DECREASING MEDICARE READMISSIONS

The Capstone Group

Marinka Bulic - Jyothi Golkonda - Diane Hunt - Aziz Lalji - Emad Osman

INTRODUCTION

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• Readmission rate at University Hospital is

above national average

– Hospital Readmissions Reduction Program will

result in reduced payments if this is not improved

• Program aims to reduce hospital readmissions in patients

with certain diagnoses by reducing payments to hospitals

with higher-than-average readmission rates

• Diagnoses included in this program include

– Acute Myocardial Infarction (AMI)

– Congestive Heart Failure (CHF)

– Pneumonia

BACK GROUND

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• University Hospital is part of a multi-site Accountable

Care Organization (ACO)

• Outpatient clinics in the ACO use Epic EHR

• Hospitals in the ACO use Centricity EHR

• The 3 pharmacies that are part of the ACO receive

eRx and respond back with prescription fill data.

• 3 labs are part of the ACO

– Labs receive electronic orders and report back electronically

to the EHRs

– Terminology is not consistent within the three labs. All three

labs use different terms and different test combinations.

IMPACT

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• Financial

– Cost to the hospital if readmission rates not

improved over the next 3 years

• 2013: $130,000

• 2014: $265,000

• 2015: $409,000

– Total projected losses of $803,000

• Clinical

– Quality measure metrics below national standards

as well, impacting reputation of organization overall

GOAL

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• To reduce admissions in patients with AMI,

CHF, and pneumonia from 21% to 10% over

the next two years

CLINICAL WORKFLOWS AND OPERATIONS

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• Discharge Medications Process

– Opportunities for improvement at all transitions of

care

• Standardize admission medication reconciliation to

improve discharge medication reconciliation process

• Utilize e-prescribing at discharge

• Enhance pharmacy to primary care provider

communication in cases where prescriptions are not filled

appropriately

CLINICAL WORKFLOWS AND OPERATIONS

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• Transition Planning

– BOOST model to assess risk for readmission at

time of presentation

• Utilize Clinical Decision Support tools within the EMR

system to stratify patients based on risk

• Specialized transitional care program from time of

admission based on individual risk factors

– Development of Transitional Care Team to

individualize care plans from time of presentation

• Facilitate follow-up post discharge

• Help with financial and social barriers at home

CARE COORDINATION

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• Primary Care Providers

– Incentivize Primary Care Providers to see

discharged patients within 72 hours of discharge

• Helps to ensure follow-up during most critical point of

transition from inpatient to outpatient care

– Encourage effective information exchange between

acute and ambulatory care settings with integrated

EMR system

CARE COORDINATION

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• Home Healthcare Providers

– Develop partnership with entities that can provide

care to patients after discharge from the hospital

• Home Healthcare intervention can start within 24-48 hours

post discharge

– Care Transition Coordinator (CTC) to help

coordinate patient care during transition from

hospital to home healthcare

CONTINUOUS QUALITY IMPROVEMENT (CQI)

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• Quality improvement program to evaluate

current processes and improve systems and

processes

– Outcome to reduce readmissions

– Monitor care coordination data

– Determine the effectiveness of the proposed

solutions

COST VS. BENEFITS ANALYSIS

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• Benefits

Before Implementation After Implementation

Overall readmission rate 21.33%

Overall readmission rate 11.73%

Readmission rate with one or combination of three diagnoses 65%

Readmission rate with one or combination of three diagnoses 36%

Medicare penalties $813,073

Medicare penalties $250,176

COST VS. BENEFITS ANALYSIS

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• Costs of implementing proposed solutions

– $470,000

• Savings from implementing proposed solutions

– $562,897

• Return on Investment (ROI)

– 20%

CMS MEASURES

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• Goal of the measures is to reduce the

readmissions rates of patients 30 days post

discharge

• Financial incentive

• Measures are implemented at various steps

during a patient’s visit including:

– At admission

– During care

– Discharge

– Post Discharge

CHRONIC HEART FAILURE

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• 1,900 patients hospitalized at University

Hospital annually with a 5% mortality rate.

