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The Care Transition Journey: Florida’s Experience
Southern California Patient Safety Collaborative June 21, 2011
ObjectivesProvide a brief overview of the Care Transitions projectOutline the plan to address avoidable readmissions in the Miami CommunitySummarize the findings associated with the implemented interventionsDescribe the community’s efforts to sustain the care transitions results
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The Care Transition Problem About one in five Medicare patients are rehospitalized within 30 days of discharge:
The majority of the rehospitalizations are from patients discharged to self-care at homeClinical evidence shows that 25%+ of the rehospitalizations are preventableSafe, accurate, and timely care coordination is key to preventing many avoidable rehospitalizationsThe majority of these readmissions occur in the first 15 days post-discharge
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Care Transitions GoalsImprove coordination of care through safe discharge planning processes
Reduce unnecessary/avoidable readmissions to hospitals
Empower patients/caregivers to self-manage their diseases
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AL: Tuscaloosa
NE: Omaha
CO:Northwest Denver
NJ: Southwestern NJ
FL: Miami
NY: Upper Capital
GA: Metro Atlanta East
PA: Western PA
IN: Evansville
RI: Providence
LA: Baton Rouge
TX: Harlingen HRR
MI:Greater Lansing Area
WA: Whatcom County
14 Project Communities(2008-2011)
The Miami OpportunityProject Overview
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The Care Transition SolutionDefining the Problem
Discharge Process Mapping
Cause & Effect Diagram (Fishbone):
Prioritizing the Problems
Root‐Cause Investigation ‐
Verifying with Data
Recommended SolutionsCost‐Benefit Analysis
Action Plan for Improvement
Lessons Learned: Modifications to the
Action Plan
Root‐Cause Resolution: Control
the Plan
SNFs HHAs / ALFs
Hospitals Outpatient Facilities
Patient Empowerment
Outpatient Services
Physicians
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Community Discharge StatusCommunity Discharge Status 2007 2008 2009 2010
Self-care at home (includes ALF) 43.1% 46.1% 48.3% 47.3%
Skilled Nursing Facilities (SNF) 15.8% 16.6% 15.6% 16.2%
Home Health Agencies (HHA) 18.2% 20.2% 19.0% 18.5%
% Community’s Total Discharges 77.1% 82.9% 82.9% 82.0%
8Source: Validated through ISAT Data (Medicare hospital claims 2007-2010). ALF = Assisted living facilities
Provider-Associated Readmissions*
Last Location 1/09 - 6/09 7/09 - 12/09 1/10 - 6/10
None 29.30% 33.29% 33.24%
Home (including ALF) 22.33% 21.62% 20.70%
SNF 14.88% 13.35% 13.40%
Outpatient 10.92% 11.94% 11.57%
HHA 12.64% 12.42% 12.02%
Other** 9.93% 7.38% 9.07%*Physician claims assigned to associated provider category. **Other category includes: nursing, custodial care, comprehensiveinpatient rehabilitation, and inpatient psychiatric facilities; hospice; and end-stage renal disease treatment facilities.
Source: Data were analyzed from Medicare fee-for-service Parts A and B claims (January 2009 through July 2010). Based on last claim on file within 30 days of discharge. All utilization data were provided by CMS at the request of the QIO.
Community Readmission Status
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Risk ModelingBased on beneficiaries’ claims 2007-2008Tests patient characteristics to determine non-disease based disparitiesTests the impact of:– Primary discharge diagnosis– Services utilized during hospital stay– Co-existing conditions defined during index
hospitalization10
Dual eligibleESRDLonger length of stays (>5.65)Males (slight)African American (slight)
Results: Patient Characteristics
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Congestive heart failure*Major psych disorders*Cardio-respiratory failure/shock*Metastatic cancer/acute leukemia#
Chemotherapy/benign neoplasms#
Artificial openings for feeding/elimination* Impacts greatest (larger) number of patients # Greatest risk for readmission (smaller numbers)
Results: Primary Discharge Diagnosis
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Emergency department*EKG*Coronary care*Respiratory therapy*UltrasoundRenal dialysis#
Mental health and substance abuse#
* Impacts greatest (largest) number of patients # Greatest risk for readmission (smaller numbers)
Results: Service Utilization
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Cardiac, respiratory, and vascular diseases*GI/GU diseasesMental health disorders #
Nutrition disordersSkin disordersBlood/cancer diseases#* Impacts greatest number of patients # Greatest risk for readmission (smaller numbers)
Results: Co-existing Conditions
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Community Plan
Beneficiaries
Providers
Physicians
Stakeholders
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Miami Community Interventions
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Miami Providers
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HospitalsCare Transition InterventionSM
University of DenverHospital to Home (H2H) American College of CardiologyRe-engineered Discharge (Project RED) Boston University Transforming Care at the Bedside (TCAB) Robert Wood Johnson FoundationDischarge Preparation Checklist
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Skilled Nursing FacilitiesINTERACT II (Interventions to Reduce Acute Care Transfers)
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Home Health AgenciesHome Health Quality Improvement National Campaign– Reduce avoidable
hospitalizations– Improve the
management of oral medications
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Cross-Setting Best PracticesHospital Transfers
Clinician-to-clinician contactReason/health historyUpdated medication listLiving will/health care surrogacyContact information
Discharge ManagementPrescription management Coverage of doses until prescriptions arriveClarification of discharge paperworkPhysician follow-up visits within 7-14 days
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Cross-Setting Best PracticesHand-over
Medication verification processSBAR to improve physician interactionEarly warning signs: review with staff and familyDischarge envelope
Diagnosis-SpecificHeart failure patients: monitor weightsCoumadin (warfarin) patients: lab workUTI: final lab work after antibioticsPost-Discharge follow-up calls at 24-48 hours
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Physicians
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Physician EngagementDevelop the team (allay potential physician suspicions)Identify proficient, trustworthy clinicians– Excellent communication skills– Open to seeking guidance for discussions
with community physiciansConsider the “Two Chair Model” to foster trust
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Suggestions for Engaging Physician Champions
Equanimity is a key factorDo not assume your reputation for honesty and professional ethics overcomes medical community suspicionsReinforce personal commitment through example and ongoing communication
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Suggestions for Engaging Physician Champions (Cont.)
Communicate mantras frequently to gain physicians’ acceptanceOnce trust is established, with patience, allow the program to move forward and evolveNever give up
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Stakeholders
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Stakeholder PartnershipsDecide – new, project focused vs. joining existing partnerships– Raise public awareness– Address project initiatives
Involve patient advocates (Area Agencies on Aging, community service organizations, diagnosis-specific organizations, etc.)Patients/caregiver involvement
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Patients
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FrameworkCare Transitions InterventionSM (CTI)- Evidence-based model developed by
Eric A. Coleman, MD, MPH- www.caretransitions.org
Coaching follow-up- Hospital visit- Home visit- Three telephone calls
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Intervention Components
CTI addresses patient empowerment through the intervention’s four pillars:- Medication reconciliation
- Physician follow-up
- Disease management
- Maintaining personal health record
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CTI StrengthsPatient centered
Not designed to be disease-specific
Standardized, replicable, flexible- Added 5th and 6th “Pillars”
Provider-specific feedback
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CTI Challenges
Reducing readmissions – low priority
Patients skeptical of the offer for free services
Physician resistance
Weak electronic reporting capabilities
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Community
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Proclamation forSafe Care Transitions
Acknowledges effective care transitions are the core of a high quality health care system and a necessary foundation for the provision of safe, effective, efficient, timely, and equitable care.
Providers of the Miami Community35
Collaborate effectively to develop a timely, comprehensive care transition plan for our patients
Empower patients/caregivers to participate in their care through access to understandable health information provided in the appropriate language
Provide patients and health care partners with timely, legible, accurate, and complete discharge information
Improve health care provider communication by seeking clarification of ambiguities/discrepancies in the patient’s discharge information
Assist patients and their families to expedite timely scheduling of their post-discharge physician appointment
Support patients in comprehending, maintaining, and sharing discharge information with their physicians and other involved health care providers
Encourage patients to proactively self-manage their care by sharing updated health information with their health care team
Shared Beliefs:
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Community Activation MeasureDeveloped by the Miami CollaborativesIncorporates the Proclamation’s shared beliefs/value statements into a community assessment tool Measured with a 5-point Likert scale The tool allows any provider to assess its perceived frequency of the collaborative’s (community’s) commitment to improving care transitions communication issues
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Community Problem:Increased Heart Failure Rates
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The Heart Failure (HF) Problem30-day Readmission Rate
Source: Validated through ISAT data (Medicare claims) for the period January 2008 through January 2010. The rates (weighted and unadjusted) are based on 12-month periods ending in December for each year.
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Root-Cause Findings2008 vs. 2009
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Non-Contributable Findings
Age in years
Mortality rate
Length of inpatient stay in days
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Contributable Findings: General
Increased number of HF dischargesIncreased incidence of HF discharges and readmissions among all of the discharges/readmissions Higher poverty rates within the county
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Contributable Findings: Discharge Status
Increased number of HF discharges to home/ALF; increased 30-day readmission rateDecreased number of HF discharges to post-acute care settings; increased 30-day readmission rateIncreased number of HF patients that did not see a physician; increased 30-day readmission rate
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Contributable Findings: Co-Morbidities
Increase in heart failure patients presenting with co-morbid conditions*
Diabetes/diabetes complicationsIron deficiency and other unspecified anemias/blood diseaseOther gastrointestinal disordersDepressionOther eye disorders
• Statistically significant differences. Co-morbid conditions present in year prior to index hospitalization; accounts for patients presenting with the highest number of co-morbid conditions.
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Contributable Findings: Coaching
Inconsistent discharge informationInadequate patient self-management skills
Frequent medication discrepancy events
Intentional medication non-compliance
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QIO-Recommended Cross-Setting Interventions
Aimed at Reducing Avoidable Heart Failure Readmissions
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Improve HF AwarenessFormalize a process to flag patients with HF primary and secondary diagnosesPrioritize care needs for patients with high risk co-morbiditiesDevelop a plan to identify HF-diagnosed patients after admissionExpand HF readmission reviews to incorporate patient interviews; trend patient-identified reasons for the readmission
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Evaluate Patient Education Processes
Standardize HF patient education throughout hospital (continue pathway into post-acute care settings)Revise patient education tools to incorporate self-management skillsProvide education frequently throughout the patient stayIncorporate teach-back into patient care practices
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Improve Post-Discharge Care Needs
Make referrals to appropriate post-acute care settingIncorporate HF-specific education into post-discharge follow-up calls to patientsImprove clinician hand-over communicationsConsider implementing other post-discharge interventions
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Improve Patients’ Rate of Post-Discharge Physician Visits
Assist patients with prioritizing and scheduling physician follow-up appointmentsInform primary care physicians of the need for timely follow-up visits after a patient’s dischargeProvide timely discharge summaries to physiciansIdentify physician champions
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Involve Palliative Care ServicesPlan by stagesFrequent emergency room visits and/or hospitalizations over the last 6 monthsSemi-comatose stateMinimal oral intake (or receiving continuous IV hydration or tube feeding)Inability or difficulty with taking oral medicines
Major decline in functional status with no identified reversible causeMottling of extremitiesPrimary diagnosis of metastatic cancerPrimary diagnosis of advanced dementiaExisting DNR order
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Intervention Results
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HospitalsHeart Failure
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30-Day HF Readmission Rates Among Participating Hospitals
54Source: Medicare ISAT data that trend HF 30-day readmissions for the 6-month period ending specified month/year. Data represent the weighted averages of the hospital’s readmission rates for all discharged patients (October 2007 – January 2011).
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Skilled Nursing Facilities
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Miami SNF Readmission Rate
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Source: Medicare Part A claims & MDS admission/discharge reports that trend SNF admissions/readmissions with LOS ≤ 30 days and end in hospitalization within 30 days. Data represent the weighted averages of SNF hospitalization rates for patients who reside in the target zip codes and are reported by 3-month periods quarterly (March 2008 – through March 2010).
Home Health Agencies
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Miami HHA Readmission Rate
58Source: Medicare Part A cliaims. Patients discharged from an acute care hospital who utilize home health services, reside in the target zip codes, and are readmitted within 30-days. Data represent a 12-month period reported quarterly ending in specified month (March 2008 – June 2010).
Physician
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Physician Follow-Up Status of Heart Failure Patients
60Source: Medicare Part A & B claims (March 2009 – October 2009; September 2009 – March 2010) for 6-month period ending specified month/year. Data provider from CMS at the request of the QIO.
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Patients
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Coaching Readmission Rates
Coaching CompletedN = 922
Refuse / Did not
completeN = 412
p-value
30-Day Readmission Rate
15.08% (139) 22.57% (93) p = 0.0008
60-Day Readmission Rate
24.40% (225) 29.85% (123) p = 0.04
Source: Data were analyzed from Medicare fee-for-service Part A claims (July 2009 through July 2010). All utilization data wereprovided by CMS at the request of the QIO. 62
Readmission Rates by Type of Community Support
CoachingCoaching
OnlyN = 660
Coaching Plus
Nutritional SupportN = 234
CoachingPlus
Community Support ServicesN = 28
p-value
30-Day Readmission Rate
17.88% (118) 8.55% (20) 3.57% (1) p = 0.0006
60-Day Readmission Rate
27.27% (180) 17.52% (41) 14.29% (4) p = 0.005
Source: Data were analyzed from Medicare fee-for-service Part A claims (July 2009 through July 2010). All utilization data were provided by CMS at the request of the QIO. 63
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Physician Follow-Up Status Among Coached Patients
Discharged Patients Offered Coaching
CompletedN = 922
Refuse / Did not
completeN = 412
p-value(unadjusted)
% of patients seen by physician within 30 days of discharge or prior to readmission
78.52% (724) 70.87% (292) P = 0.002
Source: Data were analyzed from Medicare fee-for-service Part A claims (July 2009 through July 2010). All utilization data were provided by CMS at the request of the QIO.
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Community
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Community Activation Measure
66Source: FMQAI database of providers assessments from (April 2010-current). Updated: June 6, 2011
56.46%
82.90%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Miami Community Activation Assessment Linear (Miami Community Activation Assessment)
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Sustainability of Interventions
Coaching interventionTelephonic coachingScheduling physician visits prior to dischargeRe-engineered patient teachingIncreased effort to involve community resources
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Final Checklist
Establish community collaboratives to expand patient care pathways –admission through discharge and beyondEncourage patient activation by standardizing patient education practices; include patient teach-backMaintain consistent discharge practicesEngage physiciansMonitor patient satisfaction
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This material was prepared by FMQAI, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. FL9SOW2011F72T2612281
QUESTIONS
Presenter:Susan Stone, MSN, RN
Care Transitions Project DirectorEmail: [email protected]
Direct Line: 813-865-3435
Lead Coach:Beatriz Hernandez, MSHSA, RN
Care Transitions Project CoordinatorEmail: [email protected]
Direct Line: 813-865-3178
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