Innovative Solutions in Preventing Hospitals ReAdmissions Raymond Carr, DNP, RN, CENP/The Hospitals of Providence Sierra Campus Patricia Duran, DNP, RN, CENP/Gayle Greve Hunt School of Nsg

Overview of Readmission Reduction Patricia Duran

Overview of Hospital Inpatient Quality Reporting Program The Hospital Inpatient Quality Reporting Program was originally mandated by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. The goal of driving quality improvement through measurement and transparency by publicly displaying data to help consumers make more informed decisions about their health care In addition, intended to encourage hospitals and clinicians to improve the quality and cost of inpatient care provided to all patients.

Overview of Readmission Reduction Program (HRRP) Applying to most inpatient hospitals, the Department of Health and Human Services states that the HRRP will play a role in its new goals to tie an increasing share of traditional Medicare payments to quality or value in the coming years HRRP is one of 5 Value Bases Purchasing programs for Medicare (Pay for Performance). Section 3025 of the 2010 Affordable Care Act required the Secretary of the Department of Health and Human Services to establish the HRRP starting October 1, 2012 (i.e., Federal Fiscal Year [FY] 2013).

Overview of Readmission Reduction Program (HRRP) What measures are included in the Hospital Readmissions Reduction Program? Acute Myocardial Infarction (AMI) Chronic Obstructive Pulmonary Disease (COPD) Heart Failure (HF) Pneumonia Coronary Artery Bypass Graft (CABG) Surgery Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA) *HRRP doesn’t include the Hospital-Wide All-Cause Readmission (HWR) measure, which is included in the Hospital Inpatient Quality Reporting (IQR) Program.

Where are we now? Median hospital 30-day risk standardized readmission rate (%) for certain conditions, July 2010 – June 2013 Key: HF = heart failure; COPD = chronic obstructive pulmonary disease; AMI = acute myocardial infraction; PN = pneumonia. Source: Centers for Medicare & Medicaid Services, 2014 Medicare Hospital Quality Chartbook

Readmission Reduction Resources- Tried and True Patricia Duran

Resources Available Agency for Healthcare and Research Quality (AHRQ) Agency Healthcare and Research Quality – Priorities in Focus Care Coordination Hospital Readmission Programs – RED; BOOST Tool Kits Taking Care of Myself Guides Data Research

Robert Wood Johnson Foundation Healthy Communities Healthy Children, Healthy Weight Health Systems Leadership for Better Health

Robert Wood Johnson Foundation- Reducing Hospital Readmissions Best in Practice Stories – Improving Transitions Journal Articles - Hospitals With Higher Nurse Staffing Had Lower Odds Of Readmissions Penalties Than Hospitals With Lower Staffing

Institute of Hospital Improvement Reducing Hospital Readmissions Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions Toolkits Audio Resources Video Resources

The Staar Program Institute of Hospital Improvement PARTICIPATING STATES Massachusetts Michigan Washington Institute of Hospital Improvement

State Action on Avoidable Rehospitalizations May 2009 – June 2013 Dramatically improve the delivery of effective care at a regional scale.  Reduce rehospitalizations Working across organizational boundaries By engaging Payers, Stakeholders at the state, regional and national level Patients and families, and caregivers IHI provided strategic guidance, support and technical assistance to hospitals and cross-continuum teams to improve transitions in care and reduce avoidable rehospitalizations.

Working across organizational boundaries Improve transitions of care by cultivating a cross-continuum learning collaborative. Core Process Communication tools and norms, Handoff and follow-up delineations of responsibility Care coordination activities Engage state-level leadership to understand and mitigate systemic barriers to change.  Mitigation of barriers to system-wide improvement Policy and payment reforms that will reduce fragmentation and encourage coordination across the continuum of care. Prioritizing longitudinal care and reducing avoidable rehospitalizations involves new behaviors, norms, relationships, and partnerships to communicate and coordinate care between disciplines, settings, and organizations. State-level leadership is essential to understand and act on the barriers that front-line teams encounter in doing this work. Similar in many respects to the cross-continuum team at the provider-level, STAAR engages with multi-stakeholder state leaders and steering committees to lead and coordinate this initiative at the state level. This is especially relevant in states coordinating several ACA and delivery reform initiatives simultaneously.

