HOME IS THE HUBAn Initiative to Accelerate Progress to Reduce Readmissions in Virginia

WELCOME AND OVERVIEW

Abraham Segres VHHAVice President, Quality & Patient Safety

asegres@vhha.com (804) 965-1214

VIRGINIA HOSPITAL & HEALTHCARE ASSOCIATION

An association of 30 member health systems representing 107 community, psychiatric, rehabilitation and specialty hospitals throughout Virginia.

VisionThrough the power of collaboration, the association will be the recognized driving force

behind making Virginia the healthiest state in the nation by 2020.

MissionWorking with our members and other stakeholders, the association will transform Virginia’s health care system to achieve top-tier performance in safety, quality, value, service and population health. The association’s leadership is focused on: principled, innovative and effective advocacy; promoting initiatives that improve health care safety, quality, value

and service; and aligning forces among health care and business entities to advance health and economic opportunity for all Virginians.

VHHA 2015-2020 IMPROVEMENT PRIORITIES

1. Hospital readmissions1a. Hospital-wide1b. Post-acute transfers1c. Total hip/Total knee Replacement 30-day readmissions

2. Clostridium difficile – Healthcare-acquired Infections3. Patient Experience – HCAHPS 4. Serious Safety Events

OBJECTIVES

1. Understand the need to accelerate progress to reduce readmissions in Virginia

2. Have one “ah-ha” moment / new lesson learned

3. Identify one action to take in follow up to this presentation

4. Understand how the data-informed, high-leverage focus areas build on the “portfolio” of strategies at your hospital

HOUSEKEEPING

• Slides were sent this morning• Webinar is being recorded• Please use the “telephone” option

• Audio pin prompt• All participants are muted• Raise your hand • Ask a question• Warm up

DATA-INFORMED STRATEGY & HIGH LEVERAGE OPPORTUNITIES

Amy Boutwell, MD, MPP Collaborative Healthcare Strategies

Presidentamy@collaborativehealthcarestrategies.com

(617) 710-5785

OVERVIEW• Case for accelerating progress

• Review of data

• Data-informed, strategic focus areas

• Review of best practices

• Planned activities to support statewide learning and action

• Discussion

THE CASE FOR ACCELERATING PROGRESS

Slipping performance relative to national average; climbing penalties

READMISSIONS IN VIRGINIA• Virginia ranked #46 in US for average readmission penalties in 2015

• 67 of 79 hospitals received a readmission penalty

• $16,664,900 in total readmission penalties• Average penalty: $211,000• Maximum penalty: $1, 230,800

• Expansion of penalty conditions to COPD, THR/TKR substantially increased impact of penalties for VA hospitals

READMISSIONS MEASURE TREND ANALYSIS – STATE RANK

Rate of Readmission for Heart Attack Patients 30 of 51 38 of 51 ▲ 38 of 51 40 of 51 ▲ 46 of 51 ▲

Rate of Readmission for Heart Failure Patients

32 of 51 29 of 51 ▼ 32 of 51 ▲ 34 of 51 ▲ 38 of 51 ▲

Rate of Readmission for Pneumonia Patients 40 of 51 40 of 51 42 of 51 ▲ 45 of 51 ▲ 46 of 51 ▲

Rate of Readmission After Hip/Knee Surgery 34 of 51 43 of 51 ▲ 49 of 51 ▲

Rate of Readmission for Chronic Obstructive Pulmonary Disease Patients

41 of 51 42 of 51 ▲

Rate of Readmission After Coronary Artery Bypass Graft Surgery

38 of 51

July 1, 2011 - June 30, 2014

June 2011July 1, 2010 - June

30, 2013

State Rank

No Data

June 2012July 1, 2008 - June

30, 2011July 1, 2007 - June

30, 2010

No Data

No Data

Dec. 2013 * Dec. 2014 June 2015July 1, 2009 - June

30, 2012

Rank

s

THE CASE FOR ACCELERATING PROGRESS: VIRGINIA’S NATIONAL RANK ON READMISSIONS

* CMS modified its calculation of readmission rates to better account for planned readmissions. As a result, it is likely that rates will be lower than previous publications. Readmission rates are normally updated around June of each year.

68 of 89 hospitals in VA received

readmission penalties this year, totaling over$21million

HIP/KNEE REPLACEMENT READMISSION RATES & PENALTIES

State Rank State Rate

1 Vermont 4.195%

2 Nebraska 4.212%

3 North Dakota 4.337%

4 California 4.380%

5 Hawaii 4.419%

25 Wisconsin 4.681%

49 Virginia 5.170%

50 Alaska 5.261%

51 D.C. 5.403%

Condition

FFY 2016 Program Penalty

DollarsFacilities

Penalized

Heart Attack 2,285,000$ 31

Heart Failure 2,482,000$ 42

Pnumonia 2,148,000$ 48

Total Hip & Knee 11,938,000$ 41

COPD 2,231,000$ 41

Total Penalties 21,084,000$ 68

Total facilites being measured - 89

GOAL

In response to these readmission statistics, the VHHA Board has set a goal:

Reduce all-payer readmissions by 20% by 2020

Key elements of this goal:• All-payer: preparing hospitals by looking forward to the future market realities• All-condition: forward-looking to risk-based contracting and alternative payments• Dedicated focus areas: THR/TKR, post-acute, and hospital-wide readmissions

A CLOSE LOOK AT THE DATA

Using data to re-examine prior assumptions, develop data-informed strategy

READMISSIONS OCCUR ACROSS ALL AGES

Source: VA Medicare FFS data, courtesy of VHQC

TKR/THR READMISSIONS OCCUR ACROSS ALL AGES

Readmissions by Age Category

18 - 39 40 - 64 65 - 74 75 - 84 85+ 18 - 39 40 - 64 65 - 74 75 - 84 85+0K

5K

10K

15K

20K

Num

11,097

3,575

7,493

680472

18,176

16,626

7,813

1,014159

Total Hip Replacement ADMISSIONS Total Knee Replacements ADMISSIONS

Total Hip Replacement 30-Day Readmissions in Virginia Total Knee Replacement 30-Day Readmissions in Virginia

18 - 39 40 - 64 65 - 74 75 - 84 85+ 18 - 39 40 - 64 65 - 74 75 - 84 85+0

200

400

600

Num

289

219

334

15

53

405

538569

71

4

Pay CatCommercialMedicaidMedicareOther InsUninsured

Age Cat18 - 39

40 - 64

65 - 74

75 - 84

85+

Source: VHHA

READMISSIONS BY DAY POST-DISCHARGE

Source: VA Medicare FFS data, courtesy of VHQC

~25% <4 days of discharge

RE-EXAMINE A NARROW FOCUS ON KEY DIAGNOSES

Source: VA Medicare FFS data, courtesy of VHQC

Top 10 Medicaid Dx: 1. Mood disorder2. Schizophrenia3. Diabetes complications4. Comp. of pregnancy5. Alcohol-related6. Early labor7. CHF8. Sepsis 9. COPD10. Substance-use related

Top 10 Medicare Dx: 1. CHF2. Sepsis3. Pneumonia4. COPD5. Arrythmia6. UTI7. Acute renal failure8. AMI9. Complication of device10. Stroke

Methods: - Used CCS groupers- Included OB

Q1 Q2 Q3 Q4Home 16.4 16.4 15.5 15.8HHA 20.2 20 21.3 20.6SNF 19.9 20.6 20.1 20State Avg 18.6 18.5 18.7 18.6

10

12

14

16

18

20

22

Axis

Titl

e

Medicare FFS Readmission Rates, by Discharge Setting: Home, SNF, HH

READMISSIONS BY DISCHARGE DISPOSITION

20% PAC

15% HOME

Source: VA Medicare FFS data, courtesy of VHQC

HU Readmission Rate = 40%Non-HU Readmission Rate = 8%

Source: 2016 MA All Payer State-wide Readmission Analysis

READMISSIONS BY ZIP CODE

Source: VA Medicare FFS data, courtesy of VHQC

DATA-INFORMED STRATEGIC FOCUS

Modeling the impact of high leverage strategic focus on the goal

DATA-INFORMED, STRATEGIC FOCUS

• Total Medicare discharges: 227,639• Total Medicare readmissions: 50,524• Medicare readmission rate: 18%

PAC discharges: 111,000PAC readmissions: 22,000PAC readmission rate: 20%% of all readmissions from PAC: 22,000/50,500 = 44%

HU discharges: 46,958HU readmissions: 21, 881HU readmission rate: 46%% of all readmissions among HU: 21,881/50,500 = 43%

Home discharges: 116,000Home readmissions: 18,000Home readmission rate: 15%% of all readmissions from home: 18,000/50,500 = 35%

OPPORTUNITY: PATIENTS DISCHARGED TO POST-ACUTE CARE

Total Medicare discharges 277,639Total Medicare readmissions 50,524Medicare readmission rate 18.2%Total Medicare discharges to PAC* 111,000

% of total discharges to PAC 40%Total Medicare readmissions from PAC 22,000

% of total readmissions from PAC 44%Medicare PAC readmission rate 19.8%

*PAC = Home Health or SNF

OPPORTUNITY: READMISSIONS AVOIDED FROM POST-ACUTE CARE

Total Medicare discharges 277,639Total Medicare readmissions 50,524Medicare readmission rate 18.2%Total PAC readmissions 22,00020% reduction PAC readmissions 2. x 22,000 =4,400Remaining PAC readmissions 22,000 – 4,400 =17,600 New PAC readmission rate 17,600 / 111,000 =15.8%New Medicare readmission rate 46,124 / 277,639 = 16.6%

*PAC = Home Health or SNF

OPPORTUNITY: PATIENTS WITH HIGH UTILIZATION*

Total Medicare discharges 277,639Total Medicare readmissions 50,524Medicare readmission rate 18.2%Total HU discharges 46,958

% HU of total discharges 17%Total HU readmissions 21,881

% HU of total readmissions 43%HU readmission rate 47%

*HU = 4+ admissions in past 12 months

OPPORTUNITY: READMISSIONS AVOIDED FOR HU PATIENTS*

Total Medicare discharges 277,639Total Medicare readmissions 50,524Medicare readmission rate 18.2%Total HU readmissions 21,88120% reduction HU readmissions 2. x 21,881 =4,376Remaining HU readmissions 21,881 – 4,376 =17,505 New HU readmission rate 17,505 / 46958 =37%New Medicare readmission rate 46,148 / 277,639 = 16.6%

*HU = 4+ admissions/12 mo

20% REDUCTION IN POST-ACUTE CARE READMISSIONS + 20% REDUCTION IN HU READMISSIONS

Total Medicare discharges 277,639Total Medicare readmissions 50,524Medicare readmission rate 18.2%Total PAC + HU readmissions* 22,000 + 21,88120% reduction PAC readmissions 4,400 20% reduction HU readmissions 4,376Total avoided PAC+HU readmissions* 8,776New Medicare readmission rate 41,748 / 277,639 = 15%

*illustrative; not strictly additive

PORTFOLIO OF STRATEGIES

Reduce Readmissions Hospital Wide and State-Wide by 20%

by 2020

Reduce PAC Readmissions

Improve processes & practices for SNF

discharges

Improve processes & practices for Home Health discharges

Reduce HU Readmissions “Whole-person” care

Reduce Readmissions from Home

SIM/AAA investments in transitional care

coaching + linkage to services

Reduce Readmissions for THR/TKR

Improve pre-op, peri-op, post-op and

rehab practices & processes

BEST PRACTICES

Improvement in PAC, HU, and THR/TKR readmissions is possible

ALIGNED INCENTIVES:

READMISSIONS AND MEDICARE SPENDING PER BENEFICIARY

• Effectively exposes all hospitals into a “bundle” payment• Hospitals must find ways to reduce cost of care overall

• CMS will provide cost broken down by: • 3 days before hospitalization• Cost of hospitalization• Cost 30-days post discharge• Overall by: inpatient, outpatient, home health, SNF, hospice, DME

• Hospitals judged by both performance and improvement

“POTENTIAL FOR EFFICIENCY IMPROVEMENTS IN POST ACUTE CARE UTILIZATION…..”

“CONDITIONS FOR WHICH POST ACUTE CARE ACCOUNTS FOR A LARGE PERCENT OF EPISODE PAYMENTS PROVIDE HOSPITALSWITH A STRONGER INCENTIVE TO EFFICIENTLY MANAGE POST

ACUTE SERVICES.”

CMS technical guidance on MSPB

ALIGNED INCENTIVES: COST OF HOSPITALIZATIONS FROM SNF

Reason for Hospitalization Total Cost $ / HospitalizationSepsis $3 billion $17,430Pneumonia $850 million $9,500CHF $640 million $8,700Aspiration Pneumonia $618 million $12,200Complications $450 million $14,600

OIG November 2013

• Hospitalization of patients from SNF/LTC averages $11,255

• Average Medicare hospitalization cost is $8,447

• 33% higher

PAC BEST PRACTICE #1SNF WARM HANDOFFS WITH “CIRCLE BACK”

Warm RN-RN Handoff to SNF

Hospital calls back SNF 3-24h after d/c to ask 6 questions1. 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 received?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?

Source: Emily Skinner, Carolinas Healthcare System

PAC BEST PRACTICE #2ACUTE CARE MANAGEMENT TEAM “WARM FOLLOW UP”

• ACO or Bundle clinical coordinator• Air traffic control (lists of patients, PAC provider, coordinates virtual co-management rounds)

• Physical rounds in SNF • Acute Care Team sends RN / NP to see patient, discuss plan with SNF staff• Respond to changes in clinical status to manage in setting

• Virtual care management rounds with SNF• Weekly telephonic rounds ACO/bundle coordinator and SNF• LOS, progress toward discharge goals, discharge planning

• Tele-medicine consults in SNF for follow up• Tele-evals for change in clinical status

• Direct admit to SNF from home if need escalated care• Leverage the “continuum” to avoid readmissions

Key lessons:

• Took a while to develop collaborative rapport v. “hospital is in-charge”

• No substitute for verbal communication and problem solving

PAC BEST PRACTICE #3INTERACT: INTERVENTIONS TO REDUCE ACUTE CARE TRANSFERS

https://interact2.net/tools_v4.html

• Hallmark Health System • 2 hospital system, 20 ED docs, 17 PAs• “Why are almost all SNF patients admitted?”• “Patients only seen once a month”; “can’t do IVs”, etc• “If they send them here they can’t take care of them”

• Actions:• Asked ED clinicians “5 whys”• Education: posted INTERACT SNF capacity sheets in ED• Simplicity : establish contacts, standard transfer information

• Results: increase in number of patients transferred from ED to SNFSource: Dr Steven Sbardella, CMO and Chief of ED

Hallmark Health System Melrose, MA

PAC BEST PRACTICE #4HALLMARK HEALTH SYSTEM TREAT-AND-RETURN TO SNF

0

10

20

30

40

1 2 3 4 5 6 7 8 9

# Treat-and-Return to SNF

PAC BEST PRACTICE #5SNF TRANSITION TO HOME PROGRAM

• “Home and Healthy Program” • Comprehensive discharge planning: appointments, services made• Reviews all information with resident, family, caregiver• Direct contact after SNF discharge

• Phone call next day• Once a week for a month• Once a month for 3 months

Courtesy of Keswick Multi-Care, Maryland

HU BEST PRACTICE #1STRATEGIES FOR MANAGING THE CARE OF HIGH UTILIZERS

1. Real-time identification

2. Identify the “drivers” of utilization• Not the cc or primary dx, not even the chronic dz, but rather the social, behavioral, clinical

factors that drives repeated use• Often best identified using a non-clinical lens

3. Address the driver(s) of utilization• High frequency contact in the community• Problem-solving occurs over time until driver is addressed • Frequently social workers and navigators are effective

4. Use “care plans” to convey utilization history, driver(s) of utilization, services in place, and key advice to ED staff to guide care at next presentation

HU BEST PRACTICE #2HU PROGRAM AT LARGE COMMUNITY HOSPITAL

• Target population: all adults with 4+ hospitalizations in past 12 months• 427 people, collectively utilized 2200 admissions; 38% readmission rate

• Flag to identify in real-time• Identify patients upon admission when it’s their 4th or more visit in past 12 mos• IT produces a daily report – goes to a dedicated HU team

• MD, RN, SW, CHW dedicated team• Identify clinical/behavioral/social issues that may be “driving” utilization• Generate “first draft” care plan in 5 minutes – living document evolves over time

• Timely follow up• Goal is 100% contact within 48 hours of discharge

• Connection, contact, problem solving, resource mobilization to achieve “stability”• Everything effective occurs outside the limited time constraints of the clinical encounter

• Measure to drive programmatic improvement• % patients with timely follow up, % patients with care plans, # contacts, # F2F visits, # readmissions

0204060

Q1 Q2 Q3

HU Readmission Rate

ReadmissionRate

HU BEST PRACTICE #3HU PROGRAM AT LARGE COMMUNITY HOSPITAL

• Identifying HU in real-time is essential• Time to establish initial contact is while they are in-house• Essential to facilitate successful post-hospital engagement• Executive prioritization of creating the flag is needed

• Take a “continuation of care” approach• Offer to continue to care for them post-discharge to ensure their needs are met• Avoid offers to “enroll” them in a “special program” – not working well in the field

• Be proactive, persistent, and patient• Once identified as a HU, consistently engage and re-engage on subsequent visits• Establishing a trusted, helpful presence is key

• Don’t over-medicalize repeated hospital utilization• What is most “complex” about HU are the unmet social needs or behavioral influences• Rarely is the medicine itself truly complex

THR/TKR BEST PRACTICESVIRGINIA BASED SUCCESSFUL APPROACHES

• Understand the penalty – what’s being measured• Understand your data• Form a committee: inter-departmental, inter-disciplinary• Improve patient education materials – Zones with Action Steps• Perioperative Nurse Navigation• Review all readmissions: “every readmission matters”

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 300

50

100

Num

Total Knee Post Discharge Days Drgdesc

0 5 10 15 20 25 30 35 40Tka Num

POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC

RED BLOOD CELL DISORDERS W/O MCC

PULMONARY EMBOLISM W/O MCC

G.I. HEMORRHAGE W CC

CELLULITIS W/O MCC

SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W MCC

COMPLICATIONS OF TREATMENT W CC

MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTR..

RENAL FAILURE W CC

PERIPHERAL VASCULAR DISORDERS W CC

AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TIS..

38

19

18

27

13

10

24

14

22

12

11

Most Common TKR Readmission DRGs for Patients Admitted (<5 Days)

Courtesy Centra and VA Hospital Center

COORDINATED ACTION

Activities to support aligned learning & action

Statewide Learning & Action

• Statewide collaborative June 2016 to November 2018• Focus on PAC, HU, THR/TKR in parallel• Engage with partners in PAC• Engage with VHQC for cross-continuum work• Engage with AAAs for community based care/CTI• Provide, use, interpret data from VHHA & VHQC

Planned Activities for Learning & Action

June 16tth* High Leverage Strategies

August 17th* PAC & HU Data/Measurement

Sept. TBD Learning & Action Workshop

October 19th* High Utilizers

December 6th* PAC Readmissions

February 1 Learning & Action Workshop

*All webinars will be offered at 10am

DISCUSSION

ADJOURN