Hospital Readmissions.
A Dilemma for Every Manager
2013 update
Lynn Vanderburg BA, RRT NRP
Hospital Readmissions Reduction Program (HRRP)
• Legislative Context Shapes HRRP
– Patient Protection and Affordable Care Act (2010) was to provide
everyone in America with affordable Health care
• Faced stiff opposition
• To get it passed programs had to be inserted that would reduce the total
cost burden of the bill
– HRRP is one of those cost reduction programs
• Estimated to reduce Medicare payments by $7.1 billion (between 20132019)
http://www.santarosaconsulting.com/santarosateamblog/post/2012/03/29/an-early-look-at-hospital-readmissionsreduction-program
Hospital Readmission Reduction Program
• Brief overview
– The HRRP is a reimbursement penalty approach for general acute
care hospitals that have readmissions deemed “excess” by CMS
• Began fiscal year 2013 (October 1, 2012)
• Reduction is capped at 1% in 2013, 2% in 2014 and 3% in 2015 and
beyond
• Reductions apply to total DRG reimbursement
– But readmissions deemed excess are determined using 3 specific conditions
endorsed by the National Quality Foundation (NQF)
» Acute Myocardial Infarction
» Heart failure
» Pneumonia
http://www.santarosaconsulting.com/santarosateamblo
g/post/2012/03/29/an-early-look-at-hospitalreadmissions-reduction-program
Reimbursement Penalties
•
2,211 American hospitals received reimbursement penalties for high
readmission rates
– Together they will forfeit about $280 million in Medicare funds over next year
• According to Medicare, 2 out of 3 hospitals evaluated failed to meet its
new standards for preventing 30 day readmissions.
•
(penalty rate up to 1%) x (total Medicare reimbursement/yr) = lost
revenue
Rau, Jordan. Kaiser Health News. “Medicare to Penalize 2,211 Hospitals for Excess Readmissions”. Aug 13-12.
Re-hospitalizations among patients in the Medicare
Fee-for-service Program
• New England Journal of Medicine
Stephen F. Jencks, MD, MPH, Mark Williams, MD and Eric A Coleman, MD MPH.
Abstract
• I in 5 Medicare beneficiaries are readmitted within 30 days
– Which equates to 2.3 million patients
•
•
•
•
National cost of over $17 Billion
Half of patients readmitted had no physician contact
70% of surgical readmits were for chronic medical conditions.
Potentially 40% of all Readmissions are preventable
Avoidable Readmissions
• Readmissions are seen as a indicator of quality of care
– Only valid when we know what % of readmissions were avoidable.
• A review was done on 34 studies published between 1966 and 2010
looking at readmissions that were deemed avoidable
– Found: 24% were deemed avoidable
• Also noted that adults in the US received only 54.9% of recommended
care2
1. Carl Van Walraven, MD MSc, Carol Bennett, MSc, Alison Jennings, MA, Peter C. Austin, PhD, Alan Forster, MD MSc. Proportion of hospital
readmissions deemed avoidable: a systematic review.April 19-11 vol183 no. 7 E391-E402
2. Elizabeth McGlynn, Steven Asch, John Adams, Joan Keesey, Jennifer Hicks, et al. The Quality of Health care delivered to adults in the united
states. NEJM.
Readmission Factors
•
AARC webcast August 28-12 “Hospital to Home-efforts at Reducing Hospital
Readmissions”. Greg Spratt BS, RRT; Kimberly Wiles BS, RRT; Becky Anderson RRT.
•
•
•
•
•
•
69% were non compliant with meds
51% lacked knowledge: How to use Therapy Devices
45% inadequate knowledge of medications
42% unable to self manage care
37% had no follow up visit with Physician
31% develop infection post discharge
Changing Paradigms
Traditional focus
Transformational Focus
Immediate Clinical needs
Comprehensive needs of the whole
person
Patients are the recipients of care and the
focus of the care team
Pts and family members are essential
and active members of the care team.
Variety of different teams
Cross continuum Team with a focus on
the pts experience over time
Www.ihi.org/knowledge/pages/audio and video/ihi approach to reducing avoidable rehospitalizations.aspx
Readmissions Not The Only Change
NO MORE FEE FOR SERVICE
• Pay for Performance (P4P) =Value Based Purchasing(VBP)
• Rewards physicians, hospitals, medical groups and other health care
providers for meeting certain performance measures for quality and
efficiency
• Rewarding hospitals for the quality of care they provide to Medicare
patients, not just the quantity of procedures they perform
•
Also eliminating payments for “never events”
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-basedpurchasing/Downloads/FY-2013-Program-Frequently-Asked-Questions-about-Hospital-VBP-3-9-12.pdf
Find article in my favorites: Readmission 2012 and it has CMS and frequently asked questions.
