realtime readmissions feedback at penn medicine – making the data “actionable” university of...
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Realtime Readmissions Feedback at PENN Medicine –
Making the Data “Actionable”
University of Pennsylvania Health SystemUniversity of Pennsylvania Health System
Presented by:
Victoria L. Rich, PhD, RN, FAAN
Chief Nurse Executive
University of Pennsylvania Medical Center
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Who we are
PJ Brennan, MDChief Medical Officer & Senior Vice PresidentUniversity of Pennsylvania Health System
Victoria Rich, PhD, FAAN, RNChief Nursing Executive, University of Pennsylvania Medial CenterAssociate Professor, University of Pennsylvania School of Nursing
Joan Doyle, MBA, MSN, RNExecutive Director, Penn Home Care and Hospice ServicesUniversity of Pennsylvania Health SystemAssistant Dean for Clinical Practice, University of Pennsylvania School of Nursing
Linda May, PhDPrincipalCFAR
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Penn Medicine — Philadelphia, PA
School of Medicine
University of Pennsylvania Health System
Hospital of the University of Pennsylvania
#9 US News
Magnet
Pennsylvania Hospital
Penn Presbyterian Medical Center
Penn Home Car & Hospice Services
Adult admissions — 77,500
Employees — 12,700
Admissions — 18,000
Employees — 450
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Penn Medicine is working to improve Transitions-in-Care from hospital to home — and prevent readmissions
The aim is to keep patients safe and stable and give them a safe “medical landing”
It’s the right thing to do for our patients — AND we’re trying to get ahead of the curve for the new world of healthcare
What we’re learning will give us a head start in a new healthcare environment of ACOs and bundled payments.
Preadmission Hospital Stay Post-acute Care
Admission Discharge “Medical Landing”
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Realtime readmissions feedback is at the heart of our model for Transitions-in-Care
UPHS Transitions Model — Seven “Levers”
Screen for patients at greatest risk
Real-time readmis-sions feedback to actively manage patients
Interdis-ciplinary care planning
Links to post-acute follow-up services
Primary care follow up
Med mgmt across the contin-uum
Educa-tion & red flag mgmt
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It starts with the daily readmissions reports — but the report is the “least” of it
Daily Readmissions Report
Readmitted patients (across all three hospitals) — with chief complaint, facility, unit, service, attending
Detailed history of previous admissions
Full report is distributed each morning to Discharge Planners, Homecare and others.
Each hospital unit gets a tailored version, with just its own patients.
It’s the organizational “machinery” that makes the data actionable
But …
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Today’s talk about making the realtime readmissions data actionable has three parts
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“Changing the way we work”
“Speaking with a united clinical voice”
“Mobilizing other people’s energies”
The story of frontline leadership
The story of the CMO/CNO Alliance
The story of the Transitions Steering Group
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1 Changing the way we work
The story of frontline leadership
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In-the-moment and long term
Daily Troubleshooting
Readmissions data are available in time to take action on specific cases
Long-term changes to clinical practice
Tools, standards, education, faster turnaround, tighter feedback loops — based on opportunities we see in the data
UPHS Transitions Model — Seven “Levers”
Screen for patients at risk
Real-time readmis-sions feedback
Interdis-ciplinary care planning
Links to post-acute follow-up services
Primary care follow up
Med mgmt across the continuum
Education & red flag mgmt
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“”
— Executive Administrator
Findings with feet …
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Daily troubleshooting
At the System Level
Discharge Planners review every UPHS readmission, every day
Homecare/Hospice review every one of their readmissions, every day
On the phone with each other daily to troubleshoot specific patients
Hospice dispatches a team to investigate its patients, along with the inpatient medical team
Discharge Planners interview readmitted UPHS patients.
They’re learning that most patients don’t see the link between readmission and things like not taking their meds. This is a teaching opportunity
For example, a general medicine/telemetry unit started interviewing each of its readmitted patients to learn why the patients themselves thought they came back into the hospital
On the Individual Hospital Units
This got picked up at the system level
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Long-term changes to clinical practice
For example, here’s how Hospice is changing the way It works …
Hospice conducts regular case conferences to understand why their patients are readmitted.
They’ve learned that many are coming back because of pain or dehydration.
Hospice has developed a tool to indentify their patients at greatest risk for readmission.
Hospice is building in new practices for those high-risk patients:
• Frontloading visits
• Proactive phone calls
• Educating staff
• Tighter feedback loops
And they’ve developed a tool for patients to help them know when to call if their symptoms are getting out of control.
