1. Readmission Rate Deep Dive: Where Your Focus Should Be to Optimize Outcomes That Impact Your Star Rating Barb Averyt, BSHA Program Director, Care Coordination Health Services Advisory Group (HSAG) June 2015

2. Objectives 2 Review the fiscal year (FY) 2015 CMS* hospital readmission criteria used to assess financial penalties on facilities falling below the acceptable criteria. Identify the characteristics of patients that are readmitted to the hospital: timeframe, medication usage, follow-up care, etc. List three definite red flags that put patients at high risk of being readmitted within 7 days of discharge from the hospital. *Centers for Medicare & Medicaid Services (CMS)

3. Objective One 3 Review the fiscal year FY 2015 CMS hospital readmission criteria used to assess financial penalties on facilities falling below the acceptable criteria. Identify the characteristics of patients that are readmitted to the hospital: timeframe, medication usage, follow-up care, etc. List three definite red flags that put patients at high risk of readmitting within 7 days of discharge from the hospital

4. Hospital Readmission Penalty Age 65 or over Discharged from non-federal acute-care hospitals Without an in-hospital death Not transferred to another acute care facility Enrolled in Part-A Medicare for the 12 months prior to the date of the index admission 4

5. The Inclusion/Exclusion Algorithm Source document: 2014 Measures Updates and Specifications Report Hospital-Wide All-Cause Unplanned Readmission – Version 3.0, CMS, March 2014 5

6. National Impact: How Did Hospitals Fare? 6 FY 2013 Began Oct. 2012 FY 2014 Began Oct. 2013 FY 2015 Began Oct. 2014 Total hospitals penalized2,2172,2252,610 Hospitals receiving maximum penalty 307 at 1% 154 at 1% 18 at 2% 39 at 3% National average fine0.420.380.63 $$ recouped by CMS$280 million$227 million$428 million

7. 2015 Penalty—Began October 2014 This is the third year for hospital penalties. With a moving three-year baseline, hospital readmissions improve every year, making it difficult to catch up if you were already behind. Only 129 hospitals of the 2,225 that were fined in FY 2014 avoided a fine in FY 2015. 7

8. Arizona Impact: How Did Arizona Hospitals Fare? 8

9. What Is in Store For FY 2016? Based on claims data from July 1, 2011, to June 30, 2014 Up to 3 percent financial penalty to all readmissions The penalty determining diagnostic-related group (DRGs) remain the big five: 1.Acute myocardial infarction (AMI) 2.Pneumonia (PNE) 3.Congestive heart failure (CHF) 4.Chronic obstructive pulmonary disease (COPD) 5.Total knee arthroplasty/total hip arthroplasty (TKA/THA) For FY 2017, coronary artery bypass graft (CABG) will be added 9 Source Document: Federal Register / Vol. 80, No. 83 / Thursday, April 30, 2015 / Proposed Rules

10. Readmission Penalties Are Coming to Others 10

11. Objective Two 11 Review the FY 2015 CMS hospital readmission criteria used to assess financial penalties on facilities falling below the acceptable criteria Identify the characteristics of patients that are readmitted to the hospital: timeframe, medication usage, follow-up care, etc. List three definite red flags that put patients at high risk of readmitting within 7 days of discharge from the hospital v

12. The Deep Dive: West Valley, Phoenix 2013 12

13. Medicare Fee-For-Service Patient Activity in 2013 13

14. 30-Day Readmissions by Volume—2013 14

15. All-Cause Readmissions To Another Hosp ital 15

16. West Valley 2013: Five or More Emergency Department (ED) Visits 458 distinct Medicare beneficiaries (MBs); 3,532 ED visits annually Treat and release—not admitted The top diagnoses for ED visits were due primarily to causes such as abdominal pain, urinary-tract infections, headaches, and backaches 16 Diagnosis Code Description 789.09Abdominal pain, other specified site 599.0Urinary tract infection, site not specified 784.0Headache 789.00Abdominal pain, unspecified site 724.5Backache, unspecified

