the part 1 presentation slides

Readmissions Boot Camp
Resolve to Reduce Readmissions
Session 1 – Part 1 & 2 – REPEAT
Pat Teske, RN, MHA
Vikas Bhala, MPH, MBA
AHA Disclaimer
Participation in this conference call is by express
written invitation of the AHA only.
Unauthorized participants and/or any party that
assists unauthorized participants may be subject
to substantial criminal and civil penalties. If you
have not been invited to take part in this call,
please disconnect at this time.
2
AHA/HRET (HEN) Resolve to Reduce Readmissions
2014 Boot Camp - Day Two Repeated
Virtual Meeting– Summary Disclosure & Accreditation Statement
February 6, 2014
The planners and faculty of the AHA/HRET (HEN) Resolve to Reduce Readmissions
2014 Boot Camp - Day Two Repeated have indicated no relevant financial
relationships to disclose in regard to the content of this activity.
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing
Medical education through the joint sponsorship of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP)
and Health Research & Education Trust (HRET). ABQAURP is accredited by the ACCME to provide continuing medical education for physicians.
The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 2.0 AMA PRA
Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
The American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) is an approved provider with the Florida Board of
Nursing to provide continuing education for nurses. ABQAURP designates this activity for 2.0 Nursing Contact Hours through the Florida Board of
Nursing, Provider # 50-94.
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Boot Camp Overview
• Thursday Morning Repeat: Session 1 – Part 1
– Overview
– Patient Story
– Why Readmissions
– Diagnostic
– What was learned
– Measures
– Dashboard
– Risk Assessment
Our AIM
To Reduce Readmissions by 20%
by the end of the year
Boot Camp Objectives
• Identify the essential
elements of an effective
readmissions reduction
program
• Critique your current
program to determine
opportunities for
improvement
• Compose a plan to
achieve/maintain a 20%
reduction in readmissions
by the end of 2014
Where we are
Why Readmission Reduction?
Judy Clipp, BSN, RN, CMSRN
Barb Hull, BSN, RN-BC, CHFN
Columbus Regional Hospital
Our story
Columbus Regional Hospital
Judy Clipp,
BSN, RN,
CMSRN
Barb Hull,
BSN, RN-BC,
CHFN
• Regional health system serving
a 10-county region in
southeastern Indiana
• 225-bed facility providing
emergency and surgical
services and comprehensive
care in numerous specialty
• 1,700 employees, 225
physicians on medical staff,
and 250 volunteers
• http://www.crh.org/innovatio
n/dashboard.aspx
Diagnosing Your Readmissions
Pat Teske, RN, MHA
Doing things
the same way
will NOT reduce
readmissions
Diagnose
• Readmission
Rates
• To – From
• Diagnoses
• Risk Groups
• Admission
• Teaching/Coaching
• Hand Over
• Acute Care Follow
Up
• Post-Acute care
support
• Do 5
structured
interviews
Review
your data
Talk to
your
patients &
providers
Review
Your
Processes
Review
MRs
• Review 5
charts
What are the data saying?
• Pull all readmissions
and ask…
• Who are being
readmitted?
• What are their
characteristics?
• Where are they coming
from?
• Where are they going?
• What surprised you?
What are your patients saying?
• Ask a patient who was
readmitted today..
• Tell me in your own
words how you think
you became sick
enough to come back to
the hospital?
• Track results
• What are you learning?
What are your providers saying?
• Were you aware your
patient was hospitalized?
• Did you receive timely
information?
• What do you think needs
to happen for your
patient to be able to stay
healthy enough to stay
out of the hospital?
• What did you learn?
What do the records say?
• Review all records for
the patient for the past
180 days
• Note condition,
disposition, instructions
• What did you learn?
Don’t forget the processes
• Review key processes
e.g. patient education
–
–
–
–
Documents and tools
Training
Observation on practice
Monitoring
• What changes are
needed?
Policy
Training
Observation
Reality
Pulling it all together
• What did your data say?
• What did your patients
say?
• What did your providers
say?
• What did the records
say?
• How reliable are your
processes?
• Focus and prioritize
What was learned?
Kristen van Bergen, CPHQ
Assistant Director, Quality Services
Littleton Regional Healthcare
About Us
Littleton Regional Healthcare
• Critical Access Hospital in
Littleton, NH est. 1907
• 25 beds across Med/Surg, ICU
and OB units (~ 1700
discharges per year)
• Provider based primary care
and specialty practices
(employ ~ 40 of our 122
physicians and mid-level
Medical Staff members)
Kristen van Bergen-Buteau, CPHQ
Assistant Director, Quality Services
Readmission Reduction at Littleton Regional
Healthcare
Run Charts
Aim Statement
To reduce the rate if all-cause adult
inpatient readmissions by 20% by
December 2013
Why is this project important?
