Reducing Readmissions: A Review of the Relevance, Causes, and Evidence Regarding Rehospitalizations Niladri Das, MD Mary Pat Friedlander, MD Gretchen Shelesky, MD Faculty, UPMC St. Margaret Family Medicine Residency Program

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Objectives On completion of this session, the participants should be able to: 1.Identify the reasons why hospital readmissions are relevant to healthcare 2.Describe the most common causes of rehospitalizations 3.Recognize the readmission reducing interventions with the most evidence for implementation 4.Identify areas in your practice environment where you may be able to implement interventions

TRIPLE AIM Better Care for Individuals Better Health for Populations Lower Per Capita Costs

1979: $255.8 Billion Dollars or 9.2% of our GDP HEALTH CARE EXPENDITURES 2011: $2,700.7 Billion Dollars or 17.9% of our GDP SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Department of Commerce, Bureau of Economic Analysis; and U.S. Bureau of the Census 1/3

Rehospitalizations among Patients in the Medicare Fee-for-Service Program, Jencks, et. Al.N Engl J Med 2009; 360: April 2, % rate of readmissions

Rehospitalizations among Patients in the Medicare Fee-for-Service Program, Jencks, et. Al.N Engl J Med 2009; 360: April 2, 2009 NEJM Article 50% of readmissions did not have follow up contact with a physician post discharge $17.4 Billion of Billion in Medicare Payouts 70% of Surgical Readmits were for Medical Conditions

CMS: Value Based Purchasing (AKA Hospital Readmission Reduction Program) Congestive Heart Failure (CHF), Pneumonia (PNA), Acute Myocardial Infarction (AMI) Penalties for readmissions above base rate at 30 days Started with 1% Penalty on reimbursement in October 2012, escalating every year Next Up: COPD and Voluntary Orthopedic Procedures

JAMA. 2013;309(4):

Why were these 3 conditions selected? 18 month pre and post establishment of a pay-for-performance system in the U.K. They found a mortality benefit for PNA, AMI, and CHF with an establishment of such a system N Engl J Med 2012;367:1821-8

READMISSIONS HEALTH CARE SYSTEM

All Healthcare is Local

Case Study 63 y/o M with DM, HTN, Bipolar Disorder Unrestrained passenger in MVA Admitted to nearby super hopsital C4 facet fx, non-operable Basilar Pseudoaneurysm Lung Nodules with LAD Discharge home with Pain Medications and 4 PRN Bowel meds Recently Homeless Long standing history of EtOH abuse, sober, but cognitive dysfunction Lives alone Dropped a soup can on his toe 2 days prior to admission that was infected No transportation

What are Readmissions? Readmission Rate is not a measurement of quality It is not a measure of a patient’s health status It is a measure of healthcare utilization It is emblematic for several different issues in our health care system JAMA. 2011;306(16):

Commonwealth Fund pub Vol 24

Factors Contributing to Preventable Readmissions 7 Factors out of 250 different factors identified: –F–Follow-Up –C–Clinical Monitoring and Management –P–Planning Transitions –C–Coordinating Care –P–Psycho-Social needs –U–Unmet end-of-life needs –M–Medication Management Med Care 2012;50:

JAMA. 2011;306(16): Good Inpatient Care, but Poor Outpatient follow up But not all follow up is the same

JAMA. 2011;306(16): Commonwealth Fund pub vol 34 Social Support

Readmission Factors Medicare Beneficiaries with the 10 or more chronic conditions are 6 times more likely to be admitted than those with 4 chronic conditions The severity of illness on admission increases the likelihood of readmission Journal of Hospital Medicine 2013;8: Medical Care R&R 2013; 70(6)

HOSPITAL Score: One Methodology of Predicting Readmission JAMA Intern Med, Published online March 25, doi: /jamainternmed

Ann Intern Med. 2011;155(8):

State Action on Avoidable Rehospitalizations (STAAR) Team Based Approach to Readmissions 4 point model – Enhanced assessment of post-hospital needs – Effective teaching to facilitate learning by the patient and family caregivers – Post-hospital care follow up, including medical and social services – Communication of critical information as the patient transitions to the next provider JAMA 2013; (309)4:351

Other Strategies Self management of Heart Failure, 67% reduction in readmissions Oral Nutrition Supplementation significantly reduce hospital readmissions, particularly in older patient groups, with economic implications for health care Hospitals that implemented more strategies had significantly lower readmission rates Modern Healthcare (3/19/12) p0026; Circulation: Cardiovascular Quality and Outcomes. 2013; 6: ; Ageing Research Reviews Volume 12, Issue 4, September 2013, Pages 884–897

This is a picture of a TEAM. The team concept is the cornerstone of a functional medical home.

RE-Admissions “ Control costs by keeping patients out of the hospital” Change in Reimbursement Structure: ACOs, Patient Centered Medical Home, service modification Modern Healthcare (3/19/12) p0026

Take Home Points Remember the Triple Aim: Better Care for Individuals, Better Health for Populations, Lower Per Capita Costs Readmissions are multifactorial: a complex health care system that we can work to improve Every part of the healthcare team is integral in improving the system (PATIENTS)

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