The STAAR Initiative:
A State-Based Approach to Reducing Rehospitalizations
Amy E. Boutwell, MD MPP
Director of Health Policy Strategy
Co-Principal Investigator, STAAR Initiative
p
Institute for Healthcare Improvement
What can be done,, and how?
There exist
Th
i t a wealth
lth off approaches
h to
t reduce
d
unnecessary
readmissions that have been locally successful
Which are high leverage?
Which can go to scale?
Success requires engaging clinicians, providers across
organizational and service delivery types
types, patients
patients, payers
payers,
and policy makers
How tto align
H
li iincentives?
ti
?
How to catalyze coordinated effort?
The state is the unit of intervention
STAAR Initiative
STate Action on Avoidable
A oidable Rehospitalizations
Rehospitali ations
Purpose
• Improve quality, patient experience, and reduce avoidable utilization
through a multi-stakeholder initiative to reduce rehospitalizations.
Methods
• Engage
E
state-level
t t l
l lleadership
d hi and
d state-wide
t t
id process iimprovementt .
Aims
• Improve patient/family satisfaction with care transitions.
• Reduce all-cause 30-day rehospitalization rates by 30 percent.
Settings
• Massachusetts,
M
h
tt Michigan,
Mi hi
W
Washington.
hi t
STAAR Initiative
ST t Action
STate
A ti on Avoidable
A id bl Rehospitalizations
R h
it li ti
A
Approach
h off the
h STAAR IInitiative:
ii i
– Provide technical assistance to front-line teams of providers working
to improve the transition out of the hospital, the reception into the next
setting of care with the specific aim of reducing avoidable
rehospitalizations and improving patient satisfaction with care
AND
– Create a state
state-based,
based multi
multi-stakeholder
stakeholder initiative to concurrently
address the systemic barriers to improving care transitions, care
coordination over time (policies, regulations, accreditation standards,
etc)
STAAR Initiative
ST t Action
STate
A ti on Avoidable
A id bl Rehospitalizations
R h
it li ti
• Improve the transition out of the hospital
• Cross-continuum teams
• Collaborative learning
• State-based mentoring and quality improvement infrastructure
• S
Supportt state-level,
t t l
l multi-stakeholder
lti t k h ld initiatives
i iti ti
t address
to
dd
th
the
systemic barriers
• State leadershipp coordinating,
g aligning,
g g convening
g
• State-level data and measurement
• Financial impact of reducing readmissions
• Engaging payers to reduce barriers
• Working across the continuum
STAAR State Level Strategy
gy
• Hospital-level
- Improve the transition out of the hospital for all patients*
- Measure and track 30-day readmission rates*
- Understand the financial implications
p
of reducing
g rehospitalizations*
p
• Community-level
- Engage organizations across continuum to collaborate on improving care,
partner with non
non-clinical
clinical community based services,
services address lack of IT
connectivity, clarify who “owns” coordination, engage patient advocates*
- Ensure post-acute providers are able to detect and manage clinical
changes, develop common communication and education tools
• State-level
- Develop state-level population based rehospitalization data*
- Convene
C
allll payer di
discussions
i
tto explore
l
coordinated
di t d action*
ti *
- Link with efforts to expand coverage, engage patients, improve
HIT infrastructure, establish medical homes, contain costs, etc.*
* Elements of the STAAR Initiative
STAAR Collaborative:
O ti i the
Optimize
th transition
t
iti for
f allll patients
ti t
STAAR Initiative
ST t Action
STate
A ti on Avoidable
A id bl Rehospitalizations
R h
it li ti
Evaluating
g Potential Interventions:
Will / Incentives
• Who is motivated to make this change?
• Are
A there
th
iincentives
ti
and
d adequate
d
t ways tto pay ffor th
these iinterventions?
t
ti
?
• Are there winners and losers or a potential for win-wins?
Degree of Belief / Impact
• Level of evidence for the changes
• Availability or awareness of credible “best practices”
• Impact on reducing rehospitalizations
Degree of Difficulty to Implement or Replicate
• Alignment with other local and national quality initiatives
• Relative ease of implementation & measurement
• Are there partners (national and within the region) to assist with
implementation and spread?
STAAR Initiative
STate Action on Avoidable
A oidable Rehospitalizations
Rehospitali ations
1. Measure all-cause readmission
rate
2. Form a cross-continuum team
3. Cross-continuum team reviews
longitudinal, cross-setting story
off 5 recently
tl readmitted
d itt d patients
ti t
STAAR Initiative Keyy Changes
g
1.
Enhanced Assessment of Patients: why does the
patient/caregiver/SNF/outpatient provider think caused readmit?
2.
Enhanced Teaching and Learning: change focus from what
providers tell patients to what patients/caregivers learn
3.
Real-time Communication and Handoffs: timely,
y, clinicallyy
meaning information exchange with opportunity for clarification
4
4.
Timely
Ti
l Post
P t Acute
A t Care
C
Follow-Up:
F ll
U clinical
li i l contact
t t ((call,
ll h
home
health visit, office visit) within 48h or 5 days depending on risk
STAAR Collaborative (Phase 1)
State
# of Hospitals
MA
22 (27% of MA hospitals)
MI
27 (19% of MI hospitals)
WA
15 (16% of WA hospitals)
Recommended
Changes
g
% Testing or
Implementing
p
g
Description
Cross Continuum
Team
100%
Understanding mutual interdependencies, the hospital-based teams co-design care
processes with their cross-continuum partners to improve the transition out of the
hospital
Diagnostic
Review
100%
Teams perform a diagnostic review of five recently readmitted patients to
understand transitions from the perspective of the longitudinal patient experience
and to identify opportunities for improvement
Enhanced
Teaching
91%
Utilizing health literacy principles, effectively teach patients about their conditions,
medications and self-care
medications,
Enhanced
Assessment
76%
On admission, perform a comprehensive assessment of patients’ post-discharge
needs and initiate a customized discharge plan
Handoff
C
Communications
i ti
66%
Provide customized, real-time critical information to the next care provider(s);
P id th
Provide
the patient
ti t and
d hi
his or h
her ffamily
il caregiver
i
with
ith written
itt self-care
lf
i t ti
instructions
Timely Follow-up
76%
Based on assessed risk of readmission, schedule post-hospital care follow-up prior
to discharge
Support State Level Multi-Stakeholder Coalitions to
Develop State Strategy and Address Systemic Barriers
Michigan
g STAAR Portfolio of Projects
j
Massachusetts STAAR Portfolio of Projects
•
•
•
•
•
•
•
•
•
•
•
Care T
C
Transitions
ii
F
Forum
State Strategic Plan on Care Transitions
Standard transfer forms between all settings of care
DHCFP PPR Steering Committee
State Expert Panel on Performance Measurement
Quality inspectors trained in elements of a good transition
ASAPs join cross continuum teams
H
Hospital
it l requirement
i
t tto fform patient/family
ti t/f il advisory
d i
councils
il
MOLST pilot
INTERACT
Medical home demonstrations
Massachusetts STAAR Cross Continuum Map
p
Action
Description
STAAR
State Leadership, Strategy, Policy
St t Data
State
D t
MA - Division
Di i i off H
Health
lth C
Care Fi
Finance and
dP
Policy
li St
Steering
i C
Committee
itt
MI - Multi-payer collaboration to run standard reports
WA - quarterly rehospitalization reports to all WA hospitals
Financial impact
STAAR partnered with 16 CFOs to understand financial impact of
readmissions in current payment climate. Created roadmap, issue brief,
p , webinar.
manuscript,
Engaging Payers
Understand which specific challenges in delivering optimal care at
y payers
p y
in short term. Multi-payer
p y
transitions are amenable to action by
discussions in MA, MI, WA; assist with payment demonstrations.
Working Across
Continuum
Evolution of hospital-based cross continuum teams to community-based;
level of coordination between local cross continuum teams as well as
community-based non-clinical services.
Networking, mapping and identifying specific ways to coordinate care and
services is promising and concrete
concrete. The “STAAR
STAAR Effect
Effect”, Care Transitions
Map in MA , Detroit CARR.
*Cross continuum team is most durable concept in STAAR to date*
Lessons on State Level Engagement
• State-based approach allows:
─
─
─
─
─
─
Common framing of issue, common language
Inventory complementary efforts across state
Aligning efforts encourages, elevates, sustains action
State strategy
gy to systematically
y
y work through
g
No surprises- transparent intent and plan
Leverage regulatory policy levers
Thank you
Amy E. Boutwell, MD MPP
Director of Health Policy Strategy
Co-Principal Investigator, STAAR Initiative
Institute for Healthcare Improvement
@
g
aboutwell@ihi.org