Realtime Readmissions Feedback at
PENN Medicine –
Making the Data “Actionable”
University of Pennsylvania Health System
Presented by:
Victoria L. Rich, PhD, RN, FAAN
Chief Nurse Executive
University of Pennsylvania Medical Center
Who we are
PJ Brennan, MD
Chief Medical Officer & Senior Vice President
University of Pennsylvania Health System
Victoria Rich, PhD, FAAN, RN
Chief Nursing Executive, University of Pennsylvania Medial Center
Associate Professor, University of Pennsylvania School of Nursing
Joan Doyle, MBA, MSN, RN
Executive Director, Penn Home Care and Hospice Services
University of Pennsylvania Health System
Assistant Dean for Clinical Practice, University of Pennsylvania School of Nursing
Linda May, PhD
Principal
CFAR
2
Penn Medicine — Philadelphia, PA
School of Medicine
University of Pennsylvania Health System
Hospital of the
University of
Pennsylvania
Pennsylvania
Hospital
Penn
Presbyterian
Medical Center
Penn Home Car
& Hospice
Services
#9 US News
Magnet
Adult admissions — 77,500
Admissions — 18,000
Employees — 12,700
Employees — 450
3
Penn Medicine is working to improve Transitions-inCare from hospital to home — and prevent
readmissions
The aim is to keep patients
safe and stable and give them
a safe “medical landing”
Preadmission
Hospital Stay
Admission
It’s the right thing to do
for our patients — AND
we’re trying to get ahead of
the curve for the new world
of healthcare
Post-acute Care
Discharge
“Medical
Landing”
What we’re learning will give
us a head start in a new
healthcare environment
of ACOs and bundled
payments.
4
Realtime readmissions feedback is at the heart
of our model for Transitions-in-Care
UPHS Transitions Model — Seven “Levers”
Screen
for
patients
at
greates
t risk
Real-time
readmissions
feedback
to
actively
manage
patients
Interdisciplinary
care
planning
Links to
postacute
follow-up
services
Primary
care
follow up
Med
mgmt
across
the
continuum
Education &
red flag
mgmt
5
It starts with the daily readmissions reports —
but the report is the “least” of it
Daily Readmissions
Report
Readmitted patients
(across all three
hospitals) — with chief
complaint, facility, unit,
service, attending
Full report is distributed
each morning to Discharge
Planners, Homecare and
others.
Each hospital unit gets
a tailored version, with
just its own patients.
Detailed history of
previous admissions
But …
It’s the
organizational
“machinery” that
makes the data
actionable
6
Today’s talk about making the realtime
readmissions data actionable has three parts
1 “Changing
the way
we work”
The story of
frontline
leadership
2
“Speaking with a
united clinical
voice”
The story of the
CMO/CNO
Alliance
3 “Mobilizing
other people’s
energies”
The story of the
Transitions
Steering Group
7
The story of
frontline
leadership
1 Changing the way we work
8
In-the-moment and long term
Long-term changes
to clinical practice
Daily Troubleshooting
Readmissions data are
available in time to take
action on specific cases
Screen
for
patients
at risk
Real-time
readmissions
feedback
Interdisciplinary
care
planning
Tools, standards, education,
faster turnaround, tighter
feedback loops — based on
opportunities we see in the data
Links to
post-acute
follow-up
services
Primary
care
follow
up
Med mgmt
across
the
continuum
Education
& red flag
mgmt
UPHS Transitions Model — Seven “Levers”
9
“ Findings
with feet …
”
— Executive Administrator
10
Daily troubleshooting
At the System Level
Discharge
Planners review
every UPHS
readmission,
every day
On the phone
with each
other daily to
troubleshoot
specific patients
Homecare/
Hospice review
every one of their
readmissions,
every day
Hospice
dispatches a team
to investigate its
patients, along
with the inpatient
medical team
On the Individual Hospital Units
For example, a general medicine/telemetry unit
started interviewing each of its
readmitted patients to learn why the
patients themselves thought they came back
into the hospital
Discharge
Planners
interview
readmitted
UPHS patients.
They’re
learning that
most patients
don’t see the
link between
readmission
and things like
not taking their
meds. This is a
teaching
opportunity
This got picked up
at the system level
11
Long-term changes to clinical practice
For example, here’s how Hospice is changing the
way It works …
Hospice conducts regular case
conferences to understand
why their patients are readmitted.
They’ve learned that many are
coming back because of pain
or dehydration.
Hospice has developed a tool
to indentify their patients at
greatest risk for readmission.
Hospice is building in new
practices for those high-risk
patients:
•
•
•
•
Frontloading visits
Proactive phone calls
Educating staff
Tighter feedback loops
And they’ve developed a tool
for patients to help them
know when to call if their
symptoms are getting out of
control.
12
What’s next? Two things on our plate …
Building out the daily review
process on the hospital units
?
?
?
Who’s responsible? If
the daily readmissions
report goes to “everyone,” it
might as well go to “no one.”
What actions are
“automatically” taken
for a readmitted patient?
What interventions are
triggered — Homecare referral?
Patient education? Discharge
safety check? Follow-up phone
call?
Making common cause with
the Cardiac Oncology
Service Lines
?
?
?
How can we share their
readmissions data so it’s
“hearable” and
“actionable”?
How can we tap into what
the service lines are
already planning to do?
How can we shape what
they’re doing?
13
A funny thing is happening along the way — we’re
breaking down our silos and collaborating in new
ways
From
To
Service
Lines
Unit
Leadership
Trios
Discharge
Planners
Homecare/
Hospice
14
So, what does it take to make the
readmissions data “actionable”?
the way
1 Changing
we work
Daily
troubleshooting
to take action on
specific cases
Realtime
readmissions
data —
the report is
the “least”
of it
Tracking and
trending the
readmissions data
to identify longer-term
interventions
Making changes
to clinical practice
— tools, standards,
education, faster
turnaround, tighter
feedback loops
Along the way,
breaking down our silos
and collaborating in
new ways
15
It takes a village — and the village is here
today
Med/Surg UBCLs —
and their unit-based partners:
Medicine Residents Quality
Track