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What’s next? Two things on our plate …
Building out the daily review process on the hospital units
Making common cause with the Cardiac Oncology Service Lines
Who’s responsible? If the daily readmissions report goes to “everyone,” it might as well go to “no one.”
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What actions are “automatically” taken for a readmitted patient?
What interventions are triggered — Homecare referral? Patient education? Discharge safety check? Follow-up phone call?
How can we share their readmissions data so it’s “hearable” and “actionable”?
How can we tap into what the service lines are already planning to do?
How can we shape what they’re doing?
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A funny thing is happening along the way — we’re breaking down our silos and collaborating in new ways
From To
DischargePlanners
Homecare/ Hospice
UnitLeadershipTrios
ServiceLines
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So, what does it take to make the readmissions data “actionable”?
1 Changing the way we work
Daily troubleshooting to take action on specific cases
Tracking and trending the readmissions data to identify longer-term interventions
Making changes to clinical practice — tools, standards, education, faster turnaround, tighter feedback loops
Along the way, breaking down our silos and collaborating in new ways
Realtime readmissions data — the report is the “least” of it
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It takes a village — and the village is here today
HCHS, GSPP and other post-acute providers
and their unit-based partners:
Other senior leaders from CRM/SW, IS, HR, Pharmacy, Quality, HCHS, Operations
Med/Surg UBCLs —
CRCs/SWs
Pharmacists
Educators/ Clin Specs
AP Nurses
Infection ControlPeople who have been developing tools & resources
Other outpatient stakeholders
IBC, AETNA
CMO/CNO Alliance
Transitions Steering Group
Medicine Residents Quality Track
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“Changing the way we work” — lessons learned
Collaboration at the local level didn’t happen overnight. One day at a time, we earned new reputations for what each other could bring.
We focused on the work — which led to new ways of thinking about each other.
It’s not just about “educating” each other. The best way to collaborate was to work together on common problems — and bring our clinical expertise to bear.
It’s easier to “act your way to new thinking” than to think your way to new actions.
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But frontline actions, by themselves, aren’t enough …
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2 Speaking with a united clinical voice
The story of the CMO/CNO Alliance
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The CMOs and CNOs have banded together across the continuum of care
The CMO/CNO Alliance spans the care continuum:
• All three hospitals• Penn’s homecare and hospice
services
• Penn’s rehab facilities
• Physician practices
CMO/CNO Alliance
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The CMOs and CNOs set clinical direction for UPHS — with Transitions-in-Care as a major element
UPHS Blueprint forQuality and Patient Safety
Reduce mortality and reduce 30-day readmissions
Four Imperatives Priority Actions
1. Transitions in care
Transition planning
Med management
2. Reduce variations in practice
Reduce hospital-acquired
infections Reduce medication errors
3. Coordination of care Interdisciplinary rounding
4. Accountability Unit clinical leadership
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To bring clinical strategy to the frontline, we’ve established “local leadership” on each hospital unit
Leadership Trio on Each Hospital Unit
We call these trios “UBCLs,” for “Unit Based Clinical Leadership”
We needed a multi-purpose solution on the units to handle almost any Quality problem.
This isn’t a project, it’s a way of doing things. You can bolt different strategies onto it.
—UPHS CFO
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We started modestly on purpose so the leadership trios could learn to work with each other
Weekly operations meeting of the Physician Leader, Nurse Leader, Project Mgr. for Quality
Interdisciplinary rounding
Orienting house staff
Two improvement projects
2007 2008 2009 2010
13 pilot units in 2007
The job:
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Today we’ve covered the house and the trios are ready to take on Transitions, a major system-wide initiative
2007 2008 2009 2010
Today it’s 34 “official” units — and another dozen who are “operating as.”
The job: Today the trios manage Quality on the unit, drawing in others as needed.
UBCLs are ready this year to shoulder Transitions in Care, a major system-wide initiative.
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“Choice within a framework” — each year we develop targets and work with the hospital units to pick theirs
UPHS Blueprint for Quality and Patient Safety
Reduce mortality and reduce 30-day readmissions.
Four Imperatives
Priority Actions
Transitions in care Transition planning Med Management
Reduce variations in practice
Reduce hospital-acquired infections
Reduce med errors
Coordination of care
Interdisciplinary rounding
Accountability Unit clinical leadership
Transitions in Care — FY’11 Targets
Risk stratification — screening tool and daily review of realtime readmissions
Discharge time out Discharge communication Med rec on discharge HCAHPS medication domain
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“Focusing attention” — we negotiated a Transitions metric in every senior leader’s incentive plan
Hospital 1
Hospital 2
Hospital 3
Threshold (3%)
Target (5%)
High Performance (10%)HPHP
HP HP HP
METRIC: Increase referrals to post-acute services (homecare, hospice, rehab, SNF, infusion, LTAC)
We picked this metric because it supports a key element of our Transitions model — and because Penn could measure it.
