8-step Review Process & Care plan Templates 8 step process to review update your strategy for 2016

1. Conduct 1-page Readmission Analysis Use the most recent 12 months of data available. Using all hospital discharge data, exclude patients <18, all OB (DRG 630-679), discharges dead, or transfers to another acute care hospital. Define a readmission as any return to inpatient status within 30-days of discharge from inpatient status. Measure Total Medicare Medicaid Private A. Total Discharges B. Total Readmissions C. Readmission Rate (B/A) D. Total Discharges to Home E. Total Readmissions among Discharges to Home F. Readmission Rate among Discharges to Home (E/D) G. Total Discharges to Post-Acute Care Settings (home health, SNF) H. Total Readmissions among Discharges to Post Acute Care Settings I. Readmission Rate among Discharges to Post Acute Care Settings (H/G) J. Total Discharges with any coded Behavioral Health Diagnosis K. Total Readmissions with any coded Behavioral Health Diagnosis L. Readmission Rate among Discharges with any BH Diagnosis (K/J) M. Number of readmissions occurring within 7 days of d/c N. Number of patients with ≥4 hospitalizations in past year (MRNs) O. Total number of discharges among [N] (encounters) P. Total Number of 30-day readmissions among [O] Q. Proportion of All Readmissions Accounted for by High Users (P/E) R. Top 5 or 10 Discharge Diagnoses Resulting in Readmission, by Payer All Payer Medicare Medicaid 1 2 3 4 5 N. Proportion of all readmissions represented by top 10 discharge diagnoses X% Y% Z%

2. Conduct 5 Patient/ Caregiver Interviews Please interview 5-8 readmitted patients to facilitate an expanded understanding of the patient/family/caregiver perspective of readmissions. The purpose of these interviews is to elicit the “story behind the chief complaint” – understand the events that occurred between the time of discharge and readmission and/or why they chose to seek care again in the ED. Capture “all” the reasons (Feigenbaum, Rising) why a person is repeatedly using acute care and consider why they do not feel supported by or have adequate access to community-based care. Include a family/caregiver in at least 1 interview (more is better), include a provider in at least 1 interview (more is better), include at least 3 Medicaid patients. You should interview patients who are currently hospitalized and interview while on site. Helpful Resources: AHRQ Hospital Guide to Reducing Medicaid Readmissions: http://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html “Factors Contributing to All-Cause 30-Day Readmissions: A Structured Case Series Across 18 Hospitals.” Feigenbaum et al. Medical Care July 2012. “Return Visits to the Emergency Department: The Patient Perspective.” Rising et al. Annals of Emergency Medicine Fall 2014. Patient/Caregiver Interview Findings and Lessons Learned 1 2. 3. 4. 5.

3. Specify & Quantify the Target Population(s) Specify here the target population with higher than average readmission rates that are the focus of your hospital’s readmission reduction efforts. Specify the description of the population, and the size (from your data analysis): Target Population Description Target Population Size (in number of discharges per year) Define population Quantify # hospitalizations 4. Baseline Performance – Target Pop & Hospital-Wide Please provide the most recent 12 months of hospital-wide and target- population readmission rates, on a monthly basis. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Avg. Hospital-Wide Readmits Discharges Rate (%) 10% Target Pop 25% *if target pop rates aren’t higher than hospital, back to drawing board!

Your Aim Statement (1 + 2 + 3 + 4) 5. Update your Aim Statement Component Your Hospital’s Aim 1. Measurable Outcome (what?) All cause 30 day readmissions 2. Specific Target Population (for whom?) Target pop definition 3. Magnitude of Impact (by how much?) Eg 25% 4. Time Course (by when?) by December 31 2016 Your Aim Statement (1 + 2 + 3 + 4)

6. Calculate the Estimated Monthly Volume & Impact Once you have identified and quantified your target population, their baseline readmission rate, and your readmission reduction aim, estimate the monthly impact your readmission reduction efforts are expected to have. # Discharges in Target Population Target Population Readmission Rate Expected Avoided Readmissions Expected # Readmissions Example: 300 discharges per month Rate = 25% 300 x .25 = 75 RA per month Reduce by 20% .20 x 75 = 15 fewer RA Result 75 – 15 = 60 RA per month Important so you know how to staff/implement 300 discharges per month = 10 discharges per day 30 discharge per month = 1 discharge per day

