1 Roland A. Grieb, MD, MHSA Medical Director, Indiana Medicare Quality Improvement Organization Nancy Meadows, RN, BS Clinical Specialist, Care Transitions Initiative May 5, 2011 Care Transitions: Best Practices in Reducing Readmissions

Disclosures The speakers for this CME activity have no relevant financial relationships with commercial interests to disclose. 2

Objectives  Provide an overview of the Medicare Quality Improvement Organization (QIO) work being done as part of the Centers for Medicare & Medicaid Services (CMS) Care Transitions Initiative  Explain some of the commonly utilized evidence-based care transition models and interventions  Share key successes and challenges identified through participation in the transitions sub-national theme 3

Problems Affecting Care Transitions Patient ER ICU In-Patient Patient OUTPATIENT: Home PCP Specialty Pharmacy Other Services Care Giver SNF HHA NO Personal Health Record NO Coordinated Care Plan Poor Discharge Coordination NO Medication Reconciliation NO Personal Health Record Poor Care Coordination NO Medication Reconciliation NO Personal Health Record 4 Source: Case Management Society of America (CMSA)

Background  Re-hospitalizations are: Frequent - Approximately 20% of Medicare beneficiaries discharged from a hospital are readmitted within 30 days Costly - Account for $17B in annual Medicare spending - Excludes costs associated with other payers 5 Source: Jencks et al. N Engl J Med 2009; 360:

Background Potentially avoidable - 75% identified as potentially preventable based on 3M report to the Medicare Payment Advisory Committee (MedPAC 2007) % noted as potentially preventable in retrospective clinical review Allow for actionable improvement - Research and quality improvement initiatives have shown >30% reduction of 30-day readmission rates for various patient populations 6

Jencks S et al. N Engl J Med 2009;360: Rates of Re-hospitalization within 30 Days after Hospital Discharge Source: Jencks et al. N Engl J Med 2009; 360:

Why Do Hospitals Have Unwanted Readmissions? Poor Provider-Patient interface Medication management, no effective patient engagement strategies, unreliable follow-up Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers Lack of community infrastructure for achieving common goals Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH, and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:

What’s the Hold Up? If re-hospitalizations are prevalent, costly, potentially avoidable, and actionable— what’s the hold up?  Providers: Lack of financial incentives and/or decentives  State: Lack of population-based data, fragmented payer systems  Community: Difficult to engage organizations across the continuum (silos), lack of Information Technology (IT) acceptance, connectivity and infrastructures, lack of reimbursement 9

Health Care Reform: Promote Better Care After Hospital Discharge  By linking payments between hospitals and other care facilities, reform is intended to accomplish the following Promote coordinated care after discharge from the hospital Encourage investments in hospital discharge planning and transitional care to ensure that avoidable readmissions are prevented What’s in Reform for My Community? 10

Structure of Health Care Incentives Expansion of pay-for-performance (P4P) to value-based purchasing (VBP) Bundled payment pilots Potential avoidable admissions, readmissions, and sites of care Fixed hospital payments Increasing focus on “cost and comparative effectiveness” 11

Evolution of Health Service Delivery  Shift of accountability and financial risk (clinically and economically) across the continuum of care Shift to episodes of care Shift to outcomes of care 12

A Major Focal Point of Interest  National Quality Forum (NQF) included improved care transitions as 2009 and 2010 priority goals  The Joint Commission has included and is expanding as part of National Patient Safety Goals (NPSGs)  New CMS quality reporting of 30-day readmission rates (AMI, HF, and Pneumonia)  Addresses many of the hospital- and health care- acquired conditions for which CMS is now and proposing to withhold payment  Focus of numerous pilots, projects, and demonstrations  August 2008, CMS focus for QIOs in 9th Scope of Work (SOW) 13

Centers for Medicare & Medicaid Services (CMS) Care Transitions Initiative 14 A community-wide Centers for Medicare & Medicaid Services (CMS)project focusing on improving patients’ transitions across care settings to reduce avoidable hospitalizations.

The Indiana Opportunity: Care Transitions

Care Transition Initiative  Each QIO required to implement the following Hospital and community system-wide interventions Interventions that target specific diseases or conditions Interventions that target specific reasons for admissions Source: CMS Office of Public Affairs. April 13,

Key Elements to Improvement 1.Examine current state of readmissions and discharge processes 2.Assess and prioritize improvement opportunities 3.Develop an action plan of strategies to implement 4.Monitor and evaluate progress 17

Key Elements to Improvement  Identify the opportunity! Assessment, review, and redesign of provider-specific policies and processes that include (at a minimum) the following areas Patient and caregiver education and communications Medication reconciliation and safety Symptom management Discharge treatment plan and follow-up care Sharing and transfer of vital patient information 18

Examine Current Rate of Readmissions  Readmission rates by diagnoses  Readmission rate by practitioners  Readmission rates by readmission source  Readmission rates at different time frames 19

