions for Better Patient Care. Retrieved October 7, 2013
from: http://www.aha.org/research/reports/tw/11sep-tw-readmissions.pdf
This article reviews the history of the Hospital Readmissions Reduction Program, and how it was
part of the Patient Protection and Affordable Care Act (PPACA). It also outlined how the
Medicare reimbursement rates will be adjusted for hospitals with higher-than-expected
readmission rates for patients with the included diagnoses. It detailed how a percentage is
calculated, and then the hospital is penalized based on where they lie in conjunction with
national averages. It also detailed information about how these reimbursement adjustments are to
be adjusted based on risks of the patient, including age, gender, history of CABG, and the
concurrence of other medical conditions.
Ben-Assuli, O., Shabtai, I., & Leshno, M. (2013). The impact of EHR and HIE on reducing
avoidable admissions: controlling main differential diagnoses. BMC medical informatics
and decision making, 13(1), 49. Retrieved October 13, 2013 from: http://
www.biomedcentral.com/1472-6947/13/49
This study compares the use of Electronic Health Record (EHR) Information system (IS) and
HIE network by physicians for admission decisions in Emergency Department. As part of the
study 281,750 emergency department (ED) referrals in seven main hospitals in Israel were
analyzed. The study concluded that the number of seven day readmissions and single-day
admissions for all patients were reduced when physicians used EHR IS and HIE network to view
patient’s medical history while making admission decisions.
Centers for Medicare & Medicaid Services. (2013). Quality Measures. Retrieved
November 26, 2013 from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/QualityMeasures/Downloads/Hospitals-and-CAH-2014-Proposed-
EHR-Incentive-Program-CQM.pdf
This is a document that provides in table format all of the initially-proposed Meaningful Use
quality measures for eligible hospitals. It includes details about the measurements, for both the
numerator and denominator, as well as who initiated the quality measure in the first place.
Cloonan, P., Wood, J., & Riley, J. (2013). Reducing 30-Day Readmissions
[Journal]. The Journal of Nursing Administration, 43(7/8), 382-387. Retrieved from: http://
dx.doi.org/10.1097/NNA.0b013e31829d6082
This article gives background about the 30-day re-admissions rule and how this rule
was enacted in the Affordable Care Act of 2010. It further explains the penalties the rule
imposes on providers who don’t reduce the readmission rates.
67
Department of Health and Human Services. (2009). Security 101 for Covered Entities.
Retrieved December 4, 2013 from:
http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/security101.pdf
This article provided a refresher on HIPAA regulations and how they may apply to network and
firewall security of PHI. In particular, the section outlining BA’s and requirements for BAA’s
discussed how data warehouses and health information exchanges may be affected.
Fleming, M., Haney, T. (2013). Improving patient outcomes with better
care transitions: The role for home health [E-Supplement]. Cleveland Clinical Journal of
Medicine. Retrieved from: http://dx.doi.org/10.3949/ccjm.80.e-s1.02
This article explains the role home healthcare plays in reducing the 30-day readmission rates by
working with hospitals to ease the transition of patients at the time of discharge
from hospital to home healthcare.
Gerhardt, G., Yemane, A., Hickman, P., Oelschlaeger, A., Rollins, E., Brennan, N. (2013).
Medicare Readmission Rates Showed Meaningful Decline in 2012. Medicare and Medicaid
Research Review, 3(2), E1-E12.
This article outlines some statistics as they relate to hospital readmissions, including countrywide
readmission rates as well as the financial impact to CMS of unnecessary readmissions. It also
revealed that we have seen a 0.5% drop in hospital readmissions in only a year since it was
initiated.
Good Shepard Medical Center. (2013). Quality: What are Core Measures? Retrieved
December 7, 2013 from: http://www.gsmc.org/quality/.
This is a hospital web page that outlines some of the statistics behind the hospital quality
measures currently reviewed by CMS. It quotes compiled health outcomes statistics that are
directly related to readmissions quality improvements.
Hernandez, A., Greiner, M., Fonarow, G., Hammill, B., Heidenreich, P., Yancy, C., Curtis,
L. (2010). Relationship between early physician follow-up and 30-day readmission among
Medicare beneficiaries hospitalized for heart failure. JAMA: The Journal of the American
Medical Association, 303(17), 1716-1722. Retrieved on October 9, 2013 from:
http://jama.ama-assn.org/content/303/17/1716.full
This article highlighted a study that looked specifically at readmission rates in patients with
congestive heart failure. In particular, it measured average rates of follow-up after discharge,
and found that there is wide disparity between patients in terms of when their follow-up actually
occurs. Additionally, the study found that patients with early follow-up after discharge
universally did better in terms of readmission rates when compared with severity-adjusted peers
who did not have early follow-up.