CRCs/SWs

Pharmacists
HCHS, GSPP and other postacute providers

Educators/ Clin Specs
IBC, AETNA

AP Nurses

Infection Control
Other outpatient stakeholders
People who have been developing
tools & resources
CMO/CNO Alliance
Transitions Steering Group
Other senior leaders from
CRM/SW, IS, HR, Pharmacy,
Quality, HCHS, Operations
16
“Changing the way we work” — lessons
learned
Collaboration at the local level didn’t
happen overnight. One day at a time,
we earned new reputations for
what each other could bring.
We focused on the work — which
led to new ways of thinking about each
other.
It’s not just about “educating” each
other. The best way to collaborate was
to work together on common
problems — and bring our clinical
expertise to bear.
It’s easier to “act your way to new thinking” than to think
your way to new actions.
17
But frontline actions,
by themselves,
aren’t enough …
18
The story of the
CMO/CNO
Alliance
with a united
2 Speaking
clinical voice
19
The CMOs and CNOs have banded
together across the continuum of care
CMO/CNO
Alliance
The CMO/CNO Alliance
spans the care continuum:
• All three hospitals
• Penn’s homecare and hospice
services
• Penn’s rehab facilities
• Physician practices
20
The CMOs and CNOs set clinical direction for
UPHS — with Transitions-in-Care as a major
element
UPHS Blueprint for
Quality and Patient Safety
Reduce mortality and reduce 30-day
readmissions
Four Imperatives
Priority Actions
1. Transitions in
care

Transition planning

Med management

Reduce hospital-acquired
infections

Reduce medication errors
3. Coordination of
care

Interdisciplinary rounding
4. Accountability

Unit clinical leadership
2. Reduce variations
in practice
21
To bring clinical strategy to the frontline, we’ve
established “local leadership” on each hospital
unit
Leadership Trio on
Each Hospital Unit
We needed a
multi-purpose
solution on the
units to handle
almost any Quality
problem.
“
We call these trios
“UBCLs,” for “Unit Based
Clinical Leadership”
This isn’t a project, it’s a
way of doing things. You
can bolt different
strategies onto it.
”
—UPHS CFO
22
We started modestly on purpose so the leadership
trios could learn to work with each other
13 pilot units in 2007
The job:

Weekly operations meeting
of the Physician Leader, Nurse
Leader, Project Mgr. for Quality

Interdisciplinary rounding

Orienting house staff

Two improvement projects
2007
2008
2009
2010
23
Today we’ve covered the house and the trios are
ready to take on Transitions, a major system-wide
initiative
Today it’s 34 “official” units
— and another dozen who
are “operating as.”
The job: Today the trios
manage Quality on the unit,
drawing in others as needed.
UBCLs are ready this year to
shoulder Transitions in Care,
a major system-wide
initiative.
2007
2008
2009
2010
24
“Choice within a framework” — each year we
develop targets and work with the hospital units to
pick theirs
UPHS Blueprint for
Quality and Patient Safety
Reduce mortality and reduce 30-day
readmissions.
Four
Imperatives
Transitions in care
Priority Actions


Transitions in Care
— FY’11 Targets





Risk stratification —
screening tool and daily review
of realtime readmissions
Discharge time out
Discharge communication
Med rec on discharge
HCAHPS medication domain
Reduce variations
in practice


Transition planning
Med Management
Reduce hospitalacquired infections
Reduce med errors
Coordination of
care

Interdisciplinary
rounding
Accountability

Unit clinical leadership
25
“Focusing attention” — we negotiated a Transitions
metric in every senior leader’s incentive plan
METRIC: Increase referrals to
post-acute services (homecare,
hospice, rehab, SNF, infusion, LTAC)
We’re setting the
stage for a more
ambitious
“readmissions”
metric next year.
We picked this metric because it
supports a key element of our
Transitions model — and because
Penn could measure it.
Hospital 1
Q1
Q2
Q3
HP
HP
HP
Q4
Threshold (3%)
Hospital 2
Hospital 3
Target (5%)
HP
HP
High Performance (10%)
26
Quality outcomes are moving in the right direction
— including the ones focused on Transitions-inCare
MORTALITY
INFECTIONS
PEER
RECOGNITION
LENGTH OF STAY
PATIENT
& STAFF
SATISFACTION
READMISSIONS
REFERRALS
TO POSTACUTE CARE
P4P
IS ON
TRACK
27
We’re getting out ahead of the budget cycle
and negotiating with a united clinical voice
The old way
The new way
First step — set margins for
each hospital or other entity.
Entities are locked in.
Discussion of system-wide
quality initiatives before
margins are set.
Entities (separately)
submit budgets.
CMOs and CNOs submit a joint
budget for system-wide
quality initiatives they all
agree on.
Negotiation — across entities
and with Finance — occurs
after budgets are
submitted.
Negotiation occurs before
budgets are submitted.
We’re making our job AND
the CFO’s job easier.
28
We’re bringing payers to the table
Paying for the Naylor
Transitional Care Program
A major insurance company
pays Penn to provide the
“Transitional Care” (Naylor model)
follow-up program to its patients.
In this program, the same
advanced practice nurse follows
patients before and after
discharge.
Sharing the gains
Penn has also negotiated an
agreement with the insurance
company to share the savings
when patients are able to
stay out of the hospital.
29
So, how are we aligning infrastructures and
supports to make readmissions data “actionable”?
with a
2 Speaking
united clinical voice
CMO/CNO Alliance
across the continuum
of care
Local leadership on
each hospital unit
— Physician Leader,
Quality Project Manager
Clinical strategy —
with Transitions-in-Care
as a major element
Metrics as feedback
— each hospital unit and
each senior leader know
where they stand
Aligning quality
metrics across the
system, including
senior leaders’
incentive targets
Realtime
readmissions
data —
the report is
the “least”
of it
Quality redesign
to dedicate a Quality
Project Manager to
each hospital unit
Negotiating the
budget with a united
clinical voice
Bringing the payers
to the table
30
Speaking with a united clinical voice —
lessons learned
To paraphrase
James Carville:
“
It’s the work,
stupid.
”
A united clinical voice is based on
actions, not just words.
We started with the work —
developing the Blueprint,
establishing the unit teams, setting
the metrics, negotiating the budget.
Succeeding at the work is what
turned the CMOs and CNOs
into a real leadership team
that could speak with a united voice.
That’s very different from trying to
do it the other way around.
31
But leadership at the
top isn’t enough …
32
The story of
the Transitions
Steering Group
other people’s energies
3 Mobilizing
and keeping the moving parts
aligned
33
The Transitions Steering Group is in the
integration business
This interdisciplinary group of senior leaders:
Transitions
Steering Group
•
•
•
•
Sets direction for Transitions-in-Care
Integrates the moving parts
Opens doors at the system level
Troubleshoots to keep things on track
34
We developed UPHS’ Transitions Model as a
framework — with realtime readmissions feedback
at the heart
UPHS Transitions Model — Seven “Levers”
Screen
for
patients
at
greates
t risk
Real-time
readmissions
feedback
to
actively
manage
patients
Interdisciplinary
care
planning
Links to
postacute
follow-up
services
Primary
care
follow up
Med
mgmt
across
the
continuum
Education &
red flag
mgmt
35
We’re mobilizing “other people’s energies.” Our
biggest job is keeping them aligned.
Knowledge-Based
Charting (HER
protocols & tools)
under development
Penn Medicine
Leadership Forum
INTERNAL
“action learning”
Transitions
projects
Transitions
CMO/CNO
Collaboratives
Alliance across
— active
the continuum of
operational
care
arms
Unit-based
Pharmacists
Med Mgmt
redesign
EXTERNAL
CMS penalties
for
readmissions
will begin in
2012
Pay-forperformance
contracts
Public reporting
influences
patient choice
TRANSITIONS
IN CARE
for better
patient
outcomes &
reduced
readmissions
Bundled payments
and ACOs are on
the horizon
Payers willing to fund
follow-up programs and
negotiate gain-sharing
arrangements
36
For example — We took advantage of Penn’s
flagship leadership development program
Penn Medicine Leadership Forum is targeted this
year to the unit-based leadership teams — along with
homecare and other partners
The purpose of Penn
Medicine Leadership
Forum is to develop
leadership skills …
•
•
•
•
Innovation
Strategic orientation
Execution
Relationship mgmt
“Action Learning”
… and apply them
to a strategic
system-wide
initiative
This year the strategic
initiative is Transitions-inCare. Each team took on a
project to improve Transitions on
a specific hospital unit.
37
“Test beds” — each team tested an aspect of the
Transitions Model. All over the place, but look at
the energy!
Transitions Projects for Penn Medicine Leadership Forum
Real-time
readmission
analysis and
intervention
End-of-life
goals of care
Screening tool
for post-acute
referrals
Screen
for
patients
at risk
New approaches to
interdisciplinary
care planning
Team-based
Improve
Discharge
internal
Planners
Transitions
“Opt-out” for
House staff
homecare
awareness of
referral
homecare &
hospice services
Real-time
readmissions
feedback
Interdisciplinary
care
planning
Links to
post-acute
follow-up
services
UPHS Transitions Model — Seven “Levers”
Post-discharge
phone calls
Discharge
“time out”
safety check
Follow-up
appointments
with primary
care
Primary
care
follow
up
Medication
management
across continuum
Patient & family
education, with
emphasis on self
management
Discharge summary
follows patient to
post-acute services
Med mgmt
across
the
continuum
Education
& red flag
mgmt
38
To pull it all together, we turned the teams’ work
into an integrated Transitions process for the health
system
Preadmission
Hospital Stay
Post-acute Follow-up
Discharge
Admission
Work as far
“upstream”
as possible
— prior to
admission
where that
makes sense.
Risk stratification
1 Screening on admission
2
Medical
“Landing”
Daily review of realtime readmissions report
Interdisciplinary rounds
3 Plan of care looks ahead to post-discharge
4
Referral to post-acute care as early as feasible
Patient and family education
Education for post-discharge care and meds, with emphasis on self management
5
6
Med reconciliation on discharge
Discharge communication
7 Discharge safety check (for high-risk patients)
8
Discharge summary to primary care & post-acute
9
Schedule appointment with primary care
(for high-risk patients)
Follow-up phone calls
(for high-risk patients)
10
39
We can’t implement the new Transitions
process all at once — so where to start?
The readmissions data helped us decide
where to focus first:
Readmits and
the top 10-20%
at greatest risk for
readmission
The “big three”
diagnoses that will
affect CMS payments for
readmissions in 2012
— Heart Failure,
Heart Attack,
Pneumonia
Two Penn service
lines with the biggest
impact on those three
diagnoses —
Cardiac and Oncology
40
We’re learning a lot from the readmission
data. Some things have surprised us …
Readmits and
the top 10-20%
at greatest risk for
readmission
Readmits are younger
than we expected. Twothirds are younger than 65.
One-third are younger than 49.
The “big three”
diagnoses that will
affect CMS payments for
readmissions in 2012
— Heart Failure,
Heart Attack,
Pneumonia
Two Penn service
lines with the biggest
impact on those three
diagnoses —
Cardiac and Oncology
Link between Oncology
and Pneumonia. Analysis
of our Pneumonia readmits
shows that almost a third are
on the Oncology service.
And overall analysis of
readmits shows that 30%
are Oncology
41
So, how are we using other people’s energies to
make the readmission data “actionable”?
3
Mobilizing other
people’s energies
Transitions model as
a framework — seven
“levers” that make the
biggest difference
Realtime
readmissions
data —
the report is
the “least”
of it
Tapping into other
people’s projects
and efforts — and
keeping the moving
parts aligned
Leadership
development in
“action-learning” mode
Tracking and trending
the readmissions data
to figure out where
to focus first
42
Mobilizing energies — lessons learned
By tapping into other people’s efforts
and projects, you can create results
and critical mass as you go.
You get change that sticks,
because people are creating it
themselves.
You don’t have to do all the
work yourself.
Your job is to align what might
otherwise work at cross purposes.
Tapping into other people’s energies and momentum
creates “pull” for the changes you want to make. Other
people pull the changes along.
43
It takes a village — and the village is here
today
Med/Surg UBCLs —
and their unit-based partners:
Medicine Residents Quality
Track