•Improved patient outcomes
•Improved cross-continuum collaboration
•Decreased resource utilization
18%
16%
14%
•Understanding each other goes a LONG
way (e.g.. D/C to HH, NH to ED)
17%
17%
13%
12%
10%
10%
9%
8%9%
8%
6%
•Small changes can have a large impact
(e.g. ETOH HS, pick the right fax #)
13%
12%
8%8%
6%
5%
4%
6%6%
5%
4%
2%
0%
6%
3%4%
3%
4%
•ROI takes time to assess and can be
hard to sell (e.g. D/C calls)
Recommendations and Next
Steps
0%
Changes Tested,
Implemented or Spread
•Discharge follow-up calls & action items
to PCP
•Follow-up appointments booked prior to
discharge
•Discharge Summaries and Med-Rec
forms to PCP within 48 hours of
discharge
•Transitions in Care cross-continuum
meetings
•Improved collaboration with postdischarge facilities
•Interdisciplinary care plans
Lessons Learned
LRH Readmission Rate
• Expand collaboration to other nonclinical continuum members
Linear (LRH Readmission Rate)
16
12
10
8
6
4
2
59
11
9
9
8
5
6
7
100
89
84 82
84
14 14 78 75 81
65
64
8
7
5 5
4 4
78
73 71
68 70
66
59
10
9
6 6
3
0
4
3
2
76 76 75
80
67
62
60
5
4 4
2
83
40
6 6
3 3
4
3
0
0
Readmissions
Admissions
20
Pts Readmitted
Linear (Readmissions)
•Start looking at ED readmits w/in 72
hours and apply HS methodology to that
population
•Continue working on specific crosscontinuum barriers and challenges as they
are identified
Team Members
Hospital, Provider-based Practices, FQHC,
Home Health, Hospice, Independent
Living, Nursing Homes, Senior Council,
Education Consortium
What we Learned
• Improvements in process don’t necessarily mean immediate
improvements in readmission rates! The world needs to get used to our
new processes.
• There may be no significant trends in readmissions by diagnosis, but the
opportunities are similar regardless of primary reason for utilization –
communication, communication, communication (with the patient/family,
between agencies and between providers)
• “Hot Spotters” existed, but we couldn’t reduce their utilization until we
established cross-continuum collaboration and patient-specific care plans
• DO NOT:
– Insist on cleaning up internal processes before any other cross-continuum
work can begin – “Neat” and “Sterile” are two very different standards!!
– Get bogged down in data – track what you need to show progress, but keep
moving!
– Try to fix the whole system at one time – small changes can have significant
impact
What we Learned
• Barriers can be overcome:
– Patient “non-compliance” – It’s a misnomer! We just need to ask the right
questions to identify what’s getting in the way of good health, and then
connect to appropriate resources
– “Non-compatible” medical records systems – Look closer, and think outside
the box (but within the rules)
– 30-day rule – Convince your providers that IT IS OKAY to dictate and sign
SOONER!
– Medications are an issue
• Electronic Reconciliation forms in paper format as orders
• Who signs the 485??
• Polypharmacy & cross-reactions could be the issue, not a separate health condition
– Receiving providers all have “Different” needs – not really. It’s all about
communication & developing a shared vocabulary
– Lack of a social safety net – “Hot Spotters” have many socioeconomic barriers
in a rural area, and partnering with non-clinical resources can help create and
maintain population health
What can others learn from our
journey?
• Start collaborating across the continuum – NOW!
– Multiagency meetings to identify collective opportunities
(LTC, ALF, HH, PCT, ACA, etc)
– Task forces focused on specific transitions in care and on
specific “Hot Spotters”
• Be willing to use LOTS of Rapid Cycle Improvement –
every form & script is a draft and that’s okay
• Think outside the silos – there ARE resources we’re not
tapping in rural areas, and most are NOT health-care
related … this is probably true in urban/suburban
areas, too!
Readmission Data and Measures
Helen Ning, Data Analyst, AHA/HRET
Carmela Estrada Bondad, Senior Program Manager, AHA/HRET
HEN Readmissions Results to
Date
Preventable Readmissions
Readmission within 30 days (All Cause)
•
70% reporting, 5.63% reduction to date
HEN Readmissions Results to
Date
Preventable Readmissions
Heart Failure (HF) Patients
• 19% reporting, 11.68% percent reduction to date
•
856 Heart Failure Patients prevented from being readmitted baseline through
Month 10.
– This translates to an estimated cost savings of $8,217,600
Measure Alignment
• Focus for 2014 is Measure Alignment to the National measures
• If you have been with our HEN for the past two years, now is a great time
to look at your measures and determine whether they are aligned
• If you are new to the project, here are some considerations when choosing
your measures.
–
–
–
–
–
What are you already measuring?
What are you planning to measure?
Identify Existing Measures
Are they in the Encyclopedia of Measures as Recommended Measures?
If not, there is an option to add user-defined measures, however, they need to
be reviewed and approved before creating them.