Assess and Prioritize Focus on:  Specific patient populations  Stages of the care delivery process  Hospital organizational strengths and available resources  Hospital priority areas and current and upcoming quality improvement initiatives 20

Hospital Readmission Rates Patients discharged 1/1/2007—12/31/2007 within the HSA 21

HSA Admission Sources: Discharges and Re-hospitalizations 22

HSA Re-hospitalizations: Top 10 MS-DRGs 23

Patient’s Perspective of Care Survey Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Hospital Compare September

Hospital Compare September 2008 Patient’s Perspective of Care Survey Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 25

26 Source: Improving Care Transitions. Jane Dorman. Care Management Institute, Kaiser Permanente. January 13, 2010.

Typical Failure Modes in the Transition Process Medication errors and/or adverse events Poor, incomplete, or missing discharge instructions Lack of follow-up appointment Follow-up scheduled too long after hospitalization Inadequate or lack of outpatient management Ineffective provider-to -provider communications (skills and tools) Confusion over self-care instructions Lack of adherence to medications, therapies, and diet Lack of social support 27

Develop an Action Plan  Learn from where failures lie  Develop community connections to eliminate barriers to successful care transitions  Develop strategies and interventions to engage patients, families, and caregivers in addressing the issue 28

Targeted Areas for Improvement  Communication  Medication reconciliation  Patient empowerment and self-management skills  Physician follow-up  Plan of care 29

Major Strategies to Reduce Avoidable Readmissions  During Hospitalization Use a multi-interdisciplinary care team approach Risk screen patients Risk assessment of patients for “end-of-life” discussions Establish effective communication Use of “teach-back” and coaching skills to educate patients and caregivers 30

 At Discharge Implement comprehensive and patient-tailored care plans Use “teach back” and coaching skills to educate patients and caregivers Schedule and prepare patients and caregivers for “early” follow-up appointments Medication reconciliation and patient medication self- management techniques Facilitate discharge communications with post-acute care providers 31 Major Strategies to Reduce Avoidable Readmissions

 Post Discharge Promote patient and caregiver self-management Coaching home visits and/or telephonic follow-up Telehealth for at-risk patients Personal Health Records for information management Emergency Care Plans and Zone Tools for symptom management 32 Major Strategies to Reduce Avoidable Readmissions

 Post Discharge Verification that follow-up appointments are scheduled Timely transmission of discharge summaries to primary care physicians Early physician follow-up - low risk 0-14 days - high risk 0-7days Establish community networks 33 Major Strategies to Reduce Avoidable Readmissions

Major Interventions InterventionKey ElementsKey PlayersLocation Boston Medical Center Re-Engineered Discharge/RED med/projectred/ Patient education; comprehensive discharge planning; After Hospital Care Plan (AHCP); post-discharge phone call for medication reconciliation Nurse discharge advocate, clinical pharmacist Hospital and home (phone only) Care Transitions Program ns.org/ Care Transitions Intervention (CTI); medication self- management; patient-centered record (PHR); follow-up with physician; and risk appraisal and response Transitions coach Home 34

Major Interventions InterventionKey ElementsKey PlayersLocation Transitional Care Model (TCM) are.info/ Care coordination; risk assessment; development of evidence-based plan of care; home visits and phone support; patient and family education Transitional care nurse (TCN) Hospital and home Home Health Care Telemedicine emodels.com/care_model s/18/key_elements Telehealth care; Telemonitoring; front-load and in-home visits Telemedicine nurse and traditional home health nurse Home care 35

Major Interventions InterventionKey ElementsKey PlayersLocation Home Health Quality Initiative (HHQI) ity.org/hh/default.aspx National cross setting initiative; strategies and best practice tools that will reduce potentially avoidable acute care hospitalization (ACH) from Home Health Home health stakeholders and multiple health care providers Home care Nursing Home Interventions to Reduce Acute Care Hospitalizations (INTERACT)- cs/ContentServer?cid= &pagename=Med qic%2FMQTools%2FToolTem plate&c=MQTools Strategies and tools that will reduce potentially avoidable acute care transfers (ACT) from nursing homes Nurse, Certified Nursing Assistants (CNA), discharge advocate Nursing Home (NH) and Skilled Nursing Facility (SNF) 36

Major Interventions InterventionKey ElementsKey PlayersLocation Better Outcomes for Older Adults Through Safe Transitions (BOOST) e.org/ResourceRoomRedesig n/RR_CareTransitions/CT_Ho me.cfm Clinical interventions, practical step-wise project management tools, and resources to train multidisciplinary teams about quality improvement and best practices in discharge planning and effective communication strategies Nurses, social workers, case managers, residents, hospitalists Hospital and home 37

