Reducing Readmissions - K

“Taking it to the Next Level”
Amy E Boutwell, MD, MPP
Collaborative Healthcare Strategies
Lexington, Massachusetts
1. Describe the impact of your hospital’s current readmission
reduction efforts.
2. Describe 3 specific opportunities to expand your hospital’s current
readmission reduction efforts.
3. Model and estimate the impact of an expanded portfolio of
readmission reduction efforts.
Cases: Are These Patients Served by Your Readmission Project?
Will Today’s Efforts Get Us Out of the Penalty Zone?
Moving From Pilot to Portfolio
Active participation and discussion are encouraged!
Are these patients served by your current readmission projects?
Caught in a cycle…..
• 77F recently hospitalized for an infected dialysis catheter returns to
the hospital 8 days following discharge with shortness of breath.
• 61M with 8 hospitalizations this year for shortness of breath returns to
the hospital 10 days after discharge with shortness of breath.
• 86M with cancer hospitalized for constipation and abdominal pain
returns to the hospital 1 day after discharge with abdominal pain.
77F recently hospitalized with sepsis returns 8 days
later with shortness of breath
• 1st hospitalization
• Tunneled catheter placed to initiate dialysis
• Acquired blood stream infection (sepsis)
• All anti-hypertensives and diuretic held
• Stabilized in ICU; transferred to floor; 14 day hospitalization
• At discharge
• BP stable x 24 hours “off pressors”
• Felt fine; eager to go home
• Readmission
• Progressively short of breath days 3-7
• Volume overloaded
• Never resumed diuretics after d/c
• Patient demoralized to be back in hospital
61M with 8 hospitalizations this year for SOB returns
to hospital 10 days post d/c with SOB
• 1st hospitalization
• Isn’t really “first” hospitalization is it?
• Intern H&P covers issues as if first presentation of HF
• Recognized marginal housing issues
• Recognized personality issues (inappropriate with staff)
• Refuses to work with PT
• At discharge
• Patient can not be placed in SNF due to criminal history
• Readmission
• Gained 30 lbs in 8 days
• “oh honey, it always takes them about a week to tune me up”
• Grabs remote, turns on TV and orders dinner
86M with metastatic cancer presents with abd pain
and constipation, returns 1 day later with abd pain
• 1st hospitalization
• Constipation x 8 days with abdominal pain
• Resolved in ED; ED concerned pain was due to cancer
• Observed, felt fine, started on bowel regimen
• At discharge
• Family eager to take him home
• Readmission
• Recurrent abdominal pain
• Family concerned it was due to cancer
• Family eager to “do everything” to have dad comfortable
• Patient clearly did not want to be there; didn’t argue with family
Dartmouth Atlas: All-cause Medical Readmissions
54 hospitals penalized
20 penalty >0.9-1%
What is Your Hospital’s Readmission Reduction Aim?
What is Your Current Strategy?
• “Discharge Advocate” for HF patients
• “Coleman Coach” for high risk d/c to home
• Pharmacist-conducted medication management for high risk
• Nurse-conducted follow up calls for high risk
• Teach-back for high risk
• Make follow up appointments prior to discharge for high risk
• Link HF patients to outpatient HF clinic
• Others…..
….and how quickly?
Structure of CMS Readmission Penalties
• Readmission performance based on observed to expected
readmissions for HF, AMI, PNA discharges
• Rolling 3-year average; FY13 based on 2008-2011 readmissions
• Adjustment factor 0.1-1% reduction in DRG payments  2%, 3%
• 2,217 hospitals; $280 million total; average penalty $125k
Care Transitions in Medicare VBP
Jan 1 2013 1/3 of HCAHPS Questions
1. Preferences re: d/c plan
2. Good understanding…
3. Understand each med
2. Cdiff
2015 Inpatient Quality
1. MI- asa rx @ d/c
2. MI-statin rx @ d/c
3. HF d/c instructions
4. HF- LVEF function
5. HF-ACE/ARB rx @ d/c
6. CVA- anti-coag for AF
7. CVA-statin rx @ d/c
8. CVA education
9. CVA asses for rehab
10. VTE- anti-coag overlap
11. VTE d/c instructions
HCAHPS Survey Questions
How often did nurses/ doctors treat you with courtesy and respect?
How often did nurses / doctors listen carefully to you?
How often did nurses / doctors explain things in a way that you could
Before giving you any new medicine, how often did hospital staff tell you what
the medicine was for?
Before giving you any new medicine, how often did hospital staff describe
possible side effects in a way you could understand?
Did the doctors, nurses, or other hospital staff talk with you about whether you
would have the help you needed when you left the hospital?
Did you get information in writing about what symptoms or health problems to
look out for after you left the hospital?
Staff took my preferences and those of my family/caregiver into account
in deciding what my healthcare needs would be when I left the hospital
When I left the hospital, I had a good understanding of the things I was
responsible for in managing my health.