• ALSO – HRET can extract data from other sources, i.e., state databases*
and NHSN
Recommended Measures:
Readmissions
• Current Top Two Most Popular Measures
EOM Measure ID
Topic Measure Name
EOM-Read-75
Readmit Readmission within 30 days (All Cause)
EOM-Read-77
Heart Failure (HF) Patients - Readmissions within 30
Readmit days (All Cause)
Recommended Measures:
Readmissions
• Other/New Measures
Measure
Definition
Numerator
Denominator
Source
Readmissions
within 30 days
(All Cause) –
Acute
Myocardial
Infarction
AMI Patients who
were readmitted
within 30 days for
any reason
Patients readmitted to the
same facility , for any
reason, within 30 days of
date of discharge after
hospitalization for AMI
All AMI patients discharged alive
(index
hospitalization, principal diagnosis code of AMI, excluding
those discharged AMA or to another acute care hospital)
(AMI principal diagnosis codes 41000, 41010, 41011,
41020, 41021, 41030, 41031, 41040, 41041, 41050, 41051,
41060, 41061, 41070, 41071, 41080, 41081, 41090, 41091)
Based on
CMS Hospital
Compare
measure
Readmissions
within 30 days
(All Cause) –
Pneumonia (PN)
PN Patients who
were readmitted
within 30 days for
any reason
Patients readmitted to the
same facility , for any
reason, within 30 days of
date of discharge after
hospitalization for PN
All PN patients discharged alive
(index
hospitalization, principal diagnosis code of PN, excluding
those discharged AMA or to another acute care hospital)
(PN principal diagnosis codes 4800, 4801, 4802, 4803,
4808, 4809, 481, 4820, 4821, 4822, 48230, 48231, 48232,
48239, 48240, 48241, 48249, 48281, 48282, 48283, 48284,
48289, 4829, 4830, 4831, 4838, 485, 486, 487.0)
Based on
CMS Hospital
Compare
measure
Days since last
readmissions
N/A
AHA/HRET
HEN - Rural
Tracker
EOM-Read-76
EOM-Read-78
Days since last
readmissions
Days since last
readmissions
Additional ConsiderationsReadmissions
• Denominator Exclusions:
– Deaths
• Numerator
– Changing type of admission
• Readmissions count for acute inpatient index admission to acute
inpatient readmission
• Example 1: acute inpatient was discharged and admitted to inpatient
rehab within the same hospital  NOT a readmission
• Example 2: acute inpatient was discharged and transferred to another
facility then was admitted to original facility as acute inpatient 
Readmission
– Readmission to same hospital
– For EOM-Read-75: All Payer, All Cause 30 Day
– Counts for month of index admission
Scenario 1: Is this a 30 day
readmission?
• Pt. A
– Acute care admission 12/9 – 12/15
– Observation stay 12/19 – 12/20
– Acute care admission 1/18 – 1/20
• No, this is not a 30 day readmission. The index
discharge date for this patient was 12/15. The
patient did not have another acute care
admission within 30 days after 12/15.
Observation stays are not counted as a
readmission.
Scenario 2: Is this a 30 day
readmission?
• Pt. B
– Acute care admission 12/9 – 12/15
– Acute care admission 12/19 – 12/21
– Acute care admission 12/30 – 1/8
• Yes, this patient is actually accounting for two
readmissions. The 12/19 readmission counts
because the patient was readmitted 4 days after
the 12/15 discharge. The 12/30 admission is a
readmission from the 12/21 discharge. Each
discharge (excluding death) is an opportunity for
a readmission.
What is my readmission rate?
Penalty Info
• Defined readmission as an admission to a subsection(d)
hospital within 30 days of a discharge from the same or
another subsection(d) hospital
• Adopted readmission measures for the applicable
conditions of Acute Myocardial Infarction (AMI), Heart
Failure (HF) and Pneumonia (PN)
• A hospital’s excess readmission ratio for AMI, HF and PN is a
measure of a hospital’s readmission performance
compared to the national average for the hospital’s set of
patients with that applicable condition
• Established a policy of using the risk adjustment
methodology endorsed by the National Quality Forum
(NQF)
Penalty Amounts
• For FY 2013, up to 1% reduction
• For FY 2014, up to 2% reduction
• For FY 2015, up to 3% reduction (COPD, TKA, THA
are added)
• For more information go to:
http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/AcuteInpatientPPS/ReadmissionsReduction-Program.html
Readmissions Dashboard
Pat Teske, RN, MHA
Dashboard Considerations
• Which key processes are
you trying to impact?
– Doctors visits made within
10 days
– Post discharge calls
completed within 48 hours
– Etc.
• Data collection
– Who, when, what, how
much, etc.
• Analysis and display
– Who, how often, where,
etc.