Hospital Performance
• Value Based Purchasing Program (VBP)
– Begin to pay hospitals for their actual performance
• Requires portion of Medicare reimbursement to be withheld
and returned proportionate to how the Hospital performs
3 Categories
45%
30%
25%
Patient Experience
Outcome Measures
Clinical Processes
Value-based Purchasing:
What Hospitals and Healthcare Systems Need to Know Now to Manage Their Medicare Dollars
Pat Bickley, Jude Odu-Health Care Dataworks
www.HCD.com
Changing Reimbursement
Payment Reform for Hospitals
Fiscal Year
Value Based
Purchasing
Hospital Readmission
Reduction Program
Hospital
Acquired
Conditions
Total
2013
1.00%
1.00%
0
2.00%
2014
1.25%
2.00%
0
3.25%
2015
1.50%
3.00%
1.00%
5.50%
2016
1.75%
3.00%
1.00%
5.75%
2017
2.00%
3.00%
1.00%
6.00%
.
Alexander, K.,LHA Legislative & regulatory Update. LA Assn for Healthcare Quality Annual Education Conference,
April 2012
Patient Satisfaction ‐ HCAHPS
Some of the 20 Key Performance Measures:
• Nurse communication
• Cleanliness and quiet
• Doctor communication
• Responsiveness of hospital staff
• Pain management
• Discharge information
• Communication about medications
• Overall rating of hospital
http://www.mdahq.citymax.com/f/nikolas_matthes.pdf slide 16 of PP presentation listed:Value‐based Purchasing
FY 2015
Value-Based
Purchasing
Proposed “Efficiency” Category
Redistribution of Domain Weighting
20%
30%
Patient Experience of
Care
Outcome Measures
Efficiency
20%
30%
Clinical Processes of
Care
Retrieved 1/31/13
www.StratisHealth.com, the
Medicare Quality Improvement
Organization
13
Higher Per Capita Spending Doesn’t Translate into
Higher Life Expectancy
Source: 2006 CIA Fact Book
Life Expectancy-Per Capita Spending
Time For Disease Management
• COPD was predicted to be #3 cause of death by 2020
• It reached this milestone in April 2011 according to CDC
• Population >65 will increase 73% by 2025
– Baby Boomers are over 80 million strong.
• PCP shortages of 20-27% by 2025.
– Allergists, PCP, anesthesiologists.
• There are over 100 Million patients in the US classified as having chronic
conditions
Kallstrom, T. “The Long Term Implications of the Affordable Care Act”. AARC Times, Oct 2012. pg 20-21
Pulmonary Issues Aren’t Going Away!
 RT as a Physician Extender
• Work in PCP office assessing patients
 RT as Case Managers
•
•
•
•
•
•
Teach self management
Modify patients behavior at home
Coach, encourage and give advice
Regular communication between patient and RT
Identify unmet health needs
Keeps patients:
– Out of Hospital
– Out of ED
– Out of Physician office
HARP(Hospital admissions risk program)
• Melbourne, Australia study
• Patient focused and self management of care through acute
and community health sectors
Case Managed COPD
Control Group
ED Visits
10%
ED Visits
Admits
25% Hosp Admits
41%
Hospital LOS
18%
51%
Hosp LOS
45%
Bird, S et al. “An integrated Care Facilitation model Improves QOL & reduces use of Hosp
resources by pts w/ COPD & CHF”. 2010:16(4):326-33.
RT Case Managers
COPD/Asthma Enrolled
319
ER Before
ER after
Hosp before
Hosp after
305
134
94
37
Part time position for a Respiratory Case Manager for COPD
and Asthma
Total cost saving: $106, 874
Was then granted permission to hire 2 full Time positions.
Dwan, J. “Outcomes of an Asthma/COPD Case Manager Program.” RC Nov 2002.
Questions a Manager needs to ask
• Is reducing the hospitals readmission rate and being an active team
player in the P4P a priority for your hospital? And you?
• Do you know your hospitals 30 day readmission rate?
• Do you believe that you and your staff have the capability to make
improvements?
– This is a cross roads for change.
Do you know?
www.whynotthebest.org
This is the way to find out how much your hospital is being penalized.
Clinical
Conditions
Top performers
US National
Average
What is your
readmission
rate?
Heart Failure
17.3%
24.73%
?
Heart Attack
15.2%
19.97%
?
Pneumonia
13.6%
18.34%
?
Source: The Commonwealth Fund’s website Why Not the Best? Derived from Medicare’s Hospital Compare database
.
Comparing Hospitals
21
Change is Here!!