Improving Transitions of Care Provide an enhanced assessment of post-hospital needs Involve family caregivers and community providers as full partners in completing a needs assessment of  patients’ home-going needs.  Reconcile medications upon admission.  Create a customized discharge plan based on the assessment. Provide effective teaching and facilitate enhanced learning Customize the patient education materials and processes for patients and caregivers. Identify all learners on admission   Use Teach Back regularly throughout the hospital stay to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self- care. STAAR hospital teams focus on the implementation of four key recommended process-level improvements that require extensive collaboration between the hospitals and their community partners to effectively co-design better processes.  

Improving Transitions of care (cont)  Provide Real-time Handover Communications Reconcile medications at discharge.  Provide customized, real-time critical information to next clinical care provider(s).  Give patients and family members a patient-friendly discharge plan.  For high-risk patients, a clinician calls the individual listed as the patient’s emergency contact to discuss the patient’s status and plan of care. Ensure Timely Post-Hospital Care Follow-Up Identify each patient’s risk for readmission.   Prior to discharge, schedule timely follow-up care and initiate clinical and social services based upon the risk assessment.

Outcome/Process Measures: Readmissions 30-Day All-Cause Readmissions (overall hospital and pilot-unit) Counter Measures – Observation Hours

Available Resources through IHI How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations Readmissions Diagnostic Worksheet

Readmission Improvement The Hospitals of Providence East Campus Raymond Carr, DNP, RN, CENP

Improving Transitions of Care In 2016, A Discharge Collaborative was held with Home Health Agencies Feedback Obtained Form to Improve information at TOC developed Implemented on a pilot unit Improvement spread after pilot successful

Improving Transition Processes at “EAST” Improving the process of Teach Back Improving Understanding for Pt/Family Improving Self-Management Improving Knowledge of Transition of Care 2016 saw an improvement of All Cause Readmission from 17% to 13%

Readmission Reduction at East - 2017 Higher Risk Score – Patients identified by a High Risk Calculator by Tenet now available Targeted Diagnosis – Data Analysis done to determine Focus of patients with co-morbidities Team approach used – Integrated with Patient Rounds for Patient Experience

Process High Risk Patient identified daily Tool for Team documentation in chart Integrated into Patient Experience Rounds Intense Education to patient/family along with supplies for discharge and self-management Teach Back used by educator and by nursing staff

Challenges to Readmission Reduction Patient/Family Illiteracy of Disease Process Reinforcement of Patient/Family to see PCP circumvented by PCP when sent to ED PCP office visits not available within chosen time frame

Pilot Outcomes Summary: Table 1. Readmissions presented as number of occurrences   January 2017 February 2017 March 2017 Var, Feb - March Total Admissions 988 974 1084 110 Overall Readmissions 79 68 100 32 Total Related Readmissions 24 42 18 COPD 2 1 -1 CHF 3 Pneumonia AMI Table 2. Readmissions presented as a percentage of "Total Related Readmissions" January February March %Var, Feb - Mar 8% 7% 9% 2% 30% 35% 42% 4% 0% -4% 13% 5% -8% 1% Summary: As shown in Table 2 and line graph below, there was a decrease in COPD, CHF, and Pneumonia readmissions in March compared to February. There was a 2% increase in total readmissions, a 7% increase in readmissions related to previous visit and a 1% increase in AMI readmissions.  

Pilot Outcomes

SOLUTIONS FROM Robert Wood Johnson Foundation https://www.youtube.com/watch?v=QwdLww8Y8gQ

References Agency for Research Health and Quality. (2018). Readmission Reduction Retrieved June 15, 2018 from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HospitalQualityInits/HospitalRHQDAPU.html Agency for Research Health and Quality. (2018). Readmission Reduction tools Retrieved June 15, 2018 from https://www.ahrq.gov/patient-safety/index.html Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions. Cambridge, MA: Institute for Healthcare Improvement; 2009. Boutwell, A. Jencks, S. Nielsen, GA. Rutherford, P. STate Action on Avoidable Rehospitalizations (STAAR) Initiative: Applying early evidence and experience in front-line process improvements to develop a state-based strategy. Cambridge, MA: Institute for Healthcare Improvement; 2009. Centers for Medicare and Medicaid Services (2017). Readmission Reduction Program. Retrieved June 27, 2018 from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions- Reduction- Program.html Institute of Hospital Improvement (2018). Reduce Avoidable Readmissions Retrieved July 1, 2018 from http://www.ihi.org/Topics/Readmissions/Pages/default.aspx