17. Hot-Spotting: 10 ZIP Codes, Three Hospitals, 126 MBs, 751 Admissions/Readmissions ZIP Code # of MBs Admissions Attributed 853103 18 8502713 77 8538215 81 85381 9 55 85373 8 41 8535129168 8534519126 8530810 62 8530613 83 85053 7 40 17

18. Then, What Happened? The community asked HSAG to conduct a focused data review on the patients that were readmitted within 7 days. 18

19. Questions to Drive Analysis for 7-Day Readmissions From what provider setting did the patient come? How many of the patients readmitted within 7 days had a physician follow-up visit? How many of those who were readmitted within 7 days were on high-risk medications, and which ones? How many of those readmitted within 7 days died, and when did they die? How many of those patients were on high-risk medications? What was the most frequent diagnosis for the patients who were readmitted within 7 days? 19

20. Source of Readmissions Within 7 Days of Hospital Discharge 60 percent of patients readmitted within 7 days from hospital discharge had been discharged to home without home health agency (HHA). 20 *Nursing Home (NH)

21. Physician Follow-Up Visit 846 (60 percent) patients were discharged to home without HHA. Less than one out of four (197 or 23 percent) had a physician follow-up visit within the first week of being home and before their readmission. 21

22. Physician Follow-Up Visit (cont.) The data showed physician office visits only occurred for patients discharged to home without home health. Could it be that a home health visit provided enough social and medical support that the physician office visit was not essential for the first week? 22

23. Physician Follow-Up Visit (cont.) 88 of those patients who saw their physician were readmitted the same day or within 24-hours of the physician office visit. 23

24. High-Risk Medications How many of those readmitted within 7 days were on high-risk medications (anticoagulants, diabetic medications, opioids)? – Which high-risk medications? – Was one group of medications used more than another (volume)? 24

25. High-Risk Medications (cont.) 396 patients were on high-risk medications— more than one out of every four. 25

26. Group Question Which high-risk medication had the largest usage? A.Anticoagulants B.Diabetic medications C.Opioids 26

27. High-Risk Medications Readmissions’ drug category breakdown: – Anticoagulants = 80 patients – Diabetic agents = 104 patients – Opioids = 212 patients 27 20% 26% 53%

28. How Many of the Patients Who Were on High-Risk Medications Expired? 156 of the 396 patients on high-risk medications expired within a year. More than 1 out of every 3. ExpiredAnticoagulantsDiabetic AgentsOpioid Home without HHA211644 Home with HHA4516 NH51218 Other357 Total333885 28

29. Considerations Should all patients who are discharged to home on a high-risk medication always have a home health safety evaluation or be part of a care transition coach program? AnticoagulantsDiabetic AgentOpioidTotal Home without HHA56 or 70%55 or 53%136 or 64%247 29

30. Deaths Among the Readmitted Of the 1,400 who were readmitted within 7 days, 554 expired within a year or more following the readmission. Only 9 of the 554 had been on hospice services from the hospital discharge. 30 40%

31. For the 554 7-Day Readmits Who Expired, When Did That Occur? 31

32. Looking at Additional Geographic Areas Phoenix Metro Area Southern Arizona Northern Arizona Data elements: – 7-day readmission rate – Type of discharge disposition (alone, with HHA, NH, etc.) – High-risk medication usage – Primary care physician (PCP) visit within 14 days – “Super users” by ZIP code 32

33. Phoenix Metro 30-Day Readmission Rates, All Cause 33

34. Phoenix Metro 7-Day Readmission Rates, All Cause 34

35. Phoenix Metro 7-Day Readmission Rates by Settings Of those patients readmitted within 7 days, 56 percent were discharged from hospitals without HHA. 35

36. Phoenix Metro 7-Day Readmissions Discharged Home Alone = 3,194 36 Total Phoenix Metro 7-day readmission rate from all settings 3,194 5,693 Total Phoenix Metro 7-day readmission rate from home alone