We’re setting the stage for a more ambitious “readmissions” metric next year.
Q1 Q2 Q3 Q4
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Quality outcomes are moving in the right direction — including the ones focused on Transitions-in-Care
MORTALITY INFECTIONS LENGTH OF STAY READMISSIONS
PEER RECOGNITION
PATIENT & STAFF SATISFACTION
REFERRALS TO POST-ACUTE CARE
P4P IS ON TRACK
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We’re getting out ahead of the budget cycleand negotiating with a united clinical voice
The old way The new way
First step — set margins for each hospital or other entity. Entities are locked in.
Discussion of system-wide quality initiatives before margins are set.
Entities (separately) submit budgets.
CMOs and CNOs submit a joint budget for system-wide quality initiatives they all agree on.
Negotiation — across entities and with Finance — occurs after budgets are submitted.
Negotiation occurs before budgets are submitted.
We’re making our job AND the CFO’s job easier.
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We’re bringing payers to the table
Paying for the Naylor Transitional Care Program
Sharing the gains
A major insurance company pays Penn to provide the “Transitional Care” (Naylor model) follow-up program to its patients.
In this program, the same advanced practice nurse follows patients before and after discharge.
Penn has also negotiated an agreement with the insurance company to share the savings when patients are able to stay out of the hospital.
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So, how are we aligning infrastructures and supports to make readmissions data “actionable”?
2 Speaking with a united clinical voice
CMO/CNO Alliance across the continuum of care
Local leadership on each hospital unit — Physician Leader, Quality Project Manager
Quality redesign to dedicate a Quality Project Manager to each hospital unit
Bringing the payers to the table
Realtime readmissions data — the report is the “least” of it
Negotiating the budget with a united clinical voice
Clinical strategy — with Transitions-in-Care as a major element
Metrics as feedback — each hospital unit and each senior leader know where they stand
Aligning quality metrics across the system, including senior leaders’ incentive targets
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Speaking with a united clinical voice —lessons learned
To paraphrase James Carville:
It’s the work, stupid.“
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A united clinical voice is based on actions, not just words.
We started with the work — developing the Blueprint, establishing the unit teams, setting the metrics, negotiating the budget.
Succeeding at the work is what turned the CMOs and CNOs into a real leadership team that could speak with a united voice.
That’s very different from trying to do it the other way around.
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But leadership at the top But leadership at the top isn’t enough …isn’t enough …
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3 Mobilizing other people’s energies and keeping the moving parts aligned
The story of the Transitions Steering Group
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The Transitions Steering Group is in the integration business
This interdisciplinary group of senior leaders:
• Sets direction for Transitions-in-Care
• Integrates the moving parts
• Opens doors at the system level
• Troubleshoots to keep things on track
Transitions Steering Group
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We developed UPHS’ Transitions Model as a framework — with realtime readmissions feedback at the heart
UPHS Transitions Model — Seven “Levers”
Screen for patients at greatest risk
Real-time readmis-sions feedback to actively manage patients
Interdis-ciplinary care planning
Links to post-acute follow-up services
Primary care follow up
Med mgmt across the contin-uum
Educa-tion & red flag mgmt
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We’re mobilizing “other people’s energies.” Our biggest job is keeping them aligned.
INTERNAL
EXTERNAL
Knowledge-Based Charting (HER protocols & tools) under development
Transitions Collaboratives — active operational arms
Penn Medicine Leadership Forum “action learning” Transitions projectsCMO/CNO
Alliance across the continuum of care
Unit-based Pharmacists Med Mgmt
redesign
Bundled payments and ACOs are on the horizon
Payers willing to fund follow-up programs and negotiate gain-sharing arrangements
Pay-for-performance contracts
Public reporting influences patient choice
CMS penalties for readmissions will begin in 2012
TRANSITIONS IN CARE for better patient outcomes & reduced readmissions
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For example — We took advantage of Penn’s flagship leadership development program
Penn Medicine Leadership Forum is targeted this year to the unit-based leadership teams — along with homecare and other partners
This year the strategic initiative is Transitions-in-Care. Each team took on a project to improve Transitions on a specific hospital unit.