10. When I left the hospital, I clearly understood the purpose for taking each
of my medications.
1% to start FY15
1% FY13 to 2%
1% FY13 to 3% FY15
3,000 hospitals
2,114 hospitals
Process improvements, targeted services & aligned efforts within
and across settings
Are We Adding New Work > Δ Daily Work?
• A lot of focus on NEW work and NEW tools
• Transitional care coaches
• Transitional care Nurse Practitioners
• Disease-specific clinics
• Pharmacists and pharm techs for medication management
• Medical home care managers
• Tele-monitoring
• We have a lot of opportunity to improve our DAILY work:
• 81% of patients requiring assistance with basic functional needs failed to have a
home-care referral
• 64% said no one at the hospital talked to them about managing their care at home
• 42 million family caregivers; 50% perform nursing tasks; 75% manage meds; 33%
do wound care…2/3 without skilled home care
Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices.Marblehead, MA: HCPro, Inc.; 2006.
AARP . Home Alone: Family Caregivers Providing Complex Chronic Care. November 2012.
Let’s Run the Numbers:
One Strategy Won’t Get Us There
Medicare admits/year
5,000 admissions
Medicare RA rate
# Medicare RA /year
1,000 readmissions
Pilot project
200 high risk patients
Pilot group RA rate
Expected # RA pilot
Expected effect of pilot
# RA reduced by pilot
# Medicare RA/year
=1000 – 10 = 990
© Amy Boutwell 2013
Cross-setting Portfolio
Improving Transitions from the Hospital to Post-Acute Care Settings to Reduce Avoidable Rehospitalizations
Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations
Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
STAAR Initiative
STate Action on Avoidable Rehospitalizations
1. Know your data
2. Form a cross-continuum team
3. Review transitions across settings
Available at:
Improve standard care for all patients
Enhanced Assessment of Patients: Identifying high-risk criteria
and meeting needs; engaging pt/family/outpt to identify needs
Enhanced Teaching and Learning: change focus from what
providers tell patients to what patients/caregivers learn
Real-time Communication: timely, clinically meaning
information exchange with opportunity for clarification
Timely Post Acute Care Follow-Up: clinical contact (call, home
health visit, office visit) within 48h or 5 days depending on risk
Cross-Setting Portfolio
• Improve hospital-specific transitional care process:
 RED, BOOST, STAAR, H2H, Next Step in Care
• Improve SNF and Home Health transitional care processes:
 INTERACT, front-loading HH episodes
• Provide new transitional care services:
 Self management coaching, nurse navigators, care coordinators
• Provide ongoing management for very high risk:
 High-utilizer, high risk diagnoses population management
• Link to community-based supports and services:
 AAA, ADRC, nutrition programs, respite, faith based services
Baystate Medical Center, MA
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Outcome Improvements
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Outcome Improvements
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Engaging the Patient and Caregiver
• >80% of patients requiring assistance with basic needs failed to have a
home-care referral
• >60% said no one at the hospital talked to them about managing their
care at home
Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices. Marblehead, MA: HCPro, Inc.; 2006.
Engaging the Caregiver
• 42 million family caregivers
• 46% perform nursing tasks
• 75% of them manage medicines
• 33% of them do wound care
• 66% of the patients had no VNA
Available at:
“We ask caregivers to do things that would make even
nursing students tremble…….
… caregivers are responsible for medical and
nursing care including medication management and wound
~ Susan Reinhard
SVP & Director, AARP Public Policy Institute
“Despite frequent encounters with the acute care system, family
caregivers were not prepared for the medical and nursing tasks
they were expected to provide at home…
“We asked family caregivers how they learned to manage their
family members’ medications and 61 percent said, ‘I learned on
my own.’ Clearly, professionals need to do a better job of training
family caregivers.”
~ Carol Levine
Director of Families and Health Care Project
United Hospital Fund
Next Step In Care- a guide for caregivers
Carolinas HealthCare “SNF Circle Back”
Multi-hospital system in North Carolina
Pilot in one hospital; commitment to spread system-wide if effective
Problem: early readmissions from SNF
• warm handoffs to SNF
• Call back to SNF 3-24 hours after transfer to answer questions
• Details:
• RCA revealed SNF-readmission patters
• Hospital readmission champion met with SNFs to discuss shared goals
• Hospital (with some leadership effort) asked SNF to participate in this communication
• RN calls nurse at SNF
• SW or care coordinator calls for follow up clarification 3-24 hours after transfer
• Daily workflow (with some modifications for weekends, done next business day)
• Follow up calls are scripted and documented in Allscripts system
• Pilot on paper with 1 RN and 1 SW
• Pilot expanded to RN call report to SNF
• Pilot expanded to add follow up calls
• Pilot expanded to build questions into Allscripts
• Expand to all; new standard of practice
Source: Emily Skinner, Carolinas Healthcare System
Carolinas HealthCare SNF Circle Back -2SNF Circle Back Questions
1. Did the patient arrive safely?
2. Did you find admission packet in order?
3. Were the medication orders correct?
4. Does the patient’s presentation reflect the information you
5. Is patient and/or family satisfied with the transition from the hospital
to your facility?
6. Have we provided you everything you need to provide excellent
care to the patient?
• Transitions are a PROCESS (forms are useful, but only a tool to achieve intent)
Source: Emily Skinner, Carolinas Healthcare System
Interacting with Your Hospitals
Information Transfer From the Hospital
INTERACT has a sample
Hospital to Post-Acute Care
Transfer Form that puts the data
into a format that is easy to read
and flows logically for a receiving
Interacting with Your Hospitals
Information from the NH to Hospital
The NH to Hospital
Transfer Form has
two pages.
 The first page has
information that ED
physicians and nurses
identified as essential
to make decisions
about the resident.
Interacting with Your Hospitals
INTERACT Transfer Checklist
This Transfer Checklist
can be printed or taped
onto an envelope, and is
meant to compliment the
Transfer Form by
indicating which
documents are included
with the Form
Hennepin County Medical Center
• 2007, medication events, patient complaints re: d/c process
• Evaluated medication orders
• Found that only 8% of their patients had NO errors
Medication reconciliation was complete >90% of the time!
• Common medication errors:
• Formulation errors
• Duplicates
• Incorrect dose
• Missing medications
• Insulin dosing errors
Bruce Thompson, AHRQ Innovations Exchange
Hennepin County Medical Center- experience
• New Process: Enhanced medication review
MD orders Pharm D and CCSNF
Identify patients being d/c to SNF
When bed available, MD, Pharm D and CC paged
MD has 4 h to enter d/c orders
CC scans orders hourly; paged Pharm D when entered
Pharm D & CC have 2 hours to review; clarify with MD
When errors are noted, resident AND attending are paged
Outcomes: intervention group had 5.7% readmissions v. 10.2%
High patient satisfaction, high physician satisfaction
Bruce Thompson, AHRQ Innovations Exchange
• Consistently lowest HF readmissions in US past 3 yrs
• How?
• Standardize processes for all
• Advanced practice nurse follow up for high risk
• Hospital-medical home joint review of every readmission
• Goal: “zero defects”
Source: Paul Convery MD, CMO
• “Supplemental care bundle” by hospital staff
Medication review & evaluation by clinical pharmacist
Condition-specific education by care coordinator
Enhanced discharge planning by care coordinator
Follow up call
Personal health record & supplemental d/c form to pt and PCP
• Medication Review & evaluation
Med rec at admission
Daily medication review and education
Additional medication change recs as indicated
Med rec at discharge
Counseling on d/c medications
Follow up call at 5-7 days
Koehler et al Journal of Hospital Medicine 2009
Baylor- experience
• 120 patients were approached
• 60 declined to give consent
• 56 unable to give consent 2/2 mental status, dementia & no proxy
• N=41
• Among 41 patients served, average age 78
• ~25% live alone; ~60% live with family; 15% AL
• Dx: Pna, HF, syncope, COPD, cellulitis, GI, GI bleed, UTI, AF, CVA
• Readmission rate for “bundle” group 10% v. 38% control
• Those that had readmission had longer time to RA 36 days v. 15
• No readmissions occurred due to medication issues
Koehler et al Journal of Hospital Medicine 2009
3-Part Strategy
Improve standard hospital-based care for all
Identify risk
Identify learner
Early follow up
Collaborate with receivers to improve transition
“SNF Circle Back”
Warm handoffs
Provide enhanced
services for high risk
Nurse follow up calls
Pharmacist/tech medication
CTI coach
HF clinic
© Amy Boutwell 2012
Let’s Run the Numbers:
Three-part strategy
Medicare admits/year
5,000 admissions
Medicare RA rate
# Medicare RA /year
1,000 readmissions
1. Improve standard care
5,000 admissions
Expected effect
(20% RA rate)
Expected # RA reduction
100 RA avoided
2. Collaborate with
1650 admissions (1/3 total)
Expected effect
(30% RA rate)
Expected # RA reduction
99 RA avoided
3. Enhanced Service for
200 admissions
Expected effect
(25% RA rate)
Expected # RA reduction
10 RA avoided
Total (*illustrative)
209 RA avoided*
209/1000 = 20% overall*
© Amy Boutwell 2012
1. Know your data (perform a root cause analysis)
2. Know your partners (meet them and work together)
3. Know what’s going on (align within and across orgs)
4. Know your high risk patients (identify and manage)
5. Know the best practices & start testing (don’t delay)
Step 1: Know your Data
Example Insights from running your own data
• Payer
• Primary and secondary diagnoses
• Discharge disposition
• Time to readmissions; average # days between RA
• High utilizing patients
Step 1: Know your Data
Example Insights from running your own data
• 6,478 Medicare FFS admissions among 4,732 people
• 6,148 Medicare FFS alive discharges (some exclusions)
• 908 30-day readmissions; 14% all cause readmission rate
