DO DIETITIANS HAVE A ROLE? Renee Wing, Sodexo Dietetic Intern Orange Park Medical Center January 22, 2013

 Highlights of the legislation  Statistics  Interventions  Dietitians’ role

 Section 3025 of the Affordable Care Act - Readmission Reduction Program.  Starting October 1, 2012, payments to hospitals exceeding a formulated readmission ratio will be reduced. Up to 1% in 2013 – Estimated savings of $300 million Up to 2% in 2014 Up to 3% in 2015

 Discharge diagnoses of CHF, AMI, and Pneumonia are used as measures to evaluate readmissions.  Additional discharges to be considered include: COPD, CABG, PTCA, and other vascular surgeries. To be reviewed in 2015.

 Readmission – admission to a hospital within 30 days of discharge from the same or other hospital.  Readmission does NOT need to be for the same condition or a related condition.

 Transfer to another acute care facility.  Planned readmissions.  Same day readmissions for the same condition.  Discharged against medical advice.  Patient without at least 30 days of post- discharge enrollment in FFS Medicare  Maryland

 1 million hospitalizations in 2010  Costs $34 billion annually  Among the conditions associated with 30% of preventable readmissions.  Highest volume and expenditure (along with pneumonia)

CHF STATISTICS

National average readmission rate for CHF is 24.7% Out of 4829 in the United States → 95 hospitals in the United States were Better than U.S. National Rate 3959 hospitals in the United States were No different than U.S. National Rate 162 hospitals in the United States were Worse than U.S. National Rate 613 hospitals in the United States did not have enough cases to reliably tell how well they are performing Out of 189 in Florida → 6 hospitals were Better than U.S. National Rate 161 hospitals were No different than U.S. National Rate 11 hospitals were Worse than U.S. National Rate 11 hospitals in Florida did not have enough cases to reliably tell how well they are performing

OPMCShandsMayoMemorialBaptist # CHF Discharges # CHF Readmissions CHF Readmission Rate 24.8%25.8%24.9%25.4%25.5% CHF Excess Readmission Ratio Penalty*0.00%0.21%0.05%0.34%0.14% *Based on calculation which combines data on CHF, AMI, PNA

 Factors beyond anyone’s control  Disease Specific Factors  Patient Factors  Physician Factor  System Factors CausesOf30DayHospReadmissionInHeartFailurePatients.pdf

Nassar AI, Hasaneen AG, Alshikha MA, Enany BE (2012) Three Months Morbidity and Mortality of Newly Diagnosed Systolic Heart Failure Patients after their First Admission. J Clinic Experiment Cardiol 3:183. doi: /

 Enhanced transitional care  Education and self-management  Multi-disciplinary team

12 Steps: 1. Assess language need 2. Make follow-up appointments 3. Pending labs 4. Post d/c services and equipment 5. Medication plan 6. Develop d/c plan 7. Teach d/c plan 8. Education 9. Assess understanding 10. How to manage a problem 11. Transmit d/c summary 12. Telephone reinforcement

 Multidisciplinary Outpatient Management Team includes a dietitian Follow-up individualized Significantly lower readmissions in intervention group  Tele-monitoring Daily calls to automated system Answers would trigger “red flags” to clinician who would then contact patient No significant difference in readmissions

 Nutrition and Healthy Aging in the Community – IOM workshop held in 2011 Include nutrition assessment goals in d/c plan Improve integration of hospital and post-d/c care  AND Recommendations MNT – initial visit of at least 45 minutes with 1-3 follow-up visits of at least 30 minutes. CHF patients shown to reduce sodium and fluid intake and improve quality of life

 Do dietitians have a role in the efforts to reduce readmissions?  What implications does this have for the RD’s role in the hospital?  What do you think about the transitional care strategies?