“Action Learning”
• Innovation• Strategic orientation• Execution• Relationship mgmt
The purpose of Penn Medicine Leadership Forum is to develop leadership skills …
… and apply them to a strategic system-wide initiative
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“Test beds” — each team tested an aspect of the Transitions Model. All over the place, but look at the energy!
UPHS Transitions Model — Seven “Levers”
Screen for patients at risk
Real-time readmis-sions feedback
Interdis-ciplinary care planning
Links to post-acute follow-up services
Primary care follow up
Med mgmt across the continuum
Education & red flag mgmt
Transitions Projects for Penn Medicine Leadership Forum
Real-time readmission analysis and intervention
End-of-life goals of care
Screening tool for post-acute referrals
House staff awareness of homecare & hospice services
Improve internal Transitions
New approaches to interdisciplinary care planning
Team-based Discharge Planners
“Opt-out” for homecare referral
Post-discharge phone calls
Discharge “time out” safety check
Follow-up appointments with primary care
Discharge summary follows patient to post-acute services
Medication management across continuum
Patient & family education, with emphasis on self management
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To pull it all together, we turned the teams’ work into an integrated Transitions process for the health system
Preadmission Hospital Stay Post-acute Follow-up
Admission Discharge Medical “Landing”Work as far
“upstream” as possible — prior to admission where that makes sense.
Risk stratification
Interdisciplinary rounds
Patient and family education
Discharge communication
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Screening on admission
Daily review of realtime readmissions report
Plan of care looks ahead to post-discharge
Referral to post-acute care as early as feasible
Education for post-discharge care and meds, with emphasis on self management
Med reconciliation on discharge
Discharge safety check (for high-risk patients)
Discharge summary to primary care & post-acute
Schedule appointment with primary care(for high-risk patients)
Follow-up phone calls (for high-risk patients)
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We can’t implement the new Transitions process all at once — so where to start?
The readmissions data helped us decide where to focus first:
Readmits and the top 10-20% at greatest risk for readmission
The “big three” diagnoses that will affect CMS payments for readmissions in 2012 — Heart Failure, Heart Attack, Pneumonia
Two Penn service lines with the biggest impact on those three diagnoses — Cardiac and Oncology
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We’re learning a lot from the readmission data. Some things have surprised us …
Readmits and the top 10-20% at greatest risk for readmission
The “big three” diagnoses that will affect CMS payments for readmissions in 2012 — Heart Failure, Heart Attack, Pneumonia
Two Penn service lines with the biggest impact on those three diagnoses — Cardiac and Oncology
Readmits are younger than we expected. Two-thirds are younger than 65. One-third are younger than 49.
Link between Oncology and Pneumonia. Analysis of our Pneumonia readmits shows that almost a third are on the Oncology service.
And overall analysis of readmits shows that 30% are Oncology
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So, how are we using other people’s energies to make the readmission data “actionable”?
3 Mobilizing other people’s energies
Transitions model as a framework — seven “levers” that make the biggest difference
Tapping into other people’s projects and efforts — and keeping the moving parts aligned
Leadership development in “action-learning” mode
Tracking and trending the readmissions data to figure out where to focus first
Realtime readmissions data — the report is the “least” of it
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Mobilizing energies — lessons learned
By tapping into other people’s efforts and projects, you can create results and critical mass as you go.
You get change that sticks, because people are creating it themselves.
You don’t have to do all the work yourself.
Your job is to align what might otherwise work at cross purposes.
Tapping into other people’s energies and momentum creates “pull” for the changes you want to make. Other people pull the changes along.
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It takes a village — and the village is here today
HCHS, GSPP and other post-acute providers
and their unit-based partners:
Other senior leaders from CRM/SW, IS, HR, Pharmacy, Quality, HCHS, Operations
Med/Surg UBCLs —
CRCs/SWs
Pharmacists
Educators/ Clin Specs
AP Nurses
Infection ControlPeople who have been developing tools & resources
Other outpatient stakeholders
IBC, AETNA
CMO/CNO Alliance
Transitions Steering Group
Medicine Residents Quality Track
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This is our moon shot…
Blueprint for Quality & Patient Safety (2.0)
Penn Medicine will eliminate preventable deaths and preventable 30-day readmissions by July 1, 2014.
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Patient Navigation
There is no accepted definition
Role established in 1990 by a Harlem physician to
assist indigent cancer patients.
However, “Navigators do things for patients by
working with the patients and others in both the
social network of the organization and in the
community.”