• Measures include:

– Left ventricular function assessment

– Monitoring of diet/fluid intake

– Medication reconciliation

ACUTE MYOCARDIAL INFARCTION

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• 2,000 of patients admitted are due to AMI

• ⅔ of patients do not make a complete

recovery

• Great potential measure to increase quality of

care

• Measures include:

– Aspirin at arrival

– Beta blocker prescription

– Adult smoking cessation counseling

PNEUMONIA

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• 4th leading cause of deaths in patients 65 + in

the area

• Measures

– Vaccine status for influenza and pneumonia

– Antibiotic timing with 6 hrs of arrival

– Smoking cessation counseling

PATIENT SURVEY

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• HCAHPS - Hospital Consumer Assessment of

Healthcare Providers and Systems

• National standard of collection patient

satisfaction

• Public reporting creates:

– Competition amongst hospitals to create better care

– Transparency which allows patients to chose the

better hospital for their care

PATIENT EDUCATION

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• Education includes:

– How to take their medication

– Follow up appointments

• 30% drop in ED readmissions when patient receive

education

• Project RED - Re-Engineered Hospital Discharge Program

Pilot Program

– Follow-up appointments

– Confirmation of medication routines

– Understanding diagnosis

– Results:

• from the 370 participants, there was a 30% fewer readmissions

• 94% of patients had a follow-up appointment with their primary care

physician

INTEGRATION OF SYSTEMS

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• Use CCDAs to exchange patient data between University

Hospital (using Centricity system) and the primary care

physicians or home healthcare providers (using Epic

systems)

• Work with the labs to formulate the standard terminology

(for example CPT codes for procedures, LOINC codes for

labs with a standard unit of measure) for data exchange

between the clinics/hospitals and the labs

• Add a data warehouse to collect data from labs,

pharmacies, hospitals and outpatient clinics

DATA FLOW DIAGRAM

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USE CASE DIAGRAM

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PROJECT PLAN

Medicare Readmission Reduction: Timeline

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

MRR

Univ.

Health

Projects

Go Live

MU Stage

2

Planning

Design PLAN BUILD

2014

TODAY

PREP, TEST & TRAIN

ICD-10

Go-Live

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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

- ITS Clinical Applications

Program 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

ASSUMPTIONS

• Accurate and Timely Documentation – For decision support logic to be effective, To be effective, the data in the

patient record will need to be wholly, accurate and timely.

• Decision Support – For the project to be effective the care instructions developed as part of the

MRR initiative will need to be reviewed and executed accordingly.

• Integration – Project assumes significant investment in integration and interoperability

efforts between both systems and standardization of data standards

CONSTRAINTS / LIMITATIONS

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• Data Standards – In the current state the University Health existing architecture hosts (2)

separate EMRs. This is identified as a limitation to this project with regards to

the lack of standardization of data across both EMRs.

Recommendation • 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 – With the existing architecture and use of (2) separate EMRs, clinician’s

application workflow, data mining/reporting will be constrained.

Recommendation

• Significant investment and time into the development of future state

workflows and development of clear policies and procedures for use of

both EMRs.

KEY GROUPS

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ROLES / RESPONSIBILITIES

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RISKS

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SYSTEM REQUIREMENTS

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• General

– Integrates with existing Centricity and EPIC EMR architecture

• Integration

– Full integration ability with all ancillary systems

• Decision Support

– Alert Functionality based on core measures identified

• Printing

– Patient Discharge Summary

• Workflow

– Complies with ICD-10 documentation requirements

– Complies with MU requirements

• Reports

– Ability to assess increase/decrease of readmission within core measure

population

TESTING

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• The objectives of testing for the University Hospital Readmission Reduction

project are to: – Document that the system reliably and repeatedly performs as designed.

– Ensure regulatory documentation standards are met.

– Verify business and system requirements are satisfied.

– 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

• Unit Testing – focus on application components (i.e. a unit of functionality) as they are built.

• Application / Functional Testing – Confirms that the component functions of the product/application perform to meet the business and

technical design requirements.

• Regression / Performance Testing – Performance Testing validates the ability of the application to function under maximum volumes and

peak transaction loads.

• 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.

TRAINING

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• Training Plan –

– The training strategy will have two core focuses:

• Curriculum Development

– Developed by SME’s, Analysts

– Based on Stakeholder Analysis

• Education

– Classroom

– Online

– Self-Study

– Job Aids

– Blended solution of classroom and online

DEPLOYMENT

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• Recommendation

– Deployment of the MRR project will be a big bang approach of

implementing ALL functionality at once, commonly known as a

big bang approach.

• Fully Staffed Command Center

• At the elbow support for end-users

• Command Center team responsible for triage of service requests,

troubleshooting, testing and education needed.

The Capstone Group

Marinka Bulic

Jyothi Golkonda

Diane Hunt

Aziz Lalji

Emad Osman

1 Research park, Chicago, IL 11111

Phone: 666-555-4444

Email: capstone@cg.com