Readmissions Coordinating & Transforming Care August 23, 2012

Today’s Agenda  Issue overview  Comparison Framework  Cardiology Connection  Next Steps 2

Source: Commonwealth Fund, 2010 Medicare Readmission Rates 2009 Medicare readmission data revealed that Illinois ranked #48 for Heart Failure, #47 for Heart Attack, and #43 for Pneumonia.

CMS Readmissions Independent payment reduction program Goal – 20% reduction by 2014 Penalizes excess readmissions ACA: exclude unrelated, planned Uses AMI, CHF, Pneumonia diagnostic categories as index admissions (w/more to come) Imposes a 1% cap of total Medicare payments in 2013, 2% , 3% & thereafter Select hospitals – not yet CAH, LTC, Rehab or Children’s Excludes case volumes < 25 4

Illinois Readmission Activity Projected Medicare estimates:  2010 = $30.3 M  2011 = $25.3 M  Improvement in $20.2 M  128 Hospitals (CMS data ) 12.5% No Penalty 72.7% Some Penalty 14.8% Maximum Penalty Nationally: (34.5%) (57.4%) ( 8.3%)

Key Initiatives Improving transitions of care Developing & improving palliative care Redesigning hospital discharge processes Strengthening hospitalist programs Measuring reductions in readmissions using standardized metrics

Illinois Readmission Profile  Activity across Illinois hospitals  Unique Patient Identifier  Hospital agreements & submission  3M’s APR-DRG software readmission chains for clinically-related causes  All payer hospital-specific & aggregate reports

Illinois SMART ACT - Readmissions HFS “Performance-based” System for PPR HFS seeks a $40M savings in FY2013 Uses 3M’s PPR software & APR-DRGs as foundation Hospitals to be individually compared against a target PPR rate threshold using 2010 data – Above threshold – pymt w/hold – Below threshold – no pymt w/hold 8

Summary Comparison IHA HFS Medicare Primary Focus Quality Improvement $40 M Budget Savings Reimbursement Penalty for Non-compliance Patient Population All payers/Acute care inpatients; OBV, ED Medicaid beneficiaries - inpatients Medicare beneficiaries - inpatients Readmission criteria Clinically-related cause: 7 & 30 days Clinically-related cause: 30 days All cause for readm w/in 30 days of index d/c for AMI, CHF or Pneumonia Readmission Method Chain Yes/No Data Timeframe Starts w/ Q and then quarterly FY 2010 CMS Hospital Compare - 3yrs rolling (7/1/08 - 6/30/11) 9

Medicare Patients’ Readmissions Rate (Hospital Compare *and IHA Readmissions Resource**) (All Cause)* (Clinically Related Causes)** (All Cause)* CMS

Using IL Resource for Quality Improvement & Culture Transformation 11

Potential Preventable Readmission (PPR) A readmission that is clinically related to the index hospitalization. 12

Readmission Chain A sequence of PPRs that are all clinically related to the index hospitalization. May contain an index hospitalization and 1 PPR (most common), or may contain index and multiple PPRs. 13

3M Potential Preventable Readmissions (PPR) Methodology Exclude:  Newborns  Obstetrical  Major metastatic malignancy  Other malignancy  HIV  Trauma  Burn  Left against medical advice 14

Readmission Example #1 Patient admitted on 4/1 (Day 1), discharged on 4/5 (Day 5) w/diagnosis of CHF, subsequently readmitted with same diagnosis on 4/29 & d/c on 5/8 15 IHAHFSCMS Index d/c date D/C diagnosis 4/5 CHF 4/5 CHF 4/5 CHF Readmission CHF Yes - Clinically related Yes -within 30 days of index d/c w/CHF Equals1 Chain 1 Readmission Paymt PenaltyN/AApplies

Readmission Example #2 Patient admitted on 4/1 (Day 1), discharged on 4/5 (Day 5) w/diagnosis of Pneum, subsequently readmitted with Hip Replacement on 4/29 & d/c on 5/3 16 IHAHFSCMS Index d/c date D/C diagnosis 4/5 Pneu 4/5 Pneu 4/5 Pneu Readmission Hip Replacement No - Not Clinically related Yes - index d/c re: Pneu and readm within 30 days Equals0 Chain 1 Readmission Paymt PenaltyN/ANoneApplies

Readmission Example #3 Patient admitted on 4/1 (Day 1), discharged on 4/5 (Day 5) w/diagnosis of Hip Replacement, subsequently readmitted with CHF on 4/29 & d/c on 5/8 17 IHAHFSCMS Index d/c date D/C diagnosis 4/5 Hip Replacement 4/5 Hip Replacement 4/5 Hip Replacement ReadmissionNo - Not Clinically related No - index d/c not 1 of 3 diagnosis Equals0 Chain 0 Readmission Paymt PenaltyN/ANone

Readmission Example #4 Patient admitted on 4/1 (Day 1), discharged on 4/5 (Day 5) w/diagnosis of Hip Replacement, subsequently readmitted with CHF on 4/29 & d/c on 5/8 & readmitted w/CHF on 5/15, d/c on 5/28 18 IHAHFSCMS Index d/c date D/C diagnosis 4/5 Hip Replacement 4/5 Hip Replacement 4/5 Hip Replacement Readmission (CHF) 5/15 No – unrelated Yes No – unrelated Yes No – not 1/3 cond Yes – for cause 30 days re: CHF index Equals 0 Chain/ 1 Chain 0 Chain/ 1 Chain1 Readmission Paymt PenaltyN/ANone/Applies

Key Considerations IHA/HFS What is d/c date? What is d/c diagnosis? Any readmission activity w/in 30 days of d/c? Is readmission diagnosis clinically related? If so, a chain begins – and WILL continue unless “broken” by: Any non-related readmission within 30 days Time interval > than 30 days Any PPR exclusion activity 19

Key Considerations CMS What is d/c date? What is d/c diagnosis? Is the d/c diagnosis 1 of 3 – AMI, CHF or Pneumonia? AND Any readmission activity w/in 30 days of d/c? If so, then meets YES criteria Readmission penalty will be applied 20

Illinois Readmission Reports Hospital Level Reports (9)  Service line  Index APR DRG  Point of Origin  Discharge status  Principal Payer  Top readmission APR DRGs  Claim level  ED/OC Encounters 21

22 Heart Failure – CMS National % Illinois % Cardiology Connection

23

24

25

26

27

28

29

30

31

Next Steps Cultural Opportunities Assessment Communication CMS/IHA; HFS; Patient & Family Advisory; Committees: Quality/Medical Records/Medical Staff/Nurse Staff/Senior Leadership External partners Education & Training: Training recorded, future webinars, site visits Initial Target & Proposed Action Plan 32

Future Institute Activities Suggested topics Specialty Hospitals Across Hospital Activity Provider Possibilities Enhancing Cultural Gains 33

Additional Support  Contact COMPDATACOMPDATA Includes recorded webinar training Phone: 866/  HFS Medicaid Readmission PolicyReadmission  SAVE the DATE: October 3 (Wed) 12 – 1pm 34

35