Esteban Ramirez D O F A C

Esteban Ramirez, D. O. , F. A. C. O. I Hospitalist Department Indiana Univ. Health Arnett PREVENTING READMISSIONS

Objectives Why is reducing readmissions so important CMS’ definition of a readmission Definition of Value Based Purchasing Become familiar with the measures that CMS is looking at this year Familiarize yourself with the Projects available to assist with minimizing readmissions.

Why look at Readmissions Deficit Reduction Act 2005: mandated the Secretary of Health and Human Services include measures of hospital outcomes and efficiency in the Hospital Inpatient Quality Reporting (IQR) program. Affordable Care Act: in 2010, Section 10303(a) of this Act directed the Secretary of Health and Human Services to develop additional outcome measures focused on the five most resource-intensive conditions as well as primary and preventive care.

Why look at readmissions? The NEJM in 2009 and the Medicare Payment Advisory Commission (Med. PAC) 2005 reported that 18 -20% of Medicare patients are readmitted in 30 days. Med. PAC estimated that 30 day readmissions cost Medicare ~$15 Billion dollars 78% of readmissions are thought to have been preventable. For example, >50% of pts readmitted within 30 days did not have on record a post hospitalization visit (NEJM 2009)

What is a readmission per CMS ANY diagnoses after being discharged within 30 days. Common misconception is that it has to be the same as the discharge diagnosis Could be an admission to another hospital Observation visits , ED visits, and same day readmissions (to the discharging hospital) do not count as a readmission AMI Exception: Planned PTCA, CABG within 30 days of discharge CMS has chosen to focus on 3 diagnoses at first to start penalizing hospitals for higher than expected readmission rates. Pneumonia Heart failure Myocardial Infarction

Value Based Purchasing CMS is using it’s purchasing power to drive up the quality of healthcare. DRG payments for Fiscal Year 2013 will be based on the organization’s Total Performance Score Items included in the calculation are: ○ 17 processes of care in: Pneumonia, Heart Failure, Acute myocardial infarction, Healthcare associated infections, Surgical care improvement ○ 8 measures in HCAHPS In following years, it is expected that the number of measures will increase

Value Based Purchasing Funding to these institutions will be reduced by 1% 2013. In further years, it will be increased Money can be earned back by improving your overall performance on the above measures

How do we currently compare? Using the data from Medicare claims over the last 3 years CMS has determined the national average of readmissions per diagnosis. Rates of readmission vary by state which has led Medicare to surmise that readmission rates can be decreased by the lower performing hospitals. ○ States with lower readmission rates: Idaho (13. 3%), Oregon (15. 7%), Utah (14. 2%) ○ States with higher readmission rates: Illinois (21. 7%), Louisiana (21. 9%), New Jersey (21. 9%)

How do we compare? Using the above data, the hospitals are being compared on 30 day readmission rates for pneumonia, myocardial infarction and heart failure: Better than US national rate of readmissions No different than US national rate of readmissions ○ IUH Arnett and St. Elizabeth Hospitals Worse than US national rate of readmissions ○ This group will have 1% withheld from their DRG payment

How do we compare? ** This data is available now on the HOSPITAL COMPARE public website** This site is managed by the Department of Health and Human Services. http: //www. hospitalcompare. hhs. gov/

How do we compare? Recently released Hospital Compare data (7/2012): ○ Better than national average for readmissions: Citrus Memorial Hospital, in Inverness, FL and Sarasota Memorial Hospital, in Sarasota, FL. ○ Worse than national average: 1. Beth Israel Deaconess in Boston, MA 2. Florida Hospital, Orlando, FL 3. Franciscan St. James Health, Olympia Fields, IL 4. Henry Ford Hospital in Detroit, MI 5. Mount Sinai Hospital, NY 6. Olympia Medical Center, Los Angeles, CA 7. Tampa VA Medical Center, Tampa, FL 8. San Juan VA Medical Center, San Juan, Puerto Rico

Preventing Readmissions Multiple organizations/groups have initiatives to address this Institute for Healthcare Improvement (STAAR) and American College of Cardiology (H 2 H) INTERACT and Community Based Transition Programs from CMS National Priorities Partnership Hartford Foundation Project RED- RED= Re-Engineered Discharge Designed by researchers at Boston Univ. and Boston Medical Center funded by Agency for Healthcare Research and Quality (AHRQ) and National Institutes of Health (NIH) Showed significant decrease in utilization of ED visits and Hospital Utilization. Trended toward reducing readmissions Project BOOST- Better Outcomes for Older Adults through Safe Transitions led by the Society of Hospital Medicine and includes Joint Commission, CMS, CDC, IHI, Blue Cross and Blue Shield, AHRQ, Kaiser Permanente 6 sites that have utilized this have produced 21% reduction in readmissions