CRCs/SWs

Pharmacists
HCHS, GSPP and other postacute providers

Educators/ Clin Specs
IBC, AETNA

AP Nurses

Infection Control
Other outpatient stakeholders
People who have been developing
tools & resources
CMO/CNO Alliance
Transitions Steering Group
Other senior leaders from
CRM/SW, IS, HR, Pharmacy,
Quality, HCHS, Operations
44
45
This is our moon shot…
Blueprint for Quality &
Patient Safety (2.0)
Penn Medicine
will eliminate
preventable deaths
and preventable 30-day
readmissions
by July 1, 2014.
46
47
Patient Navigation

There is no accepted definition

Role established in 1990 by a Harlem physician
to assist indigent cancer patients.

However, “Navigators do things for patients by
working with the patients and others in both the
social network of the organization and in the
community.”
Health Services Research Trust
48
Emerging Roles for Nurses Across the
Care Continuum
A. Inpatient Care setting
B. Across settings
C. Outpatient
49
A. Inpatient
I.
Inpatient Care Coordinator
Also Called:
Primary Care Coordinator, Patient Care Coordinator, Unit Based Care
Manager, Hospital-Based Case Manager
Capsule Description:
Serves as a primary contact for physicians and other care
providers; responsible for managing patient care needs and
progress, care plan development and discharge planning
Key Functions/Attributes:
- Interacts with patients and families throughout the length of stay
- Collaborates with other medical staff face-to-face as needed
Individuals Commonly Deployed: Social Worker, Case Manager, RN with BSN, RN with MSN and
CNL licensed
50
B. Across Settings
II.
Inflection Point Navigator
Also Called:
Nurse Life Care Planner
Capsule Description:
Provides guidance to patients, families and physicians during acute
inflection points in healthcare (such as cancer diagnosis) or catastrophic
illness
Key Functions/Attributes:
- Works independently of hospital systems
- Act as consultants for businesses, families or courts of law
Individuals Commonly Deployed: RN
51
B. Across Settings (con’t)
III. Disease-Specific Chronic Care Coordinator
Also Called:
Diabetes Coach, Chronic Disease Manager, Asthma Coach
Capsule Description:
Counsels patients regularly regarding disease-related symptom
management and advises patients on lifestyle choices to improve
prognosis
Key Functions/Attributes:
- Meet with patients on a monthly basis (at minimum)
- Provide disease management over the phone and in person
Individuals Commonly Deployed: Community Member, Pharmacist, RN, licensed NP
52
C. Outpatient
IV. Co-morbidity Chronic Care Coordinator
Also Called:
RN Chronic Care Coordination (CCC) Coordinator, Health Coach,
Team Member, Case Manager
Capsule Description:
Follows patients deemed heavy users of expensive inpatient care due to
multiple chronic illnesses, high ED utilization or recent discharge from a
SNF; promotes more active and informed patient role in self care
Key Functions/Attributes:
- Provides assistance via the telephone
- Conducts in-home visits and office appointments as needed
Individuals Commonly Deployed: Community Member, Medical assistant, RN, Social Worker, Case
Manager
53
C. Outpatient (con’t)
V.
IT Based Care Coordinator
Also Called:
Telehealth Nurse
Capsule Description:
Utilize technological resources to prevent complications associated with
chronic health conditions to avoid hospital admissions.
Key Functions/Attributes:
- Performs initial visit in person during first week of care
54
Role
CNL (generalist)
CNS (expert)
Education
RN prepared at the Master’s degree level as a
generalist
RN prepared as an advanced practice nurse (APN) in
a clinical specialty at the Master’s, post Master’s or
Doctoral level
Direct Manager
Unit Administrator or Nurse Manager
Specialty Area Administrator or CNO
Function
 Provides and manages treatment at the point of
care for patients, families and communities as a
generalist
 Implements the principles of “mass
customization” to ensure consistency of clinical
care within populations
 Expert clinician in a particular specialty or
subspecialty ; functions as an expert
 Provides knowledge and expert skill in a specialized
area to nurses and other member of the
multidisciplinary care team for complex or critically ill
patients
Patient Focus
Coordinates care for patient individuals and
patient cohorts
Designs, implements and evaluates patient-specific
and population based plans of care
Clinical Area of
Practice
Hospital units/wards, outpatient clinics or home
health agencies
Entire facility
Key Activities
 Assess and modify to patients’ care plan as
necessary
 Perform patient and family education
 Lead multidisciplinary groups in formulation and
implementation of solutions to address system
issues concerning patient care delivery
 Act as consultant to other nursing and medical
staff in a specific area of specialization for
complex diagnoses or critically ill patients
 Accountable for care delivered and outcomes of
care for specified cohorts of patients
Common CrossContinuum
Roles
Inpatient Care Coordinator, Unit Based Care
Manager
Disease-Specific Chronic Care Coordinator
Reference: Hall, G et al., “Working Statement Comparing the Clinical Nurse Leader sm and Clinical Nurse Specialist Roles: Similarities,
Difference and Complementarities”, December 2004, available at: http://www.aacn.nche.edu/cnl/pdf/CNLCNSComparisonTable.pdf,
assessed July 20, 2011
55
Community Health Care
Worker -
The Future of Transitions
In Care ????
56
General Services Provided by a
Patient Navigator

Facilitating communication among patients, family members,
survivors and healthcare providers

Coordinating care among providers

Arranging financial support and assisting with paperwork.

Arranging transportation and childcare.

Ensuring that appropriate medical records are available at
medical appointments.

Facilitating follow-up appointments.

Community outreach and building partnership with local
agencies and groups.

Ensuring access to clinical trials.
57
Thank You….