1. 8-step Review Process & Care plan Templates
8 step process to review update your strategy for 2016

2. 1. Conduct 1-page Readmission Analysis
Use the most recent 12 months of data available. Using all hospital discharge data, exclude patients <18, all OB (DRG ), discharges dead, or transfers to another acute care hospital. Define a readmission as any return to inpatient status within 30-days of discharge from inpatient status.
Measure
Total
Medicare
Medicaid
Private
A. Total Discharges
B. Total Readmissions
C. Readmission Rate (B/A)
D. Total Discharges to Home
E. Total Readmissions among Discharges to Home
F. Readmission Rate among Discharges to Home (E/D)
G. Total Discharges to Post-Acute Care Settings (home health, SNF)
H. Total Readmissions among Discharges to Post Acute Care Settings
I. Readmission Rate among Discharges to Post Acute Care Settings (H/G)
J. Total Discharges with any coded Behavioral Health Diagnosis
K. Total Readmissions with any coded Behavioral Health Diagnosis
L. Readmission Rate among Discharges with any BH Diagnosis (K/J)
M. Number of readmissions occurring within 7 days of d/c
N. Number of patients with ≥4 hospitalizations in past year (MRNs)
O. Total number of discharges among [N] (encounters)
P. Total Number of 30-day readmissions among [O]
Q. Proportion of All Readmissions Accounted for by High Users (P/E)
R. Top 5 or 10 Discharge Diagnoses Resulting in Readmission, by Payer
All Payer
Medicare
Medicaid 1 2 3 4 5
N. Proportion of all readmissions represented by top 10 discharge diagnoses X% Y% Z%

3. 2. Conduct 5 Patient/ Caregiver Interviews
Please interview 5-8 readmitted patients to facilitate an expanded understanding of the patient/family/caregiver perspective of readmissions. The purpose of these interviews is to elicit the “story behind the chief complaint” – understand the events that occurred between the time of discharge and readmission and/or why they chose to seek care again in the ED. Capture “all” the reasons (Feigenbaum, Rising) why a person is repeatedly using acute care and consider why they do not feel supported by or have adequate access to community-based care.
Include a family/caregiver in at least 1 interview (more is better), include a provider in at least 1 interview (more is better), include at least 3 Medicaid patients. You should interview patients who are currently hospitalized and interview while on site.
Helpful Resources:
AHRQ Hospital Guide to Reducing Medicaid Readmissions:
“Factors Contributing to All-Cause 30-Day Readmissions: A Structured Case Series Across 18 Hospitals.” Feigenbaum et al. Medical Care July 2012.
“Return Visits to the Emergency Department: The Patient Perspective.” Rising et al. Annals of Emergency Medicine Fall 2014.
Patient/Caregiver Interview Findings and Lessons Learned 1 2. 3. 4. 5.

4. 3. Specify & Quantify the Target Population(s)
Specify here the target population with higher than average readmission rates that are the focus of your hospital’s readmission reduction efforts. Specify the description of the population, and the size (from your data analysis):
Target Population Description
Target Population Size
(in number of discharges per year)
Define population
Quantify # hospitalizations
4. Baseline Performance – Target Pop & Hospital-Wide
Please provide the most recent 12 months of hospital-wide and target- population readmission rates, on a monthly basis.
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Avg.
Hospital-Wide
Readmits
Discharges
Rate (%)
10%
Target Pop
25%
*if target pop rates aren’t higher than hospital, back to drawing board!

5. Your Aim Statement (1 + 2 + 3 + 4)
5. Update your Aim Statement
Component
Your Hospital’s Aim
1. Measurable Outcome (what?)
All cause 30 day readmissions
2. Specific Target Population (for whom?)
Target pop definition
3. Magnitude of Impact (by how much?)
Eg 25%
4. Time Course (by when?)
by December
Your Aim Statement ( )

6. 6. Calculate the Estimated Monthly Volume & Impact
Once you have identified and quantified your target population, their baseline readmission rate, and your readmission reduction aim, estimate the monthly impact your readmission reduction efforts are expected to have.
# Discharges in Target Population
Target Population Readmission Rate
Expected Avoided Readmissions
Expected # Readmissions
Example:
300 discharges per month
Rate = 25%
300 x .25 = 75 RA per month
Reduce by 20%
.20 x 75 = 15 fewer RA
Result
75 – 15 = 60 RA per month
Important so you know how to staff/implement
300 discharges per month = 10 discharges per day
30 discharge per month = 1 discharge per day