Project red

Project RED Education about the diagnosis Make the follow up appointment for the patient using input from the patient Give purpose for visit Coordinate with needed labs and studies Review transportation to appointment and if needed set it up for the patient Discuss test results and if any are pending who is responsible for following up on these

Project RED Organize post discharge services Confirm medication plan Reconcile discharge plan and medications with national guidelines (heart failure, acute MI, etc…) Review what should be done if a problem arises (redevelop chest pain, increased fevers, etc. )

Project RED Expedite the discharge summary Components to DC summary: ○ Reason for hospitalization/diagnosis ○ Significant findings ○ Procedures performed ○ Condition at discharge ○ Comprehensive medication list including allergies ○ Pending tests/labs and medical issues that require follow up Assess understanding of the above May require a translator, different literacy level, involving caregivers

Project RED Provide hard copy of the discharge plan when leaving Provide telephone reinforcement at 2 -3 days. Re-assess understanding Intent on following up with appointments Assess need for second call by: ○ Pharmacist and/or ○ Nurse and/or ○ Physician

Project BOOST

Project BOOST Geared primarily to patients greater than 65 year of age. Encourages identifying high-risk patients and providing the intervention solely to this population TARGET tool to assess risk ○ Includes GAP (General Assessment for Preparedness)assess potential barriers ○ 8 P tool: done at admission Problem medications: warfarin, digoxin, aspirin, insulin in combination with clopidogrel Hx of psychiatric disorders Problem Diagnoses: COPD, heart failure, cancer, stroke, diabetes/glycemic complication Polypharmacy (>5 medications) Poor health literacy Poor social support Prior (unplanned) hospitalizations in the last 6 months - Has been identified as the single most predictive risk factor of readmissions (NEJM 2009) Palliative Care

Project BOOST Educating patients on their conditions and possible side effects of medication- Utilization of the Teach Back Method Scheduling follow-up physician appointments within 7 days Medication reconciliation at discharge to ensure that drugs prescribed at discharge don't harmfully interact with previously prescribed drugs Discharge instructions should be in at least 14 font. Avoid all capitals and jargon. Include diagnoses, possible side effects from medications, what to look for to get further care/ER visit, list of appts. Discharge summary to PCP <48 hours Direct communication with PCP for these high risk patients. Telephone contact with patient within 72 hours *There is a training and mentoring program available for this project*

Take Home Points Communicate better with our patients May require repetition or discharge instructions in a different language/interpreter or involvement of family/caregivers Communicate better between inpatient to outpatient providers Quick turn around of DC summaries <48 hrs Better quality DC summaries that include pending tests/labs Phone calls to PCPs office for high risk patients Make appointments for patients before DC Provide follow up phone call to patient 2 -4 days to ensure understanding and address unexpected issues Must use a multidisciplinary approach

Readmission Risk Calculators Center for Outcomes Research and Evaluation (CORE) has an application that is free that could be downloaded on i. Phone.

What will the future look like Improved electronic discharge process that incorporates EBM check off lists that must be completed prior to DC More availability for quicker turn around on DC summaries (including weekends and holidays) Improved access to post hospitalization care within 7 days Medical Home Model (e. g. extended hours, weekend avail. ) Use of physician extenders and/or Semi-retired physicians Improved collaboration between inpatient, outpatient and SNF/ECF healthcare workers Gather representatives from each area Analyze the process ○ Inpatient to outpatient, inpatient to SNF/ECF, SNF/ECF to Outpatient LEAN methodology Projects are currently under way to address specifically the high readmissions for Heart Failure, Pnemonia and Acute Myocardial Infarction Perhaps a future lecture series on these? Champions for each?

Questions or Comments?

References Readmission Measures Overview. www. qualitynet. org (established by CMS) Jencks S, Williams M, Coleman E. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med 2009; 360: 1418 -1428 Medicare Payment Advisory Commission (Med. PAC). Promoting greater efficiency in Medicare. June 2007. Project Boost Website: www. hospitalmedicine. org/BOOST/ Project RED website https: //www. bu. edu/fammed/projectred/ Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. Jul 25 2011; 171(14): 1232 -1237.