Reducing Patient Readmissions

Keys to Improving Patient Care

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Overview

• Impact of the Patient Protection and Affordable Care Act (PPACA) on your facility

• Critical strategies to reduce readmissions

Objectives

• Review the impact of PPACA• Identify key strategies and tactics for

reducing readmissions that can be applied in their organizations

• Describe actionable strategies for engaging community organizations across the continuum of care

• Strengthen patient involvement in their care

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Health Care Reform Legislation

• March 23, 2010=PPACA Paying for quality instead of quantity Financial penalties Community based care transitions program

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Affordable Care Act and Reducing Readmissions

• §3026 http://www.innovations.cms.gov/initiatives/Partnership-

for-Patients/CCTP/index.html?itemID=CMS1239313• §3501

http://www.ahrq.gov/qual/patientsafetyix.htm• §399KK

http://www.pso.ahrq.gov/• §3025

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Patient Safety Organization (PSO) Role

• §399KK implementation• ACA designates PSOs to help hospitals

Department of Health and Human Services supports the PSOs

• To find a PSO http://www.pso.ahrq.gov/listing/psolist.htm

• Eligible hospitals http://www.cms.gov/DemoProjectsEvalRpts/

downloads/CCTP_FourthQuartileHospsbyState.pdf

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Readmission Reduction Program

• NQF endorsed measures • Report all-payer readmission rates publicly• Excess vs. expected

For more information: www.QualityNet.org

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2012 Hospital-Specific Report Example

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The Reason Behind Readmissions

• Hospitals have responsibilities, but they are not alone

• Readmissions occur when: Patients don’t understand or can’t comply

with discharge instructions Patients in some communities lack access to

primary care, post-acute care, pharmacies Patients have multiple diagnoses that make

them more vulnerable to complications

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Published Evidence

• Four broad categories Enhanced care and support during transitions Improved patient education and self-management Multidisciplinary team management Patient-centered care planning at the end of life

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Key Strategies and Tactics (continued)

• Assess your risks Patient Hospital Financial

http://rarereadmissions.org/

• Understand your readmission history Evaluate potential cause and appropriateness of

recent readmissions http://www.ihi.org/knowledge/Pages/Tools/

HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx

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Key Strategies and Tactics (continued)

• Timely discharge summaries• Lengthen the handoff process• Provide medication on discharge• Make a follow-up plan before disharge • Telehealth• Identify frequent flyers

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Key Strategies and Tactics (continued)

• Understand what’s happening post-discharge • Provide home care on wheels• Consider physician medication reconciliation• Ensure patients understand • Focus on highest-risk patient • Listen to the patient

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Where the Gaps Are: Other Factors

• No longer does one practitioner typically take responsibility for the discharge and follow-up

• Discharging practitioners may be unfamiliar with the capacity to provide care in settings to which they send patients

• Lack of a universal electronic health information system

• The revolving door of skilled nursing facilities

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The Best Transition…

Is only as good as the reception into the next setting of care.

Boutwell A and Johnson MB: STAAR Issue Brief: Reducing Barriers to Care Across the Continuum–Working Together in a Cross-Continuum Team.

STAAR Issue Brief Series 2010 Number 3. Available at http://www.ihi.org/offerings/Initiatives/STAAR/Documents/

STAAR%20Issue%20Brief%20-%20Cross%20Continuum%20Teams.pdf

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Cross-Continuum Teams (CCTs)

• Key component of the State Action on Avoidable Rehospitalizations (STAAR) initiative

• Team composition • Infrastructure

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Cross-Continuum Teams

• Multi-stakeholder team • Provides oversight and guidance • Known as the “STAAR Effect” • New competencies developed

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Key Changes

• Enhance assessment of post-hospital needs • Effective teaching and learning • Ensure follow-up • Real-time handovers

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Avoid Rehospitalization.

Cambridge, MA: Institute for Healthcare Improvement; June 2012. Available at ww.IHI.org

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Transitions Home Collaborative Getting Started

• Executive leader selected • Sponsor convenes the team • Opportunities for improvement identified • Aim statement developed • Kick-off meeting

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CCT Recommendations

• Meet regularly • Visit each other’s sites • Complete periodic diagnostic interviews• Add patients and family members

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Questions to Ask

• How can we get timely and relevant information from community providers?

• Do we have universal patient-friendly education materials for common conditions in all settings?

• Are staff members competent in effective teaching and facilitating learning?

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Questions to Ask (continued)

• Have we co-designed real-time handover communications

• Do we utilize universal format for patient care plans?

• Who is the best clinical provider to complete follow-up phone calls?

• How do we collaborate with payers and post-acute providers to determine eligibility for certain populations?

