The Problem of Hospital

Readmission

Kaiser Health News reported more than

half of hospitals to be penalized for

excess readmissions

KHN analyzed that the average penalty

was 0.73 percent of each Medicare

payment, up from 0.61 percent last year

and higher than in any other year

SOURCE: Kaiser Family Foundation analysis of CMS Final Rules and

Impact files for the Hospital Inpatient Prospective Payment System.

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Table 1. The Hospital Readmission Reduction Program (HRRP): 3-year phase in

Year penalty applied

(Penalties: percentage reductions in

payments for all Medicare admissions

in the year)

FY 2013 FY 2014 FY 2015

Performance (measurement) period June 2008-July 2011 June 2009-July 2012 June 2010-July 2013

Diagnoses of initial hospitalization

Heart attack

Heart failure

Pneumonia

Heart attack

Heart failure

Pneumonia

Heart attack

Heart failure

Pneumonia

COPD

Hip or knee

replacement

Maximum rate of penalty 1% 2% 3%

Average hospital payment

adjustment

(among penalized and non-penalized

hospitals)

-0.27% -0.25% -0.49%

Average hospital penalty

(among penalized hospitals only)-0.42% -0.38% -0.63%

Percent of hospitals penalized 64% 66% 78%

Percent of hospitals at maximum

penalty8% 0.6% 1.2%

CMS estimate of total penalties $290 million $227 million $428 million

NOTES: Penalties are applied to each hospital in the fiscal year shown, based on its performance during a preceding 3-year

measurement period, also shown. Analysis excludes hospitals not subject to HRRP, such as hospitals not paid under the Medicare

Hospital Inpatient Prospective Payment System, such as psychiatric hospitals. COPD: Chronic obstructive pulmonary disease. FY: fiscal

year.

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Goal of Transitional Care

Decrease patient 30-day re-hospitalization

Improve data gathering

Improve communication between care team

members

Ensure patient aware of critical information,

e.g., discharge meds

Develop long term care plan with patient

Help patient prepare for MD appointments

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Why Transitional Care is

Important to the Hospital

Adheres to mission statement

CMS reimbursement is reduced for 30 days hospital re-admits

Assists hospital understanding about what happens to patient

post-discharge providing otherwise inaccessible data

Competitive advantage

• Expertise in transitional care & reporting capabilities

• Ability to compile and report on data can help to gain exclusivity for

specific disease conditions for our patient population

Supports hospital’s quality initiatives including patient safety

Hospital information is publicly reported

• www.Medicare.gov/HospitalCompare

• www.Medicare.gov/HomeHealthCompare

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Benefits to Hospital

Decrease LOS

Reduce ER visits

Strengthen relationship between

discharge planning and home care

Reduce readmission within 30 days

Standardize patient education

Increase patient and physician

satisfaction

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Benefits to Patients

Enhances self-management skills

Reduces unplanned hospitalization

Improves communication with health

care providers

Patient quality of life will improve once

medical condition is under better control

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Referral

Process

Intake

Process

Patient “Reason for

Hospitalization”

Risk

Assessment

Patient

Goal

Medication

List

30 days

Care Guide

Correct MD

Planned

Interventions

1st Medical

Appointment

Long-term

Care Plan

Patient

Preparation for

MD appointment

Admission

Process

Discharge Med

List

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TCC program lasts 30 days

Focuses on patients at high risk for complications or

rehospitalization

The Transitional Care Coach:

Reviews and reconciles medication orders

Reviews the Transitional Care Guide

Provides support in communicating with care

providers

Educates about warning signs (“red flags”) of a

worsening condition

1 or 2 hospital visits; 4 follow-up phone calls by TCC

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Individual (Patient) Measures:

1. Describes system for taking

correct meds at correct time.

2. Agrees to share medication

list with PCP and/or specialist

3. Writes a list of questions for

PCP and/or specialist and

brings to appointment

4. Agrees to bring TCG to every

health care encounter

5. Names “red flags” for

homecare diagnosis (HF,

pneumonia, or MI) that

indicate condition is

worsening

Population (Hospital) Measures: %

of patients discharged from

hospital on TCC program that…

6. See their physician within 7

days of discharge

7. Are re-admitted to the hospital

within 30 days of discharge

8. Visit ER during 30-day TCC

period

9. Reported they filled their

prescriptions

Eric Coleman’s Patient Activation Assessment Guidelines

(accessed 03-14-13

http://www.caretransitions.org/provider_tools.asp)

Specific measures of success

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Appropriate TCC Patients

Identified by staff as “high risk” after applying the

Geisinger Risk Screening Tool

• NOTE: staff call all low and medium risk patients

HF, Pneumonia, MI

Discharged home or to SNF

English-speaking only

TCC accesses Meditech each AM & looks up patients in

the worklist

• Prioritize visits by discharge date

Fundamentals of the Eric

Coleman Care Transitions Model

The patient is the hub of the care team

The TCC coaches the patient, not do for the patient but

empowers the patient to becoming engaged/informed partners

Based on patient’s perceived concerns and problems

4 pillars of Transitional Care

• Medication self-management

• The Transitional Care Guide

• Timely primary care/specialty care follow-up appointments

• Knowledge of red flags that indicate a worsening condition and

how to respond

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Measures of success for

Medication Management

Patient is knowledgeable about medications

and has a medication management system.

1. Patient describes system for taking correct

meds at correct time

2. Patient agrees to share medication list with

physician

3. Percent of total TCC program patients who

reported they filled their scripts

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Measures of success for

Transitional Care Guide

Facilitate communication and ensure continuity of care plan

across providers and settings.

Helps organize health information including medications, health

conditions, and questions for healthcare providers

Encourages patient to give information: often providers only

have what patient gives directly

1. Patient agrees to bring Transitional Care Guide to every health

care encounter

2. Patient writes a list of questions and brings to appointment

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Measure of success for Follow-

Up Appointments

Scheduling and completing follow-up visits with physicians

empowers the patient to be an active participant in his care

Help empower patient by encouraging use of the Transitional

Care Guide to record medical appointments

Coach patient to call community MD office to let them know of

need for appointment within 7 days of hospital discharge

1. Percent of patients discharged from the hospital on the TCC

program that see their physician within 7 days of discharge

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Measure of success for Red

Flags

Recognize symptoms that signal that the patient’s condition

may be worsening

Have an action plan in place for how to respond

Use Transitional Care Guide to list health conditions, red flags,

and action steps to take when a problem is identified

1. Names “red flags” for homecare diagnosis (HF, pneumonia, or

MI) that indicate condition is worsening

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Positive outcomes to date

Only 3 of 12 Take Heart patients have returned to the hospital within the 33 day admission period due to the high touch nature of the interventions• Patient seen within 24 hours of discharge

• Caregiver identified, Telehealth tracking

• Ability to reach hospital based MDs for consultation and orders directory prior to PCP follow up Visit

• Engaged medical and nursing staff

Over 90% of patients has follow up appointment with their PCP within 7 days due to newly instituted procedures

Patients unable to participate in Take Heart program because of eligibility were assessed for appropriate home health services and where applicable were followed in the community

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Conclusion

Overall, the interactions between the teams

have netted highly practical interventions and

recommendations.

The journey to population based health

improvement requires a multi-pronged

approach, frequent course correction and clear

outcomes measures for quality improvements.

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Challenges

Confusion at time of referral: No one point of referral from interdisciplinary team

Timeliness: Patients not identified for home care within 24 hours of referral

Criteria may be too rigid

Small numbers of patient referrals which meet criteria

• Difficult to measure success

• Does not allow for NYP or VNSNY to establish patterns and behaviors consistent with project vision

• Lengthens timeframe for meaningful system-wide results

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