• Gone are the days of performing breathing treatments, doing vent
checks, attending code blue, then clocking out
• RT’s are professional, licensed, highly skilled clinicians who specialize in
Pulmonary disease as well as Cardiac conditions. As leaders, we MUST
support ongoing development in clinical skills, intervention delivery,
documentation, adopting the credential of RRT as the minimum standard
for new-hires, immersing RT staff in patient advocacy, the patient care
team/care continuum, while SHUNNING complacency. Strive to keep
moving forward with improved patient outcomes, data collection to
support your claims, separation with staff who do not perform on a DAILY
BASIS, because they represent YOU. They represent all of us!
22
Various Initiatives. No Silver Bullet!
Project BOOST - Better Outcomes for Older adults through Safe
Transitions
Project RED – Re-Engineered Discharge
Hospital 2 Home
Transitional Care Model (TCM)
STate Action on Avoidable Rehospitalizations (STAAR)
initiative
STAAR (State Action on avoidable Re-hospitalizations)
• STAAR
– Launched in 2009.
– Aimed to reduce rates of avoidable re-hospitalizations in 4 States: MA,
MI, OH, WA.
– 2 years into a 4 yr initiative, 148 hospitals working in partnership with
500 cross continuum team partners.
• Strategy
– To provide technical assistance/coaching/teaching to front line teams
of providers working to improve the transition out of the hospital and
into next care setting.
Ohio Hospital Association (OHA)
• OHA worked to decrease hospital readmissions through
STAAR initiative
• 18 hospitals participated
– Resulted in 8% greater reduction in STAAR hospitals readmissions
than other Ohio hospitals
Www.ihi.org/knowledge/pages/audio and video/ihi approach to reducing avoidable rehospitalizations.aspx
Slide 7
INTERACT
• Interventions to Reduce Acute Care Transfers
– Designed to improve care of nursing home residents by identifying
and managing situations that commonly result in transfers to the
hospital
• Results of CMS Pilot
– 50% reduction of hospitalizations in 3 NH’s with high baseline rates
– 36% reduction in hospitalizations rated as potentially avoidable
Www.ihi.org/knowledge/pages/audio and video/ihi approach to reducing avoidable rehospitalizations.aspx
Merging Home Care and Hospital Readmissions
Reducing Hospital
Readmissions
Requires Improved
Community Care
Implementing
Medical Home
/Chronic Care
Model
Reducing
Hospital
Readmissions
Chronic Care
Requires
Higher/different
Payment
Lower Hospital
Readmissions
Provides ROI for
Chronic Care
Investment
Reforming
Payment for
Primary
/chronic care
2008-2010 Pittsburgh Regional health Initiative and Center for Healthcare quality and payment Reform
UCSF Medical Center
• Financial implication of Reducing Medicare Heart Failure
Readmissions
Medicare per case cost for heart failure $25,225 and with 30% reduction
in readmissions at UCSF this resulted in approx $1 million annual
savings to Medicare.
30 day readmission Rates for heart Failure with any diagnosis of Heart
failure
2009: average 24%
2010: average 18%
2011: average 13%
Www.ihi.org/knowledge/pages/audio and video/ihi approach to reducing avoidable rehospitalizations.aspx
RED - Re-engineered Discharge
• Assign a discharge advocate to ensure all components are
complete
– This significantly reduced Emergency Department use and rehospitalization within 30 days by 30%.
– This advocate intervention takes approximately 1hr to implement
– The National Quality Forum (NQF) adopted RED as one of their “safe
practices” in 2006
Jack BW, Veerappa KC, Anthony D et al. A reengineered hospital discharge program to decrease
rehospitalization. Ann Internal Med. 2009; 150: 178-187.
Sample Findings: Cost breakdown
•
Lost Revenue from Readmissions
Total readmissions (11/01/08-10/31/09)
Targeted reductions
Reduced Readmits
Contribution Margin per readmit
Margin impact
4,804
30%
1.441
$3,410
($4,913,810)
Capacity Filled with normal case load
Readmits replaced with new volume
Contribution Margin per inpatient case
Margin Impact
Margin Improvement
1,441
$4,980
$7,176,180
$2,262,370
Proactive/Preventative Patient Care
•
“Hospital-acquired infections kill 99,000 Americans each year.”
•
“That’s equivalent of a jumbo jet full of passengers crashing every other day.¹”
• 35,967 Deaths Annually from Hospital-Acquired Pneumonia²
1www.safepatientproject.org
2Nicolau
et al. “Redefing Success for VAP: 360-Degree approach”,
JMCP June 2009, Vol. 15, No. 5
Reactive VS Proactive
Respiratory Issues from Retained Secretions
Reactive Behavior
Proactive Behavior
No interventions until a problem occurs
Respiratory Protocols for ICU/floor pts.
Not routinely assessing high risk pts.
Routine Assessments
Not preventively doing lung expansion and/or airway clearance on
high risk patients
Early intervention with lung expansion and/or airway clearance
therapies
Suctioning only line of defense for MV pts.