7. Calculate the Annual Impact for the Target Population and for the Hospital-Wide Rates Once you have identified and quantified the monthly volume of target population discharges your staff/service will encounter, the current readmission rate and number, the readmission reduction goal in terms of reduced readmissions per month, evaluate overall impact on the target population and on the hospital-wide rates. # Discharges in Target Population Target Population Readmission Rate Expected Avoided Readmissions Expected # Readmissions Target Pop: x 12 = 3600 Discharges per yr 3600 x 25% = 900 RA per yr 15 x 12 = 180 Fewer RA per year New Rate: 720 /3600 = 20% Hospital-wide 12,000 discharges per year 10% RA rate = 1200 RA/ yr 1200-180 = 1020 New rate: 1020/1200 = 8.5% Ask: Does this strategy meaningfully reduce readmissions for the target population and for the hospital as a whole?

8. Compare Resource Required with Expected Results Cost of intervention(s) Example complex care team with salaries of $250,000 annually SW + Pharm + 2 CHW Benefit gained Only you can say at this point in the market- consider penalty avoided, low-acuity bed use avoided, shared savings on risk, etc. In example: 180 readmissions avoided 180 readmissions at $10,000 each (payer cost) = $1.8M in avoided utilization

Examples from teams across the US Care Plans Examples from teams across the US

Baltimore Hospitals Multiple hospitals collaborating Develop 1 page Summary Background Challenge Recommendations – staff, MDs Recent studies Care Management contact

MGH – PCP authored, in EMR, but need to search … MGH – PCP authored, in EMR, but need to search ….an example, not perfect Acute care plan Clinical: typically presenting with cyclic vomiting syndrome, often precipitated by psychosocial stressors and anxiety. Per GI, [name of GI NP] NP, patient should be treated with IVAtivan 4-6 mg and IV Zofran 8mg q 6 hrs until vomiting has subsided, with respiratory monitoring in place. He should continue on amitriptyline 100 mg QHS. Disposition Considerations If patient is to be discharged home from ED: ensure follow up with GI ([name of NP], NP for Dr. [name of GI MD]). If patient is to be admitted to Hospital: Team 4 [this is the non-housestaff hospitalist service] Advance Care Planning HC Proxy: [name], father Key Psychiatric and Psychosocial Considerations: History of depression and anxiety, seen by MGH psychiatry Provider Managing Pain/Psych Meds: Dr. [name], psychiatry Ambulatory Care Team: [name], NP - GI Dr. [name]- GI Resident PCP [name]- medicine ____________________________________ [signed by PCP with pager #] Demographics of Use Case: 36 M cyclic vomiting syndrome Utilization prior 12 months: 12/15/14 - ED, inpatient 2/3/15  ED, inpatient 6/14/15 - ED inpatient 6/25/15 - ED , inpatient 6/28/15 - ED, inpatient 8/5/15 - ED, inpatient 9/25/15 – ED, inpatient

Inpatient team Multidisciplinary Shared place for mx disc recs Care Team Goals Community Partners Appointments Services

Community Care Plan Focus on BH patients 4 pages

Hospital Care Plan Example “Underlying pathology” “Reason for care plan” Effective date Date due for review Clinical Contact Intervention Goals and Outcomes Approval

ED Care Plan Letter Patient facing Signed Chief of ED

Recommendations Start with your top 20 patients Ask 1 person to create the “summary” Brief medical issue What the recurrent presentation profile is Utilization history (# hospitalization, # ED) Imaging/testing history (CTs, CXR, stress tests, ROMIs, etc) Medical, social, familial resources = the “Team” Contact name , pager, email Recommendations for ED Create a binder Move to IT flags, links, shared drive for reliable use Case review with ED docs

Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies Thank you Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies amy@collaborativehealthcarestrategies.com 617-710-5785