Health Services Research
Trust
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Emerging Roles for Nurses Across the Care Continuum
A. Inpatient Care setting
B. Across settings
C. Outpatient
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A. Inpatient
I. Inpatient Care Coordinator
Also Called: Primary Care Coordinator, Patient Care Coordinator, Unit Based
Care Manager, Hospital-Based Case Manager
Capsule Description: Serves as a primary contact for physicians and other care
providers; responsible for managing patient care needs and
progress, care plan development and discharge planning
Key Functions/Attributes: - Interacts with patients and families throughout the length of stay
- Collaborates with other medical staff face-to-face as
needed
Individuals Commonly Deployed: Social Worker, Case Manager, RN with BSN, RN with MSN and
CNL licensed
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B. Across Settings
II. Inflection Point Navigator
Also Called: Nurse Life Care Planner
Capsule Description: Provides guidance to patients, families and physicians during acute
inflection points in healthcare (such as cancer diagnosis) or catastrophic
illness
Key Functions/Attributes: - Works independently of hospital systems
- Act as consultants for businesses, families or courts of law
Individuals Commonly Deployed: RN
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B. Across Settings (con’t)
III. Disease-Specific Chronic Care Coordinator
Also Called: Diabetes Coach, Chronic Disease Manager, Asthma Coach
Capsule Description: Counsels patients regularly regarding disease-related symptom
management and advises patients on lifestyle choices to improve
prognosis
Key Functions/Attributes: - Meet with patients on a monthly basis (at minimum)
- Provide disease management over the phone and in person
Individuals Commonly Deployed: Community Member, Pharmacist, RN, licensed NP
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C. Outpatient
IV. Co-morbidity Chronic Care Coordinator
Also Called: RN Chronic Care Coordination (CCC) Coordinator, Health Coach,
Team Member, Case Manager
Capsule Description: Follows patients deemed heavy users of expensive inpatient care due to
multiple chronic illnesses, high ED utilization or recent discharge from a
SNF; promotes more active and informed patient role in self care
Key Functions/Attributes: - Provides assistance via the telephone
- Conducts in-home visits and office appointments as needed
Individuals Commonly Deployed: Community Member, Medical assistant, RN, Social Worker, Case
Manager
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C. Outpatient (con’t)
V. IT Based Care Coordinator
Also Called: Telehealth Nurse
Capsule Description: Utilize technological resources to prevent complications associated with
chronic health conditions to avoid hospital admissions.
Key Functions/Attributes: - Performs initial visit in person during first week of care
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Reference: Hall, G et al., “Working Statement Comparing the Clinical Nurse Leader sm and Clinical Nurse Specialist Roles: Similarities, Difference and Complementarities”, December 2004, available at: http://www.aacn.nche.edu/cnl/pdf/CNLCNSComparisonTable.pdf, assessed July 20, 2011
Role CNL (generalist) CNS (expert)
Education RN prepared at the Master’s degree level as a generalist
RN prepared as an advanced practice nurse (APN) in a clinical specialty at the Master’s, post Master’s or Doctoral level
Direct Manager Unit Administrator or Nurse Manager Specialty Area Administrator or CNO
Function Provides and manages treatment at the point of care for patients, families and communities as a generalist Implements the principles of “mass customization” to ensure consistency of clinical care within populations
Expert clinician in a particular specialty or subspecialty ; functions as an expert Provides knowledge and expert skill in a specialized area to nurses and other member of the multidisciplinary care team for complex or critically ill patients
Patient Focus Coordinates care for patient individuals and patient cohorts
Designs, implements and evaluates patient-specific and population based plans of care
Clinical Area of Practice
Hospital units/wards, outpatient clinics or home health agencies
Entire facility
Key Activities Assess and modify to patients’ care plan as necessary Perform patient and family education
Accountable for care delivered and outcomes of care for specified cohorts of patients
Lead multidisciplinary groups in formulation and implementation of solutions to address system issues concerning patient care delivery Act as consultant to other nursing and medical staff in a specific area of specialization for complex diagnoses or critically ill patients
Common Cross-Continuum Roles
Inpatient Care Coordinator, Unit Based Care Manager
Disease-Specific Chronic Care Coordinator
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Community Health Care Community Health Care
Worker - Worker -
The Future of Transitions The Future of Transitions
In CareIn Care ????????
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General Services Provided by aPatient Navigator
Facilitating communication among patients, family members,
survivors and healthcare providers
Coordinating care among providers
Arranging financial support and assisting with paperwork.
Arranging transportation and childcare.
Ensuring that appropriate medical records are available at medical
appointments.
Facilitating follow-up appointments.
Community outreach and building partnership with local agencies
and groups.
Ensuring access to clinical trials.
Thank You….