Targeting Avoidable Readmissions September 21, 2016 CTIC

Why Do We Need to Avoid Readmissions? “Change the way you look at things and the things you look at change” ― Wayne W. Dyer

The Greatest Challenge in Health Care Crossing the Crevasse FEE FOR SERVICE Focus on Patient in Front of Your Face Incentive to Do More Few Quality Indicators Tremendous Fragmentation All about Cross Subsidy VALUE-BASED CARE Penalties for Higher than expected Readmissions Higher Quality Care in Home Setting Performance Payments for Chronic Care Management Bundled Payments for Care Improvement Joint Contracts with Payers Laser Focus on Patient Data

Where is Healthcare Going?

Readmission Rates

How Have We Been Doing? “Change the way you look at things and the things you look at change” ― Wayne W. Dyer

Diagnosis Specific Focus

Disease Specific Focus

How Else Do We Know Where to Focus our Work? ADMIT SOURCE AGE ADMIT: 55% are EC (Home); 1/3 are SNF DISPO: 1/3 are SNF; 45% are home/HH; 6% are Hospice (avg time lapse between adm/readmit is 9 days) AGE: 79% are over 65; 64% are over 75 Marital Status

Readmission Demographics DISCHARGE SOURCE (1st) DISCHARGE SOURCE (2nd +) SNF Home Home Health Home Health ADMIT: 55% are EC (Home); 1/3 are SNF DISPO: 1/3 are SNF; 45% are home/HH; 6% are Hospice (avg time lapse between adm/readmit is 9 days) AGE: 79% are over 65; 64% are over 75 Home SNF

Readmissions per Patient 30% of (Readmitted) Patients have 3 or more readmissions - Most (44%) of readmissions are comprised of 1 visit (or readmission); however there are 30% that have more than 3 visits. 1185 actual patients make up the 1836 readmissions - less than half (44%) of total readmissions consist of patients with one visit (readmission); the other 56% have 2 or more readmissions within 30 days *Readmission is defined as any subsequent admission within 30 days of the last admission, regardless of diagnosis.

Why do they come back? Heart Failure Sepsis Other infections End of Life Medication issues Falls Social factors “Non-compliance”??..... Transport Ability to cope at home falls

Strategies Risk Prediction Tool development Original readmission risk prediction scored by Case Manager Moved to PRISM in May 2015 Development of Care Bundles Layering of services based on patient’s vulnerability

Inpatient Clinicians Patient and Family Education Teach-Back (Show Me Tell Me) Prevention of functional decline Prevention of Delirium Nutritional maintenance Clarity of DC Instructions Discharge information and checklists Scheduling follow up appointment Consideration and communication regarding Palliative Care approach Mobility protocol PAL program

How many ‘goals’ do we expect patients to follow? What Drives Patients? How many ‘goals’ do we expect patients to follow? I need you to reduce your salt intake I need you to lose weight I need you to take these pills I need you to rest more I need you to exercise more If they don’t we label them “non-compliant” How does this label affect their experience? Primary Care Cardiologist Endocrinologist Pulmonologist Geriatrician……..

What Matters to the Patient? I can’t do that I don’t want to do that Personal Goal setting and determination of the barriers

Transition Coach Program Designed to encourage vulnerable, patients with moderate to high risk of readmission, assert a more active role during care transitions. Core Intervention developed by Dr Eric Coleman, University of Colorado Patients who received this intervention were found to have significantly reduced readmissions and the benefits were sustained for 5 months after the intervention ended ( 1 study demonstrated 50% reduction) By empowering the patient, the intent is to reduce readmission risk and maintain patient in the community for longer periods of time Also to reduce risk of adverse events related to medication discrepancies

Transition Coach Intervention Focuses on 4 main ‘pillars’: Medication self-management Use of a Personal Health Record Timely physician follow-up Knowledge of red flags and how to respond Intervention lasts 30 days: 1 in-hospital visit to introduce personal health record 1 in-home visit to review medication list 3 follow up phone calls to continue coaching

Enhancements to Transition Support Post Discharge phone calls to all patients Focus on improved understanding of DC instructions Prescriptions filled F/Up appointment scheduled Removal of barriers to any of the above Partnering with The Senior Alliance Community Health Workers 1 week of meals Transportation to F/up appointment Community resources Bundled Payment Care Improvement Initiative Care Navigator for certain DRG’s for 90 days post discharge Focus on ensuring appropriate level of care for appropriate duration

It Takes A Village Working with post-acute providers SNF’s Analysis of data to identify best performers and drive improvements Monthly case reviews on any readmission Working on SNF care bundles based on PRISM Improve communication RN:RN verbal handover IP Physician: SNF Physician Handover…… HHC Agencies Development of preferred network based on analysis of performance Bi-monthly meetings to review performance and improve communication Working on HHC care bundles based on PRISM Cross Continuum Coalitions and Taskforces STAR ForUM CTIC Sepsis Education Taskforce

HHC Preferred Partner Collaborative

Primary Care Office Prompt follow up appointments Collaboration with post-acute care team Care Managers for ongoing education, disease management and care plan adherence, checking for triggers, use of rescue kits Practice team meetings to review any readmissions for opportunities 3-5 days for PRISM ½ Home visit arrangement if unable to get to office?

QUESTIONS?: Ann Hill