7. 7. Calculate the Annual Impact for the Target Population and for the Hospital-Wide Rates
Once you have identified and quantified the monthly volume of target population discharges your staff/service will encounter, the current readmission rate and number, the readmission reduction goal in terms of reduced readmissions per month, evaluate overall impact on the target population and on the hospital-wide rates.
# Discharges in Target Population
Target Population Readmission Rate
Expected Avoided Readmissions
Expected # Readmissions
Target Pop:
x 12 = 3600
Discharges per yr
3600 x 25% =
900 RA per yr
15 x 12 = 180
Fewer RA per year
New Rate:
720 /3600 = 20%
Hospital-wide
12,000 discharges per year
10% RA rate
= 1200 RA/ yr
= 1020
New rate:
1020/1200 = 8.5%
Ask: Does this strategy meaningfully reduce readmissions for the target population
and for the hospital as a whole?

8. 8. Compare Resource Required with Expected Results
Cost of intervention(s)
Example complex care team with salaries of $250,000 annually
SW + Pharm + 2 CHW
Benefit gained
Only you can say at this point in the market- consider penalty avoided, low-acuity bed use avoided, shared savings on risk, etc.
In example: 180 readmissions avoided
180 readmissions at $10,000 each (payer cost) = $1.8M in avoided utilization

9. Examples from teams across the US
Care Plans
Examples from teams across the US

10. Baltimore Hospitals
Multiple hospitals collaborating
Develop 1 page Summary
Background
Challenge
Recommendations – staff, MDs
Recent studies
Care Management contact

11. MGH – PCP authored, in EMR, but need to search …
MGH – PCP authored, in EMR, but need to search ….an example, not perfect
Acute care plan
Clinical: typically presenting with cyclic vomiting syndrome, often precipitated by psychosocial stressors and anxiety.
Per GI, [name of GI NP] NP, patient should be treated with IVAtivan 4-6 mg and IV Zofran 8mg q 6 hrs until vomiting has subsided, with respiratory monitoring in place. He should continue on amitriptyline 100 mg QHS.
Disposition Considerations
If patient is to be discharged home from ED: ensure follow up with GI ([name of NP], NP for Dr. [name of GI MD]).
If patient is to be admitted to Hospital: Team 4 [this is the non-housestaff hospitalist service]
Advance Care Planning
HC Proxy: [name], father
Key Psychiatric and Psychosocial Considerations:
History of depression and anxiety, seen by MGH psychiatry
Provider Managing Pain/Psych Meds:
Dr. [name], psychiatry
Ambulatory Care Team:
[name], NP - GI
Dr. [name]- GI
Resident PCP [name]- medicine
____________________________________
[signed by PCP with pager #]
Demographics of Use Case:
36 M cyclic vomiting syndrome
Utilization prior 12 months:
12/15/14 - ED, inpatient
2/3/15  ED, inpatient
6/14/15 - ED inpatient
6/25/15 - ED , inpatient
6/28/15 - ED, inpatient
8/5/15 - ED, inpatient
9/25/15 – ED, inpatient

12. Inpatient team
Multidisciplinary
Shared place for mx disc recs
Care Team
Goals
Community Partners
Appointments
Services

13. Community Care Plan
Focus on BH patients
4 pages

14. Hospital Care Plan Example
“Underlying pathology”
“Reason for care plan”
Effective date
Date due for review
Clinical Contact
Intervention
Goals and Outcomes
Approval

15. ED Care Plan Letter
Patient facing
Signed Chief of ED

16. Recommendations Start with your top 20 patients
Ask 1 person to create the “summary”
Brief medical issue
What the recurrent presentation profile is
Utilization history (# hospitalization, # ED)
Imaging/testing history (CTs, CXR, stress tests, ROMIs, etc)
Medical, social, familial resources = the “Team”
Contact name , pager,
Recommendations for ED
Create a binder
Move to IT flags, links, shared drive for reliable use
Case review with ED docs

17. Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies
Thank you
Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies