Presenters: Kathy Cummings, ICSI Kattie Bear-Pfaffendorf, MHA Janelle Shearer, Stratis Health

Copyright © 2010 by ICSI James and Martha

How do avoidable readmissions impact your clients? What challenges do you face in preventing readmissions?

What is happening?

Federal 1% penalty on Medicare for “greater readmissions than expected” in 2013 Looks at heart attacks, congestive heart failure, pneumonia, COPD, and potentially other conditions Penalty increases 1% per year until reaches 3% Only big hospitals (so far) MN Medicaid payments reduced by 10%, can earn back 5% if reduce avoidable admissions over 2 years Why is reducing readmissions important? Business View

Hospital Compare Heart AttackHeart FailurePneumonia MNUSMNUSMNUS Better than national average Same as national average Worse than national average Too Small

2013 Penalties Range % Maximum was 1% Number of hospitals with a penalty –28 out of States have less penalties than Minnesota

RARE Campaign: Maintaining patient health after a hospital stay… …So We All Sleep More Peacefully.

What is the RARE Campaign? A campaign across the continuum of care to reduce avoidable hospital readmissions across Minnesota and surrounding areas Regional approach, supported by hospitals, providers, health plans, other key stakeholders Campaign is engaging other care providers, acknowledging that readmissions are the result of a fragmented health care system

Broad Community Support Operating Partners: Institute for Clinical Systems Improvement (ICSI) Minnesota Hospital Association (MHA) Stratis Health

Broad Community Support Supporting Partners: Minnesota Medical Association MN Community Measurement VHA Upper Midwest

Broad Community Support Community Partners: –Endorse and actively support the campaign A growing list of providers, health plans, state health agencies, home health agencies, nursing homes, patient advocacy groups and other community organizations Complete list on

Triple Aim Goals Population health –Prevent 6,000 avoidable readmissions within 30 days of discharge by the end of 2013 –Reduce overall readmissions rate by 20% from the 2009 and maintain that reduction through 12/13/13. Care experience –Recapture 24,000 nights of patients’ sleep in their own beds instead of in the hospital Affordability of care –Save millions of dollars in health care expenses

Care Across the Continuum

Campaign Design

Five Focus Areas Patient and Family Engagement Transition Communication Transition Support Comprehensive Discharge Plan Medication Management

Supporting Work Groups Medication Management Mental Health Epic Users Measurement Long Term Care Health Plan Care Managers

Learning Collaboratives Project Red Safe Transitions Care Transitions Intervention

Recommended Actions for Improved Care Transitions

1.Use Teach Back to assess patient’s understanding of any instructions 2.Ensure caregivers are engaged in developing the plan of care 3.Use Health Literacy Standards such as AHRQ Health Literacy Universal Precautions Patient Family Engagement and Activation

Comprehensive Discharge Planning A written patient centered plan must include: 1.Reason for hospitalization including information on disease in terms patient can understand 2.Medications to be take post transition: Purpose, dosage, when and how to take, how to obtain refills. 3.Self-care activities 4.Durable Medical Equipment 5.Symptom Recognition and Management 6.Coordination and planning for follow-up appointments

1.Medication reconciliation at each patient transition with date 2.Medication list should contain purpose for each medication 3.Pre/post hospital medications changes should be made clear to the patient 4.Medication discrepancies need to be evaluated and acted upon. 5.Use Teach Back when instructing patients on medication use Medication Management

Care Transition Support 1.Follow-up appointment within 5 business days 2.Available appointment slots 3.Follow-up arranged with ancillary services such as PT, OT, RT 4.Within 72 hours a purposeful contact with patient is made by a care team member

Follow-up Visit should focus on: 1.Patient’s goals for the visit 2.Patient’s needs for medication adjustment, test results, advance directives 3.Instruction on self management 4.Explanation of warning signs and how to respond 5.Instructions for seeking emergency and non emergency after hours care.

Transition Communication 1.PCP notified when patient admitted or discharged. 2.Patients know who is responsible for care and how to contact them. 3.Concise transfer forms with key elements must be sent with the patient in every transfer. 4.Direct reports between nursing staff. 5.Complete discharge summaries should be received by the accepting facilities within 3 business days.

What Clinic Providers Can Do Medication Management What & How Use Teach Back Offer Medication Therapy Management

What Clinic Providers Can Do Patient and Family Engagement Have the patient and family set goals for care Involve caregivers in discussions and decisions about care Use Teach Back when educating the patient and their caregivers Use language and materials that are easy for the patient and their caregiver to understand

What Clinic Providers Can Do Care Transition Support Provide access to a post-hospital appointment within five (5) business days of patient discharge, or sooner if the condition warrants

What Clinic Providers Can Do The content of the follow-up visit should focus on: –Patient’s goals for the visit –Factors contributing to admission or ER visit –Patient’s needs for medication adjustment –Follow-up on test results, monitoring and testing –Advance directives, specific future treatments such as Physician Orders for Life Sustaining Treatment (POLST) –Patient needs for instruction on self-management using Teach Back –Explanation of warning signs and how to respond using Teach Back –Instructions for seeking emergency and non-emergency after-hours care

What Clinic Providers Can Do Care Transition Communication Work with your local hospital to develop processes for notifying primary care provider when the patient is admitted and when they are discharged Contact the patient within 72 hours of discharge to review their transition plan, medications, warning signs, current status and self- management

Recommended Actions for Improved Care Transitions Mental Illnesses and Substance Use Disorders Participant Resources

Why Do Readmissions Matter to You? Small Group Discussion: 1.From your perspective, what do you want other care settings to know about your setting and the issues with care transitions? 2.What is being done in your community to prevent readmissions? 3.What improvements would you like to see in your community?

Data source – MHA Database All-payer inpatient claims for all MN hospitals But, can only look at readmit to same facility –22% readmits to different facility Software – 3M Potentially Preventable Readmissions 3M’s clinical experts developed methodology Each record designated as admission or readmission Calculates severity-adjusted PPR rates by condition & by hospital “Potentially Preventable Readmissions”

A value 1 means more than expected

4570 Avoidable Readmission Prevented 18,280 Nights of sleep At HOME

24,000 Nights At Home Will Make Our Day.

Thank You For Helping Everyone Sleep More Peacefully.