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Where the Gaps Are: Health Literacy

• “Health (il)literacy”: Nearly half of adults have trouble understanding simple health information (procedure consent, prescriptions, oral instructions)

• Less than half of patients discharged from academic general medicine know their diagnoses, treatment plans, or side effects of prescribed medications

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The High-Risk Patient

• History of readmission • Failed teach-back • Longer stay than expected • High-risk conditions • Poor, disabled, or on dialysis• Late follow-up after discharge

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Engaging the Patient: Health Literacy

• Red flags: Elderly Low income Unemployed Minority Did not finish high school Immigrant Born in U.S. but English second language Noncompliance Can’t name meds “Forgot my glasses…will read later”

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Engaging the Patient: Communication

• Eight steps for oral communication: 1. Slow down2. Plain language3. Pictures4. Limited information5. Repeat6. Teach-back7. Provide oral and written information 8. Shame-free environment

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High-Level Opportunities for Action

• Execute an effective transition from the hospital to post-acute care settings Early assessment of discharge needs More intensive management of chronic medical

conditions during hospitalization Evidence:

Transition coaching Nursing phone call follow-up Hospital-generated phone call and coaching Collaboration between sending and receiving facilities

on what data is needed during transfers

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High-Level Opportunities (continued)

• Facilitate timely follow-up care in the post-discharge setting Work with outpatient providers to schedule

appointments prior to discharge Consider early follow up for “high-risk” patients,

which may be hospital-generated call Increase referral to home health when indicated Consider enhanced outpatient support

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High-Level Opportunities (continued)

• Engage patients and caregivers as active participants and managers of their care Include medications How to monitor for and act on clinical deterioration Use of hospital-based enhanced assessment Early and repeated teaching opportunities

during hospitalization Assess patient’s understanding

Condition, diet/medications, and symptoms

Readmission Is an Opportunity

• Fragmentation of care lies behind many failed transitions

• Improving transitions will necessarily reduce fragmentation

• If we succeed, we have established a precedent for fixing other broken parts of the health care system

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Real World Success Stories

• Improved transitions out of the hospital Project RED BOOST IHI’s Transforming Care at the Bedside Hospital to Home “H2H” (ACC/IHI)

• Supplemental transitional care between settings Care Transitions Intervention (Coleman) Transitional Care Intervention (Naylor) Missouri Department of Health and Human Services

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Patient and Family Engagement

• Patient-Centered Care http://www.ipfcc.org/tools/Patient-Safety-Toolkit-04.pdf

• Promotion http://www.ahrq.gov/qual/engagingptfam.htm

• Principles http://www.gwumc.edu/healthsci/departments/nursing/

naqc/documents/Patient_Engagement_Guiding.pdf

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Community Engagement

• Know where your patients are coming from• Know where your patients are going to

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Boston University Experience

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Testing the Re-Engineered Discharge

Brian Jack, MD, Principal InvestigatorAssociate Professor and Vice ChairDepartment of Family MedicineBoston Medical CenterBoston University School of Medicine

BOOST Toolkit: Primary Components

• Tool for identification of high-risk patients• Patient and family/caregiver preparation• Enhanced communications

Discharge summary Provider to provider Patient contact Patient resource

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Institute for Healthcare Improvement

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Hospital to Home (H2H)

• H2H is a national quality improvement initiative • Goal is to reduce all-cause readmission rates in

heart failure and acute myocardial infarction• Uses a three-question framework

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Available at: http://h2hquality.org

The Care Transitions Intervention

• 750 community-dwelling adults 65 years or older admitted to the study hospital with one of 11 selected conditions

• Intervention: Tools to promote cross-site communication Encouragement to take a more active role in

their care Guidance from a “transition coach”

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Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Int Med. 2006;166(17):1822-8.

Transitional Care Model

• Nurse practitioners provide inpatient assessment• NPs review medications and goals• Design and coordinate care with patients

and providers• Attend first post-discharge MD office visit• Direct home care for one to three months• Conduct home interviews

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Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure:

a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675-84.

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Available at: http://web.mhanet.com/aspx/articles.aspx?navid=111&pnavid=4&articleid=143

AHRQ Web Resource

• Implementing Re-Engineered Hospital Discharges (Project RED) Training manual After-hospital care plan samples Tool kit

Various forms How-to ideas Evaluation Cost and implementation

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www.ahrq.gov/news/kt/red/redfaq.htm

Some Practical Tools

• Ideal discharge checklist: Society of Hospital Medicine–Quality Improvement Tools:

www.hospitalmedicine.org• Care Transitions Program

www.caretransitions.org• “Getting Ready to Go Home”–simple checklist for

patients and families at admission to help think about discharge issues:

www.hospitalmedicine.org

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Questions?

“It is not the answer that enlightens, but the question.”

–Eugene Ionesco

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Mission Statement

Our Mission Is to Advance, Protect, and Reward the Practice of Good Medicine

sshepard@thedoctors.com(800) 421-2368, ext. 1134

For additional information, go to www.thedoctors.com and click on Patient Safety.