1. Reducing Readmissions: The Value in Establishing a Respiratory Therapy Program at a Skilled Nursing Facility Rob Streeter, M.D. Vice President Medical Affairs Mercy Medical Center Mark Sphabmixay, M.D. Medical Director Avalon Health Merced April 27, 2013

2. 2 Readmission reduction is a topic at every hospital across the country. Many hospitals are finding that drivers for readmission are linked to providers of care and services outside the immediate control of the acute care hospital. Our facility was not different, and struggled with how best to mobilize resources for some of our most vulnerable patients—those who are permanent residents at skilled nursing facilities (SNFs). Situation: Readmissions from SNFs a Major Driver

3. 3 Current reimbursement arrangements promote only monthly visits by physicians at SNFs. Thus compliance with a typical discharge instruction of “see your PCP in 3 days” cannot always happen readily. Similarly, the SNFs are not currently structured to provide some of the services typically recommended at discharge, such as daily weights for CHF patients. To address the readmissions from SNFs, we explored a novel approach of hiring a respiratory therapist to assess patients with pneumonia, CHF, and COPD diagnoses. The role of this respiratory therapist was to conduct assessments beyond that provided by the SNF staff, and to provide competency training to the SNF staff. Background: Discharge Instructions & Respiratory Therapist Concept

4. 4 Pneumonia, CHF, and COPD are frequent Dx among SNF patients Prior Readmission Reduction strategies of minimal impact Collaboration with two local SNFs explored in Fall of 2011 Initial discussion with SNF physicians regarding bringing on a Nurse Practitioner met with more than minimal resistance Revisited Ancillary support by exploring Respiratory Therapy as option Spring 2012 hire of Respiratory Therapist accomplished Post-Discharge Assessments & Care Pathways developed Merced, CA is 10 th worst U.S. city for Particle Pollution* Background: Readmission Challenge Defined * State Of The Air 2012, American Lung Association

5. 5 Where is Merced? In the near Geographic center of the Central Valley About 2 hour’s drive to: Yosemite National Park (E) Sacramento (NNW) San Francisco (WNW) Monterey/Carmel (W)

6. 6 Background: Collaboration is Key Mercy Medical Center Hy-Lond Franciscan

7. 7 Our Mission is to: Deliver compassionate, high quality, affordable health care services. Provide services to our sisters and brothers who are poor and disenfranchised and to advocate on their behalf. Partner with others in the community to improve the quality of life. Dignity Health & Mercy: One Voice, One Mission Mercy is committed to furthering the healing ministry of Jesus.

8. 8 What Documents Were Developed? * Copies Available Upon Request For Employees: For Patients:

9. 9 Respiratory Competency Checklist : SNF nurses have to perform these in order to complete the training program and care for these patients (training done by RT): Mask Placement Dementia Management Breathing Treatments Breathing Techniques When to call the Respiratory Therapist (before needing to call the physician) What Skills did the SNF Staff Acquire?

10. 10 Respiratory Therapist in region costs about the same as a “New Grad” LVN or LPN, approximately $18-19/hour SNF willing to pilot program in effort to be “Discharge Facility of Choice” SNF has found that competencies of entire staff elevated “Stepping Stone” to taking on Tracheostomy Patients Cost & Competitive Advantage Considerations

11. 11 In September 2011 through December 2011, before the RT, Hy-Lond and Franciscan had a combined 30-day rehospitalization rate of 30%. RT services initiated at Hy-Lond in April/May 2012, then at Franciscan in May/June 2012 Franciscan did not return anyone to the hospital within 30 days from June 2012 through December 2012. Zero! In September 2012 through December 2012, after the RT, we had a combined 15% rate. We were able to cut the baseline rate in half! During that same period, Hy-Lond only had 5 people readmitted to the hospital (< 5%) with conditions for which the RT was monitoring. What Happened? What Were the Results? WOW!

12. 12 Rehospitalization of Respiratory Related Conditions

13. 13 Implementation of a Respiratory Therapist in the SNF setting has reduced 30 Day Readmission Rates significantly. Physician acceptance has been a “no brainer” While under current reimbursement models, such as Value Based Purchasing, acute care hospitals stand to gain the most, in the not-to- distant future, this strategy may benefit both hospital & SNF This strategy may be a consideration now for ACOs and Clinical Integration entities that desire an “easy win” for their first collaborative effort Even in the absence of ACO or CI structure, this strategy can be employed to benefit patients and their caregivers Assessment & Recommendation:

14. Thank You