37. Southern AZ 30-Day Readmission Rates, All Cause 37

38. Southern AZ 7-Day Readmission Rates, All Cause 38

39. Southern AZ 7-Day Readmission Rates by Settings Of those patients readmitted within 7 days, XX percent were discharged from hospitals without HHA. 39

40. Northern AZ 30-Day Readmission Rates, All Cause 40

41. Northern AZ 7-Day Readmission Rates, All Cause 41

42. Northern AZ 7-Day Readmission Rates by Settings Of those patients readmitted within 7 days, XX percent had been discharged from hospitals without HHA. 42

43. 7-Day Readmissions Who Discharged Home Alone and Had Physician Office Visits Prior Phoenix Metro – Home alone 7-day readmission =3,194 – Saw their physician before readmission =633 20% – Were readmitted within 24 hours =187 29% Northern AZ – Home alone 7-day readmission =444 – Saw their physician before readmission =90 20% – Were readmitted within 24 hours =24 27% Southern AZ – Home alone 7-day readmission =874 – Saw their physician before readmission =185 21% – Were readmitted within 24 hours =70 38% 43

44. 7-Day Readmissions: Home Alone and High-Risk Medications How many of those readmitted within 7 days, who were discharged home alone, were on high- risk medications (anticoagulants, diabetic medications, opioids)? 44

45. 7-Day Readmissions: Home Alone and High-Risk Medications (cont.) 45

46. 7-Day Readmissions: Home Alone, on High-Risk Medications, by Drug Category 46 Opioids significantly higher

47. Super Users—Northern Arizona ZIP Codes 86301 and 86313 47 5 or More ED Visits Per Year ZIP CodeNumber of Medicare beneficiaries Total ED visits attributed to these beneficiaries 86301 86313 3 or More Admissions/Readmissions Per Year ZIP CodeNumber of Medicare beneficiaries Total admissions/ readmissions attributed to these beneficiaries 86301 86313

48. Super Users—Southern Arizona ZIP Codes 85741 and 85704 48 5 or More ED Visits Per Year ZIP CodeNumber of Medicare beneficiaries Total ED visits attributed to these beneficiaries 85741 85704 3 or More Admissions/Readmissions Per Year ZIP CodeNumber of Medicare beneficiaries Total admissions/ readmissions attributed to these beneficiaries 85741 85704

49. Objective Three 49 Review the FY 2015 CMS hospital readmission criteria used to assess financial penalties on facilities falling below the acceptable criteria Identify the characteristics of patients that are readmitted to the hospital: timeframe, medication usage, follow-up care, etc. List three definite red flags that put patients at high risk of being readmitted within 7 days of discharge from the hospital.

50. Red Flags Senior and discharged home alone and on an opioid Senior and discharged home alone and on a diabetic medication Senior and discharged home alone and on an anticoagulant 50

51. Touch-Points and Follow-Up Patients who have a touch-point within the first week of hospital discharge, regardless of physician follow-up visit, are less inclined to be readmitted than those that do not have a touch-point. Patients who are discharged to home with no follow-up resources such as home health or a care transition coach/intervention are more inclined to be readmitted than any other group. 51

52. Where Do We Go From Here? Given this information: What needs to be done so patients are not readmitted and can be managed at home? What conversations need to be had and with whom? What would be shared? What data can you provide, share, or ask for that motivates action? 52

53. Start With Common Agreements Start with the premise that no one wants a readmission. Patients heal better when in their own familiar surroundings. Hospitals are not necessarily safe (e.g., healthcare associated infections [HAIs], falls, medication errors, etc.). With these agreements, what action can be done that bridges the patient during that vulnerable care transition period? 53

54. Final Goal: Collaboration, for the Patient's Sake “If you want to go quickly, go alone. If you want to go far, go together.” — African proverb 54

55. Questions? Thank you! Barb Averyt, BSHA baveryt@hsag.com

56. This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, 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. Publication No. AZ-11SOW-C.3-06192015-01