Dashboard Example
Criteria Based Risk Assessment
Melissa Bachhuber
San Francisco VA Medical Center
About us
San Francisco VA Medical Center
• Established in 1934
• 104 operating beds and a
120-bed Community Living
Center
• Primary and mental health
care is provided at
outpatient clinics
• There is a specialized
homeless Veterans clinic in
downtown San Francisco
Project RED Screening Criteria
•
•
•
•
•
•
•
•
•
•
•
•
•
Marginally housed/homeless
Polysubstance abuse
Lives alone, no support
>65 years old
Multiple medications; polypharmacy >10 medications
Admission diagnosis of CHF, PN, or AMI
Lives remotely
Poor adherence to treatment
No PCP
Frequent ER utilizer >3 visits in 6 months
Mental health comorbidity
Admitted in past 90 days
Change in functional status
How it works
• Usually 5 or more trigger
a consultation
• Project RED nurse:
– Provides enhanced patient
education
– Aligns with other resources
– Coordinates post discharge
needs
– Performs “sign out” with
outpatient primary care
team nurse
Evidence-based risk assessment
Pat Teske, RN, MHA
Using the LACE risk assessment
• Dr. Carl van Walraven looked at 48 patient-level
and admission level variables for 4,812 patients
discharged from 11 hospitals in Canada
• Four variables were independently associated
with unplanned 30 day readmissions
–
–
–
–
LOS
Acuity of the admission
Comorbidities using the Charlson comorbidity index
ED visits within the past 6 months
Let’s try it
Prior Hospitalization Score
Current Hospitalization Score
Facility Designed Risk Assessment
Ruth Zaltsmann, RN, MS
El Camino Hospital
Ruth Zaltsmann, RN, MS,
BSN
El Camino Hospital
 Not-for-profit community hospital
in Mountain View & Los Gatos,
California
 2 campuses (Enterprise)
- 399 beds in Mountain View
- 143 beds in Los Gatos
 First Bay Area Magnet Hospital
Creating a Risk Tool
•
•
Evaluated existing tools:
- Boost
- LACE
- Yale-New Haven Hospital
Evaluated many known contributing
factors:
- Lack of PCP
- Age
- Previous Admission
- Psychiatric Issues
- Admission/Discharge Diagnosis
- Medications (>6)
- Cognitive Impairment
- Functional Deficits
- Discharge Disposition
- Health Conditions
Scoring Patients:
Low: 0-26.9
Moderate: 27- 39.9
High: >40
Using the Risk Tool
Disposition
Age
Disposition
HH
1.8
<49 1
HH
HH
HH
HH
Home
Home
Home
Home
Home
Home
Home
RC
RC
RC
RC
RC
RC
SNF
SNF
SNF
SNF
SNF
SNF
SNF
SNF
SNF
SNF
Home
Home
RC
SNF
SNF
1.8
1.8
1.8
1
1
1
1
1
1
1
1.5
1.5
1.5
1.5
1.5
1.5
1.9
1.9
1.9
1.9
1.9
1.9
1.9
1.9
1.9
1.9
1.8
1
1
1.5
1.9
1.9
>69
>69
>69
<49
<49
<49
>49
>49
>69
>69
>49
>49
>69
>69
>69
>69
<49
<49
<49
<49
>49
>49
>49
>69
>69
>69
1.5
>69
1.5
1.5
1
1
1
1.1
1.1
1.5
1.5
1.1
1.1
1.5
1.5
1.5
1.5
1
1
1
1
1.1
1.1
1.1
1.5
1.5
1.5
Age
Dx
COPD, PNA, Chr. Bronchitis
CHF
CVA
None
CHF
COPD, PNA, Chr. Bronchitis
None
CHF
COPD, PNA, Chr. Bronchitis
CHF
COPD, PNA, Chr. Bronchitis
COPD, PNA, Chr. Bronchitis
CP
CHF
COPD, PNA, Chr. Bronchitis
CP
None
CHF
CP
CVA
None
COPD, PNA, Chr. Bronchitis
CVA
None
CHF
COPD, PNA, Chr. Bronchitis
None
1.5
No Readmit Risk Rate Rank Previous
Yes Readmit RiskAdmission
Rate Rank
Diagnosis
1
0.44 30.3%Moderate
2.8
1.22 55.0%High
1.9
2.2
1.3
1
2.2
1.9
1
2.2
1.9
2.2
1.9
1.9
1.5
2.2
1.9
1.5
1
2.2
1.5
1.3
1
1.9
1.3
1
2.2
1.9
1
1
None 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
<49
1
CHF
>69
1.5
None
>69
1.5
COPD
<49
1
CHF
>69
1.5
PNA
0.76
0.45
0.34
0.28
0.24
0.13
0.31
0.27
0.42
0.36
0.40
0.32
0.63
0.54
0.43
0.29
0.53
0.36
0.31
0.24
0.51
0.35
0.27
0.80
0.69
0.36
43.1%High
2.8
2.12 67.9%High
19.5%Low
11.3%Low
23.6%Low
21.0%Low
29.6%Moderate
26.6%Low
28.5%Moderate
24.0%Low
38.7%Moderate
35.3%Moderate
30.1%Moderate
22.3%Low
34.7%Moderate
26.6%Low
23.9%Low
19.5%Low
33.6%Moderate
25.7%Low
21.0%Low
44.4%High
40.8%High
26.6%Low
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
0.68
0.36
0.86
0.75
1.18
1.02
1.12
0.88
1.77
1.52
1.20
0.80
1.49
1.02
0.88
0.68
1.42
0.97
0.75
2.24
1.93
1.02
1 30.9%Moderate
25.6% 2.8Low1.25 55.6%High
49.1 High
25.6%Low
2.8
0.96 49.1%High
%
21.9%Low
2.8
0.78 44.0%High
40.4%High
26.3%Low
46.3%High
42.7%High
54.1%High
50.4%High
52.8%High
46.9%High
63.8%High
60.4%High
54.6%High
44.5%High
59.9%High
50.4%High
46.8%High
40.4%High
58.6%High
49.2%High
42.7%High
69.1%High
65.9%High
50.4%High
2.2 21.9% Low 44.0 High
%
1
16.0% Low 34.9 Mod
%
1.9 35.4% Mod 60.4 High
%
2.2 34.7% Mod 59.9 High
%
1.9 40.8% High 65.9 High
%
Risk Tool Findings
Risk Tool
Pros:
•
•
•
Triages patients
It is a quick 4 questions to answer
Tailored to the type of patients ECH sees
Cons:
•
•
•
•
•
Does not capture all high risk patients
Missing certain diagnosis
Only focuses on 4 components
Not necessarily evidence based
Data should be extracted from the EMR automatically
Risk
Predicted
Actual
Low
1%
7%
Moderate
11%
15%
High
27%
18%
Overcoming the short falls of
the risk tool:
• Case finding based on diagnosis
•
•
•
•
•
•
•
•
•
Pneumonia
Sepsis
UTI
Clostridium difficile
COPD
Heart failure
ACS/AMI
Pancreatitis
Abdominal surgery
• Direct referrals (the gut feeling)
•
•
•
Discharge planners
Bedside nurses
Physicians
BREAK (10 Minutes)
WELCOME BACK!
