1. Development of an Outpatient Transfusion Program to Reduce Avoidable Hospitalizations Zachary J. Palace MD CMD FACP The Hebrew Home at Riverdale Bronx, NY 2015 AMDA Foundation Quality Improvement and Health Outcome Award

2. Speaker Disclosures Dr. Palace has disclosed that he has no relevant financial relationships.

3. The Hebrew Home at Riverdale by RiverSpring Health Bronx, NY Established in 1917, an 855 bed not-for-profit skilled nursing facility, located on a 32 acre campus on the Hudson River. Twenty patient neighborhoods, including two 45 bed subacute units, and four memory care units. Services include PT, OT, ST, hydrotherapy pool and wellness center, LVAD care, on-site peritoneal dialysis, hospice and palliative care. On-site laboratory and satellite pharmacy. Medical Department composed of 7 FT physicians, 2 NP’s and Optum ©, 24/7 on-site physician coverage..

4. Learning Objectives By the end of the session, participants will be able to: Appreciate the benefits of an innovative skilled nursing facility-based quality improvement initiative in reducing avoidable hospitalizations. Appreciate the role of an inter-institutional clinical collaboration in addressing an unmet need. Recognize the benefits to the patient and the facility by avoiding hospitalization. Recognize the reduction in healthcare costs associated with outpatient transfusions.

5. Anemia Challenges Most patients with chronic anemia and a low hemoglobin do not need to be admitted to hospital Many can be managed on site (eg. iron, ESA) Some do need a blood transfusion Patients presenting to the emergency room for a blood transfusion are ADMITTED 5 ESA=erythropoeitin-stimulating agent

6. Asking the Question… How can our facility send patients for a blood transfusion without them getting admitted? Hematologists send their patients living in the community to the blood bank for transfusions. 6

7. Quality Improvement Initiative Objective: To develop a favorable alternative to the unnecessary hospitalization of nursing home residents requiring blood transfusion. The protocol was developed for the nursing home resident who is evaluated for anemia and a clinical decision is made for a blood transfusion without pursuing an extensive diagnostic workup and an inpatient admission. Through clinical collaboration with a geriatrician liaison at a local hospital, the transfusion protocol transfer form was developed. 7

8. Exclusion Criteria Active bleeding Hemodynamic instability Family request for admission 8

9. Intervention: Clinical collaboration to provide outpatient transfusions Developed transfusion transfer form. This form contains relevant patient demographic and clinical data, including diagnoses, medications, allergies, recent lab values, and previous transfusion history. Transfusion transfer form is completed by the SNF physician/nurse practitioner and faxed to the hospital-based geriatrician for further review. 9

10. Intervention: Clinical collaboration to provide outpatient transfusions Hospital-based geriatrician coordinates with the hospital blood center for an out-patient transfusion on the following day Patient is transported to the hospital blood center for transfusion and returned to the nursing home later that same day, avoiding an in-patient hospital stay 10

11. Consequences of the Elderly Being Admitted to the Hospital Loss of physical function due to prolonged immobility Development of new decubiti Nosocomial infections Acute adjustment reaction Financial impact (payer, facility) 11

12. Results 74% reduction in hospitalizations for anemia

13. Results From 7/1/09 through 12/31/14 there was a 74% reduction in patients transferred out to hospital for a diagnosis of anemia. From 7/1/09 through 12/31/14 there were 232 outpatient transfusions. 13

14. 2012 National Statistics - Outcomes for ICD-9-CM principal procedure code 99.04 Packed Cell Transfusion Weighted national estimates from HCUP National Inpatient Sample (NIS), 2012, Agency for Healthcare Research and Quality (AHRQ), based on data collected by individual States and provided to AHRQ.(www.hcupnet.ahrq.gov, 2/6/2015)www.hcupnet.ahrq.gov Total number of discharges LOS (length of stay), days (mean)Charges, $ (mean)Costs, $ (mean) All discharges 700,235 (100.00%)5.238,44810,419 Payer Medicare 448,050 (63.99%)5.338,26010,339 Medicaid 84,490 (12.07%)5.642,70611,484 Private insurance 119,720 (17.10%)4.837,60910,369 Uninsured 30,385 (4.34%)4.132,1228,632 Other 16,215 (2.32%)4.939,91610,895 Missing 1,375 (0.20%)4.630,5788,650

15. Cost savings to Medicare Hospitalization for transfusion Medicare mean cost for inpatient transfusion : $10,339 Outpatient transfusion Medicare APC payment for outpatient transfusion: CPT 36430$350 CPT P9010$217 Total: $567 Cost savings per transfusion $10,339 - $567 = $9772 For 2014, 71 outpatient transfusions x $9772= $693,812 saved APC=Ambulatory Payment Classification

16. Cost savings to facility Mean inpatient length of stay = 5.3 days Average daily SNF rate approx. $300/d. For 2014, 71 outpatient transfusions. 71 inpatient stays avoided x 5.3 days/inpatient stay= 376.3 SNF days saved @ 300/day = $112,890. Facility transportation costs for 71 patients @$170RT = $12,070. 2014 net cost saving to facility approx. $100K.

17. Conclusion Reduce avoidable hospitalization of the elderly Improve quality of healthcare delivery for patients Improve relationships with local hospital Realize cost savings to the facility and reduce costs to the healthcare system

18. Credits Special thanks to: -HHAR staff physicians and NP’s -Optum © NP’s -Montefiore Medical Center Dept. of Geriatrics Wanda Horn MD, Amy Ehrlich MD -Montefiore Blood Bank

19. Contact info Zachary J. Palace MD CMD FACP Medical Director, Hebrew Home at Riverdale zachary.palace@hebrewhome.org