• Reducing readmissions by 20% = 180 avoided RA
• 50% 30-day readmissions <10 days of d/c; 25% <96h
• Top 10 RA dx: HF, RF, UTI, sepsis, GIB, arrythmia, COPD, syncope,
gastritis/esophagitis, PNA/respiratory infection
• 369 people (8%) hospitalized >3 times; used 1339 H (22%)
• Among high utilizers, 495 30-d RA; rate 38%
• Among high utilizers, 55% d/c to home with no services (N=716)
• Top 10 dx: same HF, RF, UTI, COPD, GIB, sepsis, esophagitis
Step 1: Know your Data
Example Insights of Community-based RCA
• Patient/ Family interviews
• Did not understand d/c instructions; felt rushed
• Did not understand doctor
• Felt “lost” when returned to home
• No time to fill new medications
• Provider interviews
• MD: Did not know patient was in hospital
• MD: Did not have any information from hospital re: tx/rx
• HH: Called MD, directed patient back to ED
• SNF: Change in clinical status, no MD to evaluate
There Is No Silver Bullet…..
• 523 readmissions:
• 250 (47%) deemed potentially preventable
• Found an average of 9 factors contributed to each readmission
• Assessed factors relating to 3 phases of care:
• 57% readmissions involved an issue of care during 1st hospitalization
• 67% involved an issue during the discharge process
• 79% involved an issue relating to follow up care
• Assessed factors related to 5 domains of quality improvement:
• 73% - care transitions planning & care coordination
• 80% - clinical care
• 49% - logistics of follow up care
• 41% - advanced care planning & end of life
• 28% - medications
• 250 readmissions identified 1,867 factors!
Feingenbaum et al Medical Care 50(7): July 2012
Step 2: Know your partners
Available from your state Quality Improvement Organization
Cross-Continuum Team
“We were working on improving processes within the hospital but we
also know that because hospital stays are short and patients typically
are not fully recovered when they are discharged, we had to involve
other providers in the community.”
Kris Zitrick, Director of Quality Management Charles Cole Memorial Hospital
“At the first meeting we realized that the community partners had no
knowledge of what we were doing as a hospital to prevent
readmissions and that we needed to be educated about the role of the
post-acute providers about what happens when they take over the care
of the patients.”
Bonnie Kratzer, Director of Case Management, Charles Cole Memorial Hospital
Specific actions: share information about efforts, educate about capabilities of
organizations, decrease silos, form relationships, sense of teamwork and putting patients
first, standard transition forms
Step 3: Inventory and Align Efforts
Practices & VNA:
Essential info: meds, goals
1. CM in ED
2. Treat & return to SNF
1. Early follow up & med rec
2. Refer to AAA
3. Clarify goals of care
SNF: transition improvement
Targeted transitional care services
“Skilled Nursing”
1. Standardize process for all
2. Target: high risk, high utilizer
Fill in Your Own Cross-setting Portfolio
Improving Transitions from the Hospital to Post-Acute Care Settings to Reduce Avoidable Rehospitalizations
Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations
Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
Step 3: Inventory and Align Efforts
Partner to improve shared processes
Shared patient education materials
2. Consistent use of teach-back & teaching points
3. Medication management across settings
4. Timely communication between providers
5. Consistent caregiver engagement in care plan
6. Warm handoffs
7. Notification of PCP of ED visit/admission
8. Use Next Step in Care Resources for Shared Patients
9. Use INTERACT forms to improve transitions with SNF
10. Awareness of & linkage to community resources
Step 4: Identify High Risk Patients
• Identify based on hospital data
• Collaborate among hospitals in a community
• Pilot proactive outreach and optimize resources
• Identify the individuals returning to ED/obs/inpatient >3 times annually
and target efforts
Step 5: Move from Pilot to Portfolio
• Avoid looking for one single solution – develop portfolio
• Don’t overplan – iterate as you go
• Standardize improved transitional care process for all
• Collaborate to deliver transitional care services for target populations
The majority of success stories to date would say they built on the set
of existing recommendations but ultimately theirs is a unique solution
What are the next steps for your hospital?
What successes and challenges have you had?
What is your hospital’s plan to expand efforts in 2013?
What 1 idea will you bring back to your readmission team?
Thank you!
Amy E. Boutwell, MD, MPP
Co-Founder, STAAR Initiative
Collaborative Healthcare Strategies, Lexington, MA
[email protected]
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