Resolve to Reduce Readmissions
Session 1 – Part 2 – REPEAT
Pat Teske, RN, MHA
Vikas Bhala, MPH, MBA
AHA Disclaimer
Participation in this conference call is by express
written invitation of the AHA only.
Unauthorized participants and/or any party that
assists unauthorized participants may be subject
to substantial criminal and civil penalties. If you
have not been invited to take part in this call,
please disconnect at this time.
65
AHA/HRET (HEN) Resolve to Reduce Readmissions
2014 Boot Camp - Day Two Repeated
Virtual Meeting– Summary Disclosure & Accreditation Statement
February 6, 2014
The planners and faculty of the AHA/HRET (HEN) Resolve to Reduce Readmissions
2014 Boot Camp - Day Two Repeated have indicated no relevant financial
relationships to disclose in regard to the content of this activity.
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing
Medical education through the joint sponsorship of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP)
and Health Research & Education Trust (HRET). ABQAURP is accredited by the ACCME to provide continuing medical education for physicians.
The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 2.0 AMA PRA
Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
The American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) is an approved provider with the Florida Board of
Nursing to provide continuing education for nurses. ABQAURP designates this activity for 2.0 Nursing Contact Hours through the Florida Board of
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Today’s Overview
• Thursday Afternoon Repeat: Session 1 – Part 2
– Welcome back
– Why was there a readmission
– Caregiver involvement
– Health literacy
– Patient friendly education
– Teach back
– Caregiver reaction
Our AIM
To Reduce Readmissions by 20%
by the end of the year
Boot Camp Objectives
• Identify the essential
elements of an effective
readmissions reduction
program
• Critique your current
program to determine
opportunities for
improvement
• Compose a plan to
achieve/maintain a 20%
reduction in readmissions
by the end of 2014
Where we are
Why are patients returning?
Carmen Gutierrez
Quality Director/ Clinical Informatics
Cibola General Hospital
Our story
Cibola General Hospital
• 81 miles west of
Albuquerque/ 62 miles east
of Gallup
• Medical and surgical
hospital in Grants, NM
• 25 beds (CAH)
–
–
–
–
15 M/S/ Tele
4 ICU
3 LDRP
3 PP
What are we missing?
• 676 discharges in 2013
• 51 readmissions
• Medication reconciliation compliance
consistently above 90%
• HCAHPS up and down
• Readmission patterns?
Discharge Medication Reconciliation
and Readmission Patterns
120
100
80
60
40
20
0
Initiated NEW
patient
discharge
instruction
Identified Performance and patient
Improvement
opportunity
Identified
barriers to
discharge
that could
lead to
readmission
Discharge Medication Reconciliation
Readmissions
HCAHPS
• Involved Case Management in daily review for
readmitted patients.
• Interviewed patients to identify issues.
• Readmissions due to delays in results (ex. lab
reports), rescheduled procedures or other
issues are referred to Utilization Management
and the Chief Medical Officer for review.
What did we do?
Patient Education:
• Provided to patients during the hospital stay by all clinical
departments.
• Discharge binders are kept at the patient bedside and are
updated as needed throughout the patient stay.
Medication Reconciliation:
• Accurate medication reconciliation and pharmacy consult.
• Rx filled prior to discharge.
• Local pharmacy can arrange home delivery in some cases.
Transportation:
• Arrangement made with Cibola Area Transit for door- to- door
service.
Follow- up appointments:
• Appointments are made prior to or at discharge and
documented on the discharge instructions
Caregiver Involvement
Carol Levine
Director, Families & Health Care Project
United Hospital Fund
Carol Levine
• Co-author, Home Alone:
Family Caregivers Providing
Complex Chronic Care (AARP
Public Policy Institute/United Hospital Fund,
2012)
• Co-chair, Transitions in CareQuality Improvement
Collaborative (TC-QuIC, 2009-2012)
• Senior advisor, IMPACT
(GNYHA, 2014)
The idealized patient…and a
reality check
Manages alone…
Needs
assistance
Family caregivers are important
to transitions (and readmissions)
Many transition plans assume a considerable amount of
family care.
• The patients most at risk of readmission are often too
sick, cognitively impaired, or otherwise unable to
“self-manage.”
• The best-laid transition plans will fall apart if one key
partner—the family caregiver—cannot do the job.
• If family caregivers are not involved in planning, they
may not understand what is expected of them.
• They also have no opportunity to have barriers
accounted for in the care plan or to refuse.
Involving Family Caregivers: How?
Routinely involve family caregivers in transition
care planning, implementation, and follow-up
• Identification of family caregiver(s), role in care,
contact information
• Guided self-assessment of caregiver’s needs
• Medication reconciliation
• Discharge planning
• Post-discharge follow-up: more than satisfaction!
Communication, Communication,
Communication
Taking the time up front to use evidence-based
communication methods can save time later.
• Four Habits of Approach to Effective Clinical
Communication *
1.
2.
3.
4.
Invest in the Beginning
Elicit the Patient’s Perspective
Demonstrate Empathy
Invest in the End
• Teach Back
• LISTENING
* Frankel RM, Stein TS. The four habits of highly effective
clinicians: a practical guide. [Oakland (CA)]: Physician
Education & Development, Kaiser Permanente Northern
California Region; 1996.
Tools You Can Use Today
Tools
www.nextstepincare.org
• Identification of family caregivers
– Provider guide with sample script
• Guided self-assessment of needs
– “What Do You Need as a Family Caregiver?” threepart staff tool
• Medication education
– Provider guide “Preparing Family Caregivers to
Manage Medications”
• Discharge planning guides and checklists
Thank You
Carol Levine
Director, Families and Health Care Project
United Hospital Fund
[email protected]
www.nextstepincare.org
Health Literacy
Jennifer Pearce, MPA
Health Literacy Program
Manager, Sutter Health – Sutter
Center for Integrated Care
Jennifer Pearce
What is health literacy?
Literacy
•Having the basic skills to read,
write and compute without
regard to context
Health
literacy
• Reading, writing, computing,
communicating and
understanding in the context of
health care
Source: Weiss B. Epidemiology
94 of Low Health Literacy. Understanding Health Literacy: Implications for
Medicine and Public Health
Health literacy
Health literacy includes one’s
ability to perform multiple tasks
Obtain
Document literacy
Process
Prose literacy
Understand
Quantitative
literacy
Communicate:
listen and speak
Numeric literacy
Source: IOM. 2004. Health Literacy: A Prescription to End Confusion
Source: Schwartzberg, J. 2005. Understanding Health Literacy: Implications for Medicine and Public Health
95
Reality check
Health system
demand/complexity
Health
literacy
Patient skill/ability
Source: Parker, R. and Ratzan, S. 2010. “Health Literacy: A Second Decade of Distinction for Americans', Journal of Health Communication” 15: S2, 20 — 33
96
Patient skills:
Prevalence of low health literacy
2003 National Assessment of Adult Literacy
Below Basic
14%
Proficient
12%
Basic
22%
Intermediate
52%
97Education, Institute of Education Sciences, 2003 National
Source: U.S. Department of
Assessment of Adult Literacy
National Assessment of
Adult Health Literacy
Adult health
literacy by
highest level of
education
Only 1/3 of those with a graduate degree have the
skills to effectively manage a chronic illness
Source: U.S. Department
of Education, Institute of Education Sciences, 2003 National Assessment of Adult
98
Literacy
Adult health
literacy by
age
Only 3% of those age 65+ have the skills to
effectively manage a chronic illness
Source: U.S. Department of Education, Institute of Education Sciences, 2003 National
99
Assessment of Adult Literacy
Patient engagement fundamentally
relies on health literacy
Source: Empowerment and engagement among low-income Californians: Enhancing patient-centered care. 2012 Blue Shield of California
Foundation Survey. September 2012
100
Patient engagement requires skill
• Find a doctor and define the preferred
relationship
• Articulate health issues
• Develop partnership with the patient
• Identify/review patient preferences and
patient’s preferred role
• Share, access, and evaluate information • Identify choices
• Negotiate decisions
• Present evidence and help patient
reflect
Choices
Talk
Evidence
Shared decisions
Source: E. Bernabeo and E. Holmboe (2013). Patients, providers, and systems need to acquire a specific set of competencies to achieve truly patient-centered care.
101
Health Affairs 32, No. 2: 250-258
Why consider your patients’ health
literacy?
•
•
•
Engage and empower
Understand readmission risk
Enhance care experience:
»
»
»
Disease management
Health system navigation
Self-advocacy
Increased patient satisfaction
Improved health outcomes
Reduced readmissions
102
Single Item Health Literacy Screener
Predicts Newest Vital Sign Scores
“How confident are you at filling out medical forms
by yourself?”
1. Extremely
2. Quite a bit
3. Somewhat (cut point)
4. A little bit
5. Not at all
(Sensitivity – 100%; Specificity – 0%)
Source: Stagliano V, Wallace LS. Brief health literacy screening items predict newest vital sign scores. J Am Board Fam Med 2013;26(5):558-565.
103
The Universal Precaution Approach to
health literacy addresses this mismatch
Health system
demand/complexity
Health
literacy
Patient skill/ability
104
This approach is appropriate for
all individuals regardless of:
Reading ability
Education level
Universal
Precaution
Approach
Socio-
economic status
Source: Smith, Sandra A. (2001). Patient Education and Literacy in Labus, A. & Lauber,
A. (Eds.) Preventive Medicine and Patient Education. Philadelphia: WB Saunders, 266105
290.
Evidence: easy-to-read is
preferred!
College educated readers’response to health information
written at 5th grade level:
Recall of key messages
Satisfaction
Sources: Smith SA. Information giving: Effects on birth outcomes and patient satisfaction. Int Electronic J Health Educ 1998:;3:135-145. Online at
http://www.beginningsguides.net/content/images/stories/info-giving.pdf
106
Health literate tools
What can you do? Ask your
patients!
Timely
Effective
Safe
Patient
Efficient
Equitable
The patient has a
unique perspective
that comes from being
the only person at the
interface of all facets
of their care.
Patient
centered
Source: D. Ness & W Kramer (12/27/2011) Pioneer ACOs: Moving Toward Needed
Transformation In Health Care
http://healthaffairs.org/blog/2011/12/27/pioneer-acos-moving-toward-neededtransformation-in-health-care/
Health literate resources to
promote patient engagement
The Health Literacy Environment of
Hospitals and Health Centers
Rima Rudd & Jennie Anderson, Harvard School of Public Health
Link to materials:
http://www.hsph.harvard.edu/healthliteracy/files/2012/09/healthliteracyenvi
ronment.pdf
Health Literacy Universal Precautions
Toolkit
Designed to help ensure that systems are in place to promote better
understanding by all patients, not just those you think need extra
assistance
Link to materials:
http://www.ahrq.gov/legacy/qual/literacy/healthliteracytoolkit.pdf
Health Literacy
Universal Precautions
Toolkit
Patients cannot afford this …
110
What questions do you have?
Jennifer Pearce, MPA
Health Literacy Program Manager
Sutter Center for Integrated Care
[email protected]
www.suttercenterforintegratedcare.org
Patient Friendly Education
Benjamin E. Gillens, MSHS, BSN, RN
Project RED Team
VA Palo Alto Health Care System
Disclosures
The intent of this discloser is not to prevent a speaker with a significant financial or other
relationship from making a presentation, but rather to provide listeners with information from
which they can make their own judgments. It remains for the audience to determine whether the
speaker's interest or relationships may influence the presentation with regard to exposition with
regard to exposition or conclusion. Conflict exist when you have a financial interest in a company
and the opportunity to affect the CME content about that company’s product or services as it
relates to your control over the educational content at this activity.
Veterans Affairs Palo Alto Health Care System’s Project RED Initiative receives grant support from
the Gordon and Betty Moore Foundation.
Learning Objectives
This presentation will discuss the implementation and usage of the After
hospital Care Plan to achieve an improved discharge process.
At the conclusion of this activity, the participant will be able to:
1.
Q&A for AHCP
2.
Describe several of the most commonly cited interventions to reduce
readmissions used by Transition Coordinators
3.
Explain common barriers to readmission reduction as it relates to the
AHCP
4.
Discuss application to their respective facilities
Good-to-go
Cheryl Bailey, CNO/VP Pt. Care Services
Cullman Regional Medical Center
Our story
Cheryl Bailey
Cullman Regional Medical Center
• 145-bed not for profit medical
center
• Owned and operated by the
Health Care Authority of
Cullman County
• Serves a population of 175,000
• Annual discharges – 7,221
• Hot-wired technology;
Innovation
• Awards for Core Measures
What is the Challenge?
• Patients are ready to go home – lack focus on
discharge teaching
– Increase potential for readmission
– Family may not be present to hear the instructions
• CRMC uses technology to capture the teaching
– Beta trial started in October 2011 on a 31 bed step
down unit
– Good to go expanded to all nursing units, PT,
Respiratory, Case Management, CPAP care center,
Pharmacy, Patient Financial
Engaging Patients and Families
• Discharge sessions are captured with Apple devices at the patient
bedside
• Engage patients with spaced repetition and teach-back
• Customize educational documents/templates for different diagnoses
• Add instructional videos
• Take baseline pictures to monitor healing
• Personalize messages from the hospital staff to the patient – To do
items
• Inline Discharge Process: Easy to use,
understand, and implement
• HIPAA Compliant:
- Data travels securely over SSL
- Requires secure login credentials
• The iOS device acts as a capture and send
device
• Information does not reside on device
• Does not sync with iTunes or computers
Communicating Post Discharge
• Patients, family members, or another
caregiver can access the instructions 24/7
• Instructions can be accessed by landline,
smart phone or computer
• Patients are given access to a secure
website, toll-free phone number, and
unique ID to retrieve their instructions
• Patients can receive a text and/or email
with a notification and link to their
personalized instructions
Outcomes
•
•
•
•
Improved Accountability – nurses and patients
15% reduction in readmission
63% improvement in HCAHPS scores
Positive comments from
patients/families/staff/physicians/post acute
partners
• A success!!
Self-Care-College
Lee Greer, MD, MBA
North Mississippi Health Services
Our story
Lee Greer, MD, MBA
Chief Quality and Safety Officer
North Mississippi Health Services
North Mississippi Health Services
• Diversified regional health care
organization
• Serves 24 counties in north
Mississippi and northwest
Alabama
• The organization includes six
hospitals, four nursing homes,
and 34 clinics
• North Mississippi Medical
Center (NMMC), is the flagship
hospital and referral center in
the NMHS system
Congestive Heart Failure
• 600 patients discharged annually with a
primary diagnosis of congestive heart failure
• Traditional methods of education –
pamphlet, brochure
• “Here’s your packet – call us with questions”
mentality
Self-Care College
• Learn by doing – particularly important in
our patient population
• Observe, coach, follow-up
Three Modules
Graduation
Post Self-Care College
Huddle
Allocate resources to
help the patient
succeed
Teamwork Improves Care
300
250
30%
200
20%
150
100
Patient volume
40%
Care
Transition
began
Good
Readmission rates
NMHS Heart Failure Care Transition,
30-Day Readmission Rates
10%
50
0%
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
FY10
FY11
FY12
FY13
NMHS HF patient volume
Care transition patient volume
Self Care College
began
NMHS HF readmissions
Quest 90th (8.9%; '12 8.0%)
Data Source: Premier
Teach Back
Maureen Carroll RN CHFN
Eileen Brinker RN, MSN
University of California San Francisco
Our Story
UCSF Medical Center
• 770,000 patient visits to our clinics
and about 38,000 hospital
admissions a year
• We are one of the nation's top 10
hospitals, according to an annual
survey by U.S. News & World
Report
• Gordon and Betty Moore Grant to
Reduce Readmissions by 30%
• Collaboration with Institute of
Healthcare Improvement
• Multidisciplinary Team effort
What is Teach Back?
• A Research- Based health literacy intervention that improves
patient-provider communication and patient health outcomes*
• Teach Back is a method of patient education that ensures
patients understanding of critical information by identifying
gaps allowing the opportunity to reinforce the most important
concepts
• Verifies patient understanding and identifies GAPS in
understanding
• Best Practice that is becoming a national movement because it
works!
*Schillinger D, Bindman AB, Wang F, Stewart AL, Piette J. Functional health literacy and the quality of physician-patient communication
among diabetes patients. Patient Educ Couns. 2004;52:315–23.
Why use Teach Back?
• 1/3 (90+ million) of American adults lack sufficient
Health Literacy.
• The average reading level in America is 8th grade.
• 40 - 80 % of the medical information patients are
given is forgotten immediately
• Nearly half of the information retained incorrectly
• Average amount of time nurses use for discharge
nationally = 8 minutes.
Key Components of TEACH
BACK Method
• Responsibility of education is still on the Health
Care provider to educate
• Identify the primary learner
• Start on Admission
• Keep it to four or five main points
• Move away from YES / NO questions
• NO Jargon- no medical terms, use plain
language
• Encourage patients to ask questions
• Health Literacy
• Sit down when possible, slow down.
• Keep sessions short and frequent if possible
Teach Back is not enough
In addition to Teach Back and Heart Failure
education, chronic diseases require life style
changes.
This requires:
Time
Trust
Support
Accountability
Resources
• Picker Institute – Teach back Toolkit
http://www.teachbacktraining.org/using-the-teach-back-toolkit
• American Medical Association: Health Literacy
Educational Toolkit
http://www.ama-assn.org/resources/doc/amafoundation/healthlitclinicians.pdfhttp://www.amaassn.org/resources/doc/ama-foundation/healthlitclinicians.pdf
• Journal Article: Is Teach Back Associated with
Knowledge Retention and Hospital Readmission?
– Journal of Cardiovascular Nursing , 2012
Caregiver Reaction
Diana Galatea
Wrap up
HRET Topic Lead Vikas Bhala [email protected]
Improvement Advisor Pat Teske [email protected]
Data support [email protected]
State Hospital Associations
Change Packages on the HRET website
Readmissions Listserv (to join, go to the HRET website at
www.hret-hen.org)
How to Claim CEUs
• All registered participants will receive an email detailing how
to claim CEUs
• Group Viewing: Claiming CEUs
– Upon closing WebEx session, a window will appear with
the Evaluation for today’s event
– Group facilitator will need to complete the evaluation on
behalf of the group and enter in the names and email
addresses of those who viewed the webinar in the group
setting
– This will be the only way for us to send CEU instructions to
those who did not log in to the WebEx as an individual
– Evaluation must be completed by COB the day of the event
in order for the CEU instructions to be sent post event