Discharge planning involvement
Could result in:
Could result in:
Requiring of
Invasive
procedures
(Bronchoscopy,
re-intubation)
Prolonged
Ventilation, ICU
and Hospital LOS
Increased
Increased
morbidity/mortal Healthcare
ity
Costs
Prevention of
respiratory
complications
Faster
weaning
Decreased
ICU/
Hospital
LOS
Improved
morbidity/
mortality
Health
care
Savings
Areas for Change in Potentially Preventable
Readmissions
Improve Quality Of Inpatient Care
1.
Education
–
–
–
Choose a champion
Customize patient education
Use teach back regularly
• especially with regard to understanding discharge instructions
–
–
Teach patient self Managed Care
Involve different disciplines to teach
• For example RRT required to teach respiratory methods
Currently an average of 8 minutes is spent on
education of our patients in the hospital!
–
We don’t get reimbursed on education
http://www.ama-assn.org/amednews/2011/02/07/prsa0207.htm
Areas for Change in Potentially Preventable
Readmissions
Improve Quality Of Inpatient Care cont’d…
2.
Multidisciplinary rounds
1. Scheduled communication times to discuss patient as a team
2. Set up a discharge plan that is looked at and signed off on by all
disciplines
RRT should always be involved with chronic lung pt discharge plan
3.
Use Pulmonary Rehabilitation Facilities
1. Within 3 days of discharge
2. Teach and explain medications and lifestyle changes, exercises etc
 It is shown when pts go to an LTACH before they go home there are
three times fewer readmission bounce backs
4.
Establish follow up plan before discharge
1. Provide pt meds at discharge
2. Have a dedicated advocate/coach for pt at discharge and beyond
Areas for Change in Potentially Preventable
Readmissions
5. Early post discharge follow up
– Remote monitoring/telehealth
• It was shown that an RN or RRT giving patient education over the phone
reduced hospital admissions by 40% and ER visits by 41% for COPD
patients.1
6. Reconciliation of Medication
– Piedmont Hospital In Atlanta
• Improving their process fixed a 46% discrepancy rate.1
7. Need Proactive Thinking rather than Reactive
– There is a lack of preventative healthcare
– Symptoms treated, not the root cause
1. J. Bourbeau, M. Julien, et al, “Reduction of Hospital Utilization in Patients with Chronic Obstructive Pulmonary Disease: A
Disease-Specific Self-Management Intervention,” Archives of Internal Medicine 163(5), 2003. S
2. http://www.ama-assn.org/amednews/2011/02/07/prsa0207.htm
Get Involved
• Take on More! What projects can you Champion? What Committee
Meetings Do you Need to be Represented at? EXAMPLE: Infection
Prevention-do you Chair Hand Hygiene? Delegate attendance to multidisciplinary meetings to trusted and respected front line staff. Respiratory
Care is involved in EVERY patient care area; we need to be present to be
seen
• Reaching Beyond your Comfort Zone Partner with Nursing, Finance,
Materials Management to learn what is needed to be a contributor in your
Hospital’s Business Model vs a Drain on the Budget.
• Shun Complacency
Our Role as a Care Provider has EXPANDED and the demands from our
Department will continue to grow…
DASH= Discharge + Assessment & Summary @
Home
• DASH is a Homecare Respiratory Services program
– Driven by novel respiratory software, protocols & improved reporting
– Begins prior to discharge
• Risk evaluation
• COPD order set includes DASH (Risk evaluation, Assessment &
transition)
28% readmission in Philadelphia for COPD pts
Incorporation of DASH has reduced it to <4%
PP AARC.org webcast August 28-12 Hospital to home efforts at reducing hosp readmissions. Greg Spratt BS, RRT, CPFT
Kimberly Wiles BSRT, CPFT Becky andersonRRT
DASH
• COPD/CHF/Pneumonia all require specialization
• Early on: < 10% were coming home with a follow up appointment
• Now 90% get a follow up appt
– RT calls them at home and sets up appt with them
Changed Name from the Pulmonary Rehabilitation clinic to
“COPD Independence Program”
PP AARC.org webcast August 28-12 Hospital to home efforts at reducing hosp readmissions. Greg Spratt BS, RRT, CPFT
Kimberly Wiles BSRT, CPFT Becky andersonRRT
It takes the Village
• Re-hospitalizations are costly, frequent, and many avoidable.
• These numbers can be reduced
• Requires action beyond the level of the individual providers
– Provider, association, community and State levels are essential
•
•
•
•
Future of Healthcare is Beyond a single site
Patient centered vs task centered
Reconnect Physicians into the continuum of care
Outpatient services linked to home care data.
ACCOUNTABLE CHRONIC CARE
Data Access
• There are many sources for obtaining data on Value Based
Purchasing and Hospital Readmission Reduction:
www.medicare.gov
www.cms.gov
www.whynotthebest.org
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