CMS’s Table of Interventions 38 Report_Jan_2010.pdf

Monitor and Evaluate Progress  Critical element often not thought out Informs hospital leaders of the efficacy of strategies Helps guide implementation of additional strategies  Readmission data can be tracked and reported as quality indicator to the following Hospital boards Quality committees Front-line and clinical staff 39

Intervention Pilots in Our Community InterventionNumber of Organizations Implementing Type of Stakeholder Redesign of case management processes 5 Hospital, Inpatient Rehabilitation Coaching 8 Hospital, Home Health, Community Pharmacist involvement 4Hospital Telephonic follow-up 4Hospital Telehealth 6Home Health Early warning and reporting 4Nursing Home Redesign of educational materials and processes 6 Hospital, Inpatient Rehabilitation, Home Health 40

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Summary of Preliminary National Results 42

Total Participating Providers Among 14 Communities  70 Hospitals  277 Skilled Nursing Facilities  316 Home Health Agencies  89 Other types of providers (Dialysis, Hospice, etc.)  1,125,649 Medicare Beneficiaries 43

Preliminary Results*: CY 2007 compared to CY Care Transitions Communities in contrast to 56 Comparison Communities MeasureCT Theme (Comparison) Absolute ChangeRelative Change % readmitted-0.08%(+0.30%)-0.39%(+1.91%) Readmissions/ /1000(-0.36/1000)-4.75%(+0.15%) Admissions/ /1000(-7.62/1000) -4.59%(-2.11%) *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts. Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:

Preliminary Results*: CY 2007 compared to CY Care Transitions Communities in contrast to the Nation MeasureCT Theme (National) Absolute ChangeRelative Change % readmitted-0.08%(+0.05%)-0.39%(+0.24%) Readmissions/ /1000(-1.93/1000)-4.75%(-3.34%) Admissions/ /1000(-11.8/1000) -4.59%(-3.77%) *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts. Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:

Preliminary Results*: CY 2007 compared to CY 2009 Transitions: Hospital—Skilled Nursing Facility (SNF)—Hospital Drivers: Lack of Standard and Known Process, Information Transfer MeasureCT Theme (Comparison) Absolute ChangeRelative Change % discharged to SNF+0.56%(+0.81%)+3.79%(+6.57%) SNF readmission rate-0.41%(+0.75)-1.09%(+4.64%) *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts. Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:

Preliminary Results*: CY 2007 compared to CY 2009 Transitions: Hospital—Home Health—Hospital Drivers: Lack of Standard and Known Process, Information Transfer, Patient Activation MeasureCT Theme (Comparison) Absolute ChangeRelative Change % discharged to HH+0.4%(+1.13%)+1.67%(+8.49%) HH readmission rate-0.47%(0.00%)-1.87%(+0.30%) *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts. Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:

Preliminary Results*: CY 2007 compared to CY Care Transitions Communities in contrast to 56 Comparison Communities MeasureCT ThemeComparison Average Cost Savings/Beneficiary†$15.23$6.91 Average Cost Savings/Community†$835,441$132,482 Total Cost Savings†$11,696,180 $7,419,003 † This measure represents cost savings associated with readmissions only. *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts. Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:

National Results  Hospital readmissions work reduces hospital ‘admissions’  Population-based measures of readmission going down  Population-based measures of admission also going down  Nursing Home and Home Health utilization has increased slightly while 30-day readmission rates for Nursing Home and Home Health have decreased  Preliminary cost-savings are very promising 49 Taken from: The Care Transitions Theme: Experiences from Community-Based Hospital Readmission Reduction Initiative. Presented by Jane Brock, MD, MSPH and Alicia Goroski, MPH, The Colorado Foundation for Medical Care, December 16, 2010, Denver, Colorado. Accessed at:

Challenges to Care Coordination  Workforce and provider shortages (e.g., supply of physicians or places to go for medical care)  Limited access to specialty care  Limited financial capacity  Under-resourced infrastructures  Populations with multiple chronic conditions  Isolation and sometimes large areas due to geographic and travel distances 50

Challenges to Care Coordination  Lack of coordination and communication across information systems and between providers  Health care professionals are not necessarily trained in care coordination  Broadband availability 51

Strengths Needed in Health Care Systems  Becoming innovative to meet new changes and challenges  Improving communications across large, complex and /or multiple delivery systems  Establishing strong primary care physician infrastructure  Building and encouraging effective multiple disciplinary teams and networks to ensure access and improve quality of care 52

Strengths Needed in Health Care Systems  Learning to become less competitive and more cooperative… leading to…  Establishment of culture norms that contribute to a level of community engagement and collaboration (“shared interest in accomplishment”) 53

We Don’t Need Any “New” Interventions  We need implementation experience  We need cooperative, cross-setting, community-wide, population-focused implementation experience 54

Roland A. Grieb, MD, MHSA (812) Extension 221 This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-IN-TRAN /17/ Questions?