HIMMS (2012). Reducing Readmissions -Top Ways Information Technology Can Help
Retrieved October 13, 2013 from: http://www.himss.org/files/HIMSSorg/content/files/
68
ControlReadmissionsTechnology.pdf.
This document released by HIMSS discusses the various ways Information technology can be
used to reduce avoidable readmissions. This article identifies various IT tools to help reduce
readmissions and improve patient outcomes. Strategies discussed include Case management,
Communication, Analytics and modeling, Post-acute follow up, Health Information Exchange,
Social Media, Cloud Technology and Mobility, Robotics and Innovation.
Hubbard, T., McNeill, N. (2012). Improving Medication Adherence and Reducing
Readmissions. New England Healthcare Institute Healthcare Brief. Retrieved November
5, 2013 from: http://www.nacds.org/pdfs/pr/2012/nehi-readmissions.pdf
This article provided some of the background history to the Medicare readmission problem, and
specifically numbers about readmission rates and financial indices for how this affects the
healthcare system overall. It includes a discussion about the need for appropriate medication
reconciliation and methods to improve medication compliance at discharge. It identified the
requirement to have an accurate medication list at admission (a list of truly taken medications,
not medications simply prescribed to the patient), and the need to make sure that true
reconciliation occurs at the transition of care. In particular, this article noted that incorrect
medication follow-up is likely one of the largest reasons for readmissions in the country. The
authors noted that we need to take better advantage of the benefits provided by e-prescribing in
order to help medication compliance in patients recently discharged from the hospital.
Jack, B., Passche-Orlow, M., Mitchell, S., Forsythe, S., Martin, J. (2013). Re-Engineered
Discharge (RED) Toolkit. Agency for Healthcare Research and Quality. Retrieved
October 14, 2013 from:
http://www.ahrq.gov/professionals/systems/hospital/toolkit/redtool1.html#
This pamphlet outlines the requirements for the project RED discharge kit. In particular, it gives
some history and background for the initial project, and then provides information to healthcare
providers and hospitals on how they can initiate the same project in their environments. It
outlines the 12 steps to initiating project RED as well as evidence to back up the efficacy of the
project in reducing readmissions and improving patient care.
Jones, S., Friedberg, M., & Schneider, E. (2011). Health information exchange,
Health Information Technology use, and hospital readmission rates. In AMIA Annual
Symposium Proceedings (Vol. 2011, p. 644). American Medical Informatics Association.
Retrieved October 13, 2013 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243133/
This article discusses the results of analysis conducted on a large sample of hospitals to compare
the impact on risk standardized thirty-day hospital readmission rates due to hospital participating
in HIE and HIT use (for medication ordering, laboratory ordering, and clinical documentation).
The study concluded that hospital participation in HIE did not impact the readmission rate, but
electronic documentation was associated with modest reductions in readmission for heart failure
(24.6% vs. 24.1%, P=.02) and pneumonia (18.4% vs. 17.9%,P=.003).
69
Joynt, K., & Jha, A. (2013). A path forward on Medicare readmissions
[Magazine]. The New England Journal of Medicine, 368(13), 1175-1177. Retrieved from:
http:// dx.doi.org/10.1056/NEJMp1300122
This article describes how CMS calculates the 30-day readmission penalties for the three
diagnoses of acute myocardial infarction, congestive heart failure and pneumonia.
Kansagara, D., Englander, H., Salanitro, A., Kagen, D., Theobald, C., Freeman, M. (2011).
Risk Prediction Models for Hospital Readmission, A Systematic Review. Journal of the
American Medical Association; 306(15): 1688-1698.
This article provided an evaluation of many of the readmission predictor tools available today.
The initiation of the Medicare rule stating reduced payments for hospitals with elevated
admission rates essentially spurred a wave of methods to help not only reduce readmissions, but
also to identify those patients who may be more likely to present back to the hospital after
discharge. This article looked at this process overall and really helped to stratify whether or not
these tools impacted outcomes. Interestingly, but not surprisingly, the review determined that it
is really too early in the advent of these tools to say if they are helpful in changing outcomes or
not. Additionally, the reviewers noted that tools that included recommendations for transitional
care interventions for patients that scored higher in terms of likelihood for readmission were
more likely to be of benefit than those that did not. Finally, the reviewers pointed out the
necessity of these tools to calculate risks and enact changes in the care process in real-time, not
retrospectively; they asserted that evaluation after the fact occurs too late in the process to cause
any improvement overall. The BOOST project was mentioned specifically as a tool that shows
promise, although data does not yet fully support the use of it in all hospital admissions at this
time.
Krames Patient Education. (2013). Reducing Hospital Admissions With Enhanced Patient
Education. Retrieved October 14, 2013 from:
http://www.bu.edu/fammed/projectred/publications/news/krames_dec_final.pdf
This is a publication put out by the Krames Company, which outlines patient-education specific
endeavors healthcare providers can undertake to reduce hospital readmissions. They outline a
day-specific method to ensure patients understand their disease process as well as their role in
their healthcare provision. They stress the importance of seamless transitions and printed patient
education in these initiatives.
Logue, M., Drago, J. (2013). Evaluation of a modified community based care
transitions model to reduce costs and improve outcomes [Magazine]. BMC Geriatrics,
13(94), 1-11. Retrieved from: http://dx.doi.org/10.1186/1471-2318-13-94
The article explains how financial impact of penalties for 30-day readmission rates is calculated
by using readmission data for patients suffering from the three diagnoses.
Radawski, D. (1999). Continuous quality improvement: origins, concepts, problems and
applications. Retrieved from http://www.paeaonline.org/ht/action/getdocument action/i/
70
25258
The article describes continuous quality management as a management philosophy and method
that is widely used in different settings. This article further explains that attainment of quality in
healthcare is an ongoing process.
Rudin, R., Salzberg, C., Szolovits, P., Volk, L., Simon, S., Bates, D. (2011). Care transitions
as opportunities for clinicians to use data exchange services: how often do they occur?
Journal of the American Medical Informatics Association, 18(6), 853-858. Retrieved on
October 18, 2013 from: http://www.ncbi.nlm.nih.gov/pubmed/21531703
This article discusses a study that was conducted to evaluate the percentage of visits that
involved care transitions. The study concluded that primary care physicians had an average of
54% of visits involving care transition while specialists had an average of 79% of visits
involving care transition. HIE can play a significant role to aggregate patient records during care
transitions with a medical group or outside the group.
Scott, I. A. (2010). Preventing the rebound: improving care transition in hospital discharge
processes. Australian Health Review, 34(4), 445-451. Retrieved November 1, 2013 from:
http://www.publish.csiro.au/?paper=AH09777
This article discusses the results of a study conducted to compare the impact of peridischarge
interventions on hospital readmissions. The comparison was made between single component
interventions implemented before or after discharge and integrated multi component intervention
which included both pre and post discharge elements. The study concluded that the multi
component intervention covering pre and post discharge workflows targeted at high risk patient
populations was more effective in reducing readmissions.
Stauffer, B., Fullerton, C., Fleming, N., Ogola, G., Herrin, J., Martin, S. (2011).
Effectiveness and Cost of a Transitional Care Program for Heart Failure. Journal of the
American Medical Association Internal Medicine; 171(14): 1238-1243.
This article summarized a randomized controlled trial where a transitional care program was set
up for patients with heart failure. The outcome showed a significant reduction in readmission
rates in patients who were enrolled in the transitional care program as compared to heart failure
patients who were not enrolled in the program.
Silow-Carroll, S., Edwards, J., Lashbrook, A. (2011). Reducing Hospital Readmissions:
Lessons from Top-Performing Hospitals. The Commonwealth Fund. Retrieved October 7,
2013 from: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/
2011/Apr/1473_SilowCarroll_readmissions_synthesis_web_version.pdf
This article provided real-life examples of hospitals and how they worked to improve
readmission rates in light of the new Medicare requirements and reimbursement model
A section noting that all of the hospitals studied put forth significant resources into discharge and
transition of care planning was included. Additionally, the patient education, specifically that
71
related to making sure patients understood their medication regimens and warning signs for
worsening clinical condition, seemed to provide not only improvement in care for the patients
but downstream effects of reduced requirements for acute care.
The HCAHPS Survery. (2013). The HCAHPS Survey: Frequently Asked Questions.
Retrieved December 8, 2013 from: http://www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-
Instruments/HospitalQualityInits/downloads/HospitalHCAHPSFactSheet201007.pdf
This is a publication provided by CMS addresses the HCAHPS survey, and provides information
about the intent of the survey overall. Additionally, it provides the individual pieces of patient
care addressed in the survey and how results are tabulated across organizations.
The Society of Hospital Medicine (2013). Risk Assessment Tool: The 8 P’s. Retrieved
November 3, 2013 from: http://www.hospitalmedicine.org/ResourceRoomRedesign/
RR_CareTransitions/html_CC/06Boost/03_Assessment.cfm
The BOOST project and their Risk Assessment Tool provide a way to stratify readmission risk in
patients at hospital admission. Specifically, the BOOST project’s Risk Assessment Tool relies on
what they call the 8P’s. These include assessment of potential problem medications,
psychological factors, principal diagnosis at the time of admission, polypharmacy, poor health
literacy, patient support, prior hospitalizations, and palliative care. Based on assessment in these
8 areas, the patient is given a score that ultimately determines their need for focused transitional
care at the time of discharge. Additionally, based on the patient scoring, the BOOST project
recommends certain interventions at each category.
Stewart, S., Marley, J., Horowitz, J. (1999). Effects of a Multidisciplinary, Home-based
Intervention on Planned Readmissions and Survival Among Patients with Chronic
Congestive Heart Failure: A Randomized Controlled Study. Lancet; 354(9184):
1077-1083.
This article specifically looks at interventions to decrease readmissions for patients with CHF.
Only those patients deemed to be “high-risk” were included in the outcomes studies. Those
high-risk patients received additional education prior to discharge, thus more “transitional care”
than those patients determined to be normal or low risk. Additionally, this study showed that
those patients who had targeted follow-up (in the home in this case, although I suspect any
targeted follow-up may have resulted in the same outcomes) had markedly reduced readmission
rates, higher quality of life, and lower healthcare expenditures overall.
Tuso, P., Huynh, D., Garofalo, L., Lindsay, G., Watson, H., Lenaburg, D., Kanter, M.
(2013). The Readmission Reduction Program of Kaiser Permanente Southern California—
Knowledge Transfer and Performance Improvement. The Permanente Journal, 17(3), 58.
Retrieved on October 8, 2013 from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783066/
72
This article discusses how Kaiser Permanente Northwest Region (KPNW) and Kaiser
Permanente Southern California (KPSC) implemented the “transitional care” bundle. Using risk
stratification tools to identify patients who are at high risk for readmission and provide care
accordingly. Using standardized discharge summary to close the gap between post discharge and
visit to PCP. Medication reconciliation across continuum of care, post discharge follow up call,
follow-up with primary care physician, transition phone number on discharge instructions, palliative care consult for high risk patients and complex-disease case conference to reduce
readmissions to hospitals.
Williams, M. (2013). A Requirement to Reduce Readmissions Take Care of the Patient, Not
Just the Disease JAMA, 309(4), 394-396. Retrieved October 9, 2013 from:
http://jama.jamanetwork.com/article.aspx?articleid=1558260
This article highlights the various studies conducted on readmissions of patients discharged after
hospitalizations for heart failure, acute myocardial infarction, or pneumonia. Based on the
analysis of Medicare data from 2007 to 2009 it was concluded that 24.8% of patients
hospitalized for heart failure were readmitted, 19.9% patients hospitalized for myocardial
infarction were readmitted, and 18.3% hospitalized for pneumonia were readmitted within 30
days of discharge. Another study funded by CMS engaged hospitals, nursing facilities, home
care agencies, hospices, social service agencies, area agencies on aging, and clinicians for care
coordination. The study concluded that overall hospitalization rates were reduced but did not
impact rehospitalization rates. This could be due to the fact that patients who are hospitalized,
have health conditions that put them at greater risk for rehospitalization. Another study showed
that the average age of Medicare patients admitted with heart failure was 80 years and more than
one-third of those patients had hypertension, diabetes mellitus, or chronic obstructive pulmonary
disease. In conclusion there is no single solution to address all the issues related to
rehospitalization. Patient centered approaches involving all care team members for better care
coordination, and implementation of Project BOOST (Better Outcomes by Optimizing Safe
Transitions) can help deliver higher quality care.