22670 Haggerty Road, Suite 100, Farmington Hills, MI l Save Your Census: Strategies to Prevent Re-hospitalization March 30, 2010 Joint Provider/Surveyor Training 9SOW-MI

Background: Hospitalization of Nursing Home Residents are: Common Often disruptive for the resident and family Fraught with many complications Costly Sometimes an inappropriate and avoidable use of the Emergency Room 2

SNF Admissions/Readmissions: 40% of Medicare beneficiaries are discharged to a post acute setting. (SNF, Home Care, Hospice) 50% of these enter a nursing home for rehabilitation or long term care The rate of SNF 30 day rehospitalizations grew 29% between 2000 and 2006 from 18.2% to 23.5% The total cost for these re-admissions: $4.34 Billion Source: The Revolving Door of Rehospitalization From Skilled Nursing Facilities, /29:1 Health affairs 3

Michigan Data for 2006 : 65,477 skilled nursing home episodes 25.8% were re-hospitalized within 30 days of the initial hospitalization Total re-hospitalization payments:$ Million Source: The Revolving Door of Rehospitalization From Skilled Nursing Facilities, / 29:1 Health affairs 4

Top 5 Re-admissions from SNF: Heart Failure Respiratory Infection Urinary Tract Infection Sepsis Electrolyte Imbalance Source: Medicare Payment Advisory Commission, Washington D.C.,

These Re-admissions: Are potentially avoidable Account for 78% of all thirty-day SNF Re- hospitalizations Cost Medicare $3.39 Billion in 2006 Source: Medicare Payment Advisory Commission, Washington D.C.,

Other Costs of Re-hospitalizations: Negative outcomes associated with medical errors Stress for patients and caregivers Duplication of tests or procedures Functional decline of patients Loss of SNF revenue due to empty beds 7

Why do Re-hospitalizations Occur? 8 Transfer of information to the next care setting is often incomplete Receiving practitioners often do not know the patient and his or her preferences for care Practitioners have no accountability once a patient leaves their care Patients and caregivers have few tools to navigate all the settings

The Care Transitions Project: Three year Initiative ending July 31, 2011 Focused in the Greater Lansing Area Goals of project: ■ Reduce hospital readmissions of Medicare Beneficiaries ■ Improve collaboration across care settings ► Acute care, LTAC, SNF, HHC/Hospice/ Physicians 9

Skilled Nursing Facilities’ Role: Used INTERACT Toolkit to identify drivers of readmissions Implemented evidence-based interventions from INTERACT Toolkit to decrease the likelihood of readmissions Implemented Care Transition Coaching Joined Cross Setting Work group to reduce heart failure re- admissions Send PCP a discharge summary prior to rehab patient discharges Increased utilization of home care upon discharge 10

Burcham Hills Improvement Journey: Improving communication through patient-centered care ■ Welcoming program ■ 3 day care conferences ■ Inclusion of patient and family in discharge planning Improving communication across the continuum ■ Adding a new staff position: ► Improved communication between residential community, hospital, and healthcare center ► Risk assessments 11

Ingham County Medical Care Facility's Improvement Journey: Admission Assessments RN Gate keeper Staff Education Monitoring Results Cross Setting Collaboration through the heart failure workgroup Care transitions coaching 12

How Does a SNF get started? Obtain data: ■ Monthly hospital readmission numbers ■ Monthly emergency department visits Determine potential drivers of readmissions ■ Use INTERACT “Review of Acute Care Transfers” audit tool Initiate or Join a cross-setting Collaborative to improve communication across settings. 13

Use Interact Tools for: Reducing avoidable acute care transfers Early identification of a change in resident status To guide nursing home staff through a comprehensive resident assessment when a change is noted Improve documentation Enhance Communication 14

Find the INTERACT II toolkit at: 15

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MPRO’s Care Transitions Team: Donna Beebe, Project Manager or Sandra Soronen, Project Coordinator or Barbara J. Smith, Project Manager or

22670 Haggerty Road, Suite 100, Farmington Hills, MI l MPRO’s Mission: Improving quality, safety and efficiency across the healthcare continuum. This material was prepared by MPRO, the Medicare Quality Improvement Organization for Michigan, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-9MI