Hospital Readmissions. A Dilemma for Every Manager

2013 update

Lynn Vanderburg BA, RRT NRP

Hospital Readmissions Reduction Program (HRRP)

• Legislative Context Shapes HRRP– Patient Protection and Affordable Care Act (2010) was to provide

everyone in America with affordable Health care• Faced stiff opposition• To get it passed programs had to be inserted that would reduce the total

cost burden of the bill– HRRP is one of those cost reduction programs

• Estimated to reduce Medicare payments by $7.1 billion (between 2013-2019)

http://www.santarosaconsulting.com/santarosateamblog/post/2012/03/29/an-early-look-at-hospital-readmissions-reduction-program

Hospital Readmission Reduction Program

• Brief overview– The HRRP is a reimbursement penalty approach for general acute

care hospitals that have readmissions deemed “excess” by CMS• Began fiscal year 2013 (October 1, 2012)• Reduction is capped at 1% in 2013, 2% in 2014 and 3% in 2015 and

beyond• Reductions apply to total DRG reimbursement

– But readmissions deemed excess are determined using 3 specific conditions endorsed by the National Quality Foundation (NQF)

» Acute Myocardial Infarction» Heart failure» Pneumonia

http://www.santarosaconsulting.com/santarosateamblog/post/2012/03/29/an-early-look-at-hospital-readmissions-reduction-program

Reimbursement Penalties

• 2,211 American hospitals received reimbursement penalties for high readmission rates – Together they will forfeit about $280 million in Medicare funds over next year

• According to Medicare, 2 out of 3 hospitals evaluated failed to meet its new standards for preventing 30 day readmissions.

• (penalty rate up to 1%) x (total Medicare reimbursement/yr) = lost revenue

Rau, Jordan. Kaiser Health News. “Medicare to Penalize 2,211 Hospitals for Excess Readmissions”. Aug 13-12.

Re-hospitalizations among patients in the Medicare Fee-for-service Program

• New England Journal of MedicineStephen F. Jencks, MD, MPH, Mark Williams, MD and Eric A Coleman, MD MPH.

Abstract • I in 5 Medicare beneficiaries are readmitted within 30 days

– Which equates to 2.3 million patients• National cost of over $17 Billion • Half of patients readmitted had no physician contact• 70% of surgical readmits were for chronic medical conditions.• Potentially 40% of all Readmissions are preventable

Avoidable Readmissions

• Readmissions are seen as a indicator of quality of care– Only valid when we know what % of readmissions were avoidable.

• A review was done on 34 studies published between 1966 and 2010 looking at readmissions that were deemed avoidable– Found: 24% were deemed avoidable

• Also noted that adults in the US received only 54.9% of recommended care2

1. Carl Van Walraven, MD MSc, Carol Bennett, MSc, Alison Jennings, MA, Peter C. Austin, PhD, Alan Forster, MD MSc. Proportion of hospital readmissions deemed avoidable: a systematic review.April 19-11 vol183 no. 7 E391-E402

2. Elizabeth McGlynn, Steven Asch, John Adams, Joan Keesey, Jennifer Hicks, et al. The Quality of Health care delivered to adults in the united states. NEJM.

Readmission Factors

• AARC webcast August 28-12 “Hospital to Home-efforts at Reducing Hospital Readmissions”. Greg Spratt BS, RRT; Kimberly Wiles BS, RRT; Becky Anderson RRT.

• 69% were non compliant with meds• 51% lacked knowledge: How to use Therapy Devices• 45% inadequate knowledge of medications• 42% unable to self manage care• 37% had no follow up visit with Physician• 31% develop infection post discharge

Changing Paradigms

Traditional focus Transformational Focus

Immediate Clinical needs Comprehensive needs of the whole person

Patients are the recipients of care and the focus of the care team

Pts and family members are essential and active members of the care team.

Variety of different teams Cross continuum Team with a focus on the pts experience over time

Www.ihi.org/knowledge/pages/audio and video/ihi approach to reducing avoidable rehospitalizations.aspx

Readmissions Not The Only Change

NO MORE FEE FOR SERVICE

• Pay for Performance (P4P) =Value Based Purchasing(VBP)

• Rewards physicians, hospitals, medical groups and other health care providers for meeting certain performance measures for quality and efficiency

• Rewarding hospitals for the quality of care they provide to Medicare patients, not just the quantity of procedures they perform

• Also eliminating payments for “never events”

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/FY-2013-Program-Frequently-Asked-Questions-about-Hospital-VBP-3-9-12.pdfFind article in my favorites: Readmission 2012 and it has CMS and frequently asked questions.

Hospital Performance

• Value Based Purchasing Program (VBP)– Begin to pay hospitals for their actual performance

• Requires portion of Medicare reimbursement to be withheld and returned proportionate to how the Hospital performs

30%

25%

45%

3 Categories

Patient ExperienceOutcome MeasuresClinical Processes

Value-based Purchasing:What Hospitals and Healthcare Systems Need to Know Now to Manage Their Medicare Dollars

Pat Bickley, Jude Odu-Health Care Dataworkswww.HCD.com

Changing Reimbursement

Fiscal Year Value Based Purchasing

Hospital Readmission Reduction Program

Hospital Acquired

Conditions

Total

2013 1.00% 1.00% 0 2.00%

2014 1.25% 2.00% 0 3.25%

2015 1.50% 3.00% 1.00% 5.50%

2016 1.75% 3.00% 1.00% 5.75%

2017 2.00% 3.00% 1.00% 6.00%

.

Alexander, K.,LHA Legislative & regulatory Update. LA Assn for Healthcare Quality Annual Education Conference, April 2012

Payment Reform for Hospitals

Patient Satisfaction ‐ HCAHPS

Some of the 20 Key Performance Measures:

• Nurse communication• Cleanliness and quiet• