4/21/2016
Preventing Readmissions
from the
Post-Acute Care Continuum
Tamira Harris,
PhD, MBA, MSN
Business Advisor
Guided Outcomes/Organizational Design
Relay Health Intelligence
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14/21/2016
Agenda
• Current State
• Top 10 Challenges/Opportunities for Providers/Hospitals
• Stories from the Field
• Leveraging Technology - Changing Culture
• Opportunities and Next Steps
• Questions
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Objectives
• Demonstrate proactive approaches to care planning.
• Understand the cultural shift from reactive to proactive care
planning and collaboration.
• Identify the new role of the case manager in care planning.
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Case Management Vision
Predictive, actionable intelligence to give
Providers confidence in operationally
managing their day-to-day, hour-by-hour
caseloads – no matter what comes at
them.
 Variability management rather than crisis
response
 Patient-centered, clinically driven
operational excellence
 Sustainable financial improvement though
demand forecasting & patient flow based
alignment of resources
 Optimized patient throughput and
outcomes, house-wide and across care
settings
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Bending the cost curve
Significant growing
problem in US
Only 21% CFOs report
using data to reduce cost
$100 in Clinic;
$1,000 in ED;
$10,000 with admit
$12M cost variance
400 bed hospital compared
to US average
* http://www.medpac.gov/transcripts/readmissions%20Sept%2012%20presentation.pdf
5 Source: NEHI health policy institute
Payment Model Trajectory
Commercial Payers Leading The Way
McKesson Sponsored Research Conducted February 2014 by ORC International with 350 providers and 114 payers participating
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Provider Performance
Performance
Measures
Historical
Emerging
Physician productivity
Care team productivity
Tests ordered
Patient outcome
Procedures performed
Complications encountered
Informational/emotional needs met
Improvement
Orientation
Increasing revenue/profit
Outcomes
Improving individually oriented
financially grounded metrics
Total cost of care
Defined performance metrics – team
oriented
Measure
Internal
External
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Setting Value-based Payment Goals — HHS Efforts to
Improve U.S. Health Care*
“Our goal is to have 85% of all Medicare fee-for-service payments
tied to quality or value by 2016, and 90% by 2018. Perhaps even
more important, our target is to have 30% of Medicare payments
tied to quality or value through alternative payment models by the
end of 2016, and 50% of payments by the end of 2018.”
*Sylvia M. Burwell, US Secretary of HHS. N Engl J Med 2015; 372:897-899, March 5, 2015
“Transforming Medicare from a passive payer to an active purchaser
of high quality, efficient healthcare”- CMS
Fee for Service
Pay for Value
Hospital CEOs Ultimate Dashboard
What to Check Daily (Studer Group)
Major Service
Issues
Patient
Volume
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Stories From The Field
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Lessons Learned
•Back to the Basics
•Starts at Admission
•Risk Assessment
•Involve the Care Team
•Do it Right the First Time
•Embrace and Leverage Technology
•Focus on Patient Education and Accountability
•Create Relationship
•Alignment with Community
•Planning includes longer term post discharge
•Understand Care Transition Metrics
•
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Challenges and Opportunities
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Top Challenges for Case Management
• Evolving Roles/Professional Development
• Role Definition – Overlap - Competition
• Patient Engagement
• Patient Safety
• Increased Scope
• Defining and Demonstrating Value of Service
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Hospital Associated Infections - Safety
•1/20 hospitalized patients contract
•10,000 deaths yearly
•27 states have mandated reporting
•LOS increases 7-9 days
•Average increase in cost $40,000
•Adds $4.5-5 .7 billion /year in costs
Source: Decision Health 2014
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Emergency Department Capacity Management
• 40% more ED visits since 2000
with 20% less ED’s
• 71% of all admits present via ED
Cost/ED Visit
$1,200
$1,000
• The average cost per ED visit has
increased 44% over the past 10
years and is 10 x more expensive
than a lower level of care.
• ED Frequent Flyers has become
standard terminology
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4
4
%
$800
$600
$400
$969
$546
$200
$0
2000
2010
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Heart failure with gaps in care
High risk for hospitalization
Costly care due to
physician practice patterns
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Frequent fliers at
emergency department
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Mr. Jones
• 58 years old
• PCP: Mike Allen, MD
• Has Type 2 diabetes
• Overdue on HbA1C
• Recently hospitalized
• Just had an unnecessary MRI
Next year:
No intervention: $50,000
Managed appropriately:
$10,000
Surgery and Case Management
Better
Capacity
Management
Surgeons have to
see 7-10 patients per
day to bring 1 to the
OR
Surgical admissions
drive 65% of typical
hospital revenue
1 additional case per
day for most
hospitals = $1-3 M
gross revenue
Source: Healthcare Advisory Board (Future of General Surgery)
Innovations Center interviews and analysis
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Heard on the Streets!
“Nurse staffing is a black hole. I only
know what my CNO tells me. I think we
should be able to do better, and with
less crisis staffing.”
Resource Staffing
“Bed availability – issue is either not
enough beds, or not the right bed.
Always waiting on beds.”
“The discharge process takes too long.”
“No one manages the weekends.”
Herding cats is easier than herding
doctors.”
“Post-acute placement is horribly
inefficient, and patients that need this
level of care consume a lot of our
resources.”
Flow
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“ED and CCU wait times are too long for
other hospital services.”
“Every minute in the OR is costly! Even
though we plan, we spend too much
time reacting.”
“Our PACU gets gridlocked.”
Departmental Bottlenecks
“We need more standard clinical
processes to limit things outside the
lines. The goal is getting the patient
out the door, and greater
standardization means it’s less likely
we’ll see that patient again.”
Variability in Clinical Quality
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Safe care is not an accident
Not tolerated in any other industry
Source: http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America/Infographic.aspx
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Lessons on Flow from the Airline Industry
1. Air traffic control is managed as a system, not a place
Every aspect of an individual’s care has a direct impact on the other.
2. Airport operations function 24/7
Patient flow should be managed around the clock.
Source: Jonathan H. Burroughs - Fierce Healthcare
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Lessons on Flow from the Airline Industry
3. All departures are scheduled in advance
.
The three most common bottle-neck areas in a hospital are the
emergency department, the ICU and the surgical areas. Discharges
by severity adjusted DRGs are predictable to 1/100 th of a day.
4. All arrivals are scheduled in advance.
If emergent ED, surgical or ICU admissions are tracked over time, the
vast majority of trends are predictable.
Source: Jonathan H. Burroughs - Fierce Healthcare
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Lessons on Flow from the Airline Industry
5. Flight schedules are smoothed throughout the day and week.
Non-emergent arrivals can be transferred to lower acuity areas and
elective surgeries can be scheduled evenly throughout the week.
6. Delayed flights are taken off main runways and taxiways.
Delayed discharges and transfers could utilize a supervised holding
area to free up beds for admissions and throughput.
Source: Jonathan H. Burroughs - Fierce Healthcare
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Next Steps
•
•
•
•
Engagement
Define – Reinvent
Data Leverage
Communication
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THANK –YOU!!
Tamira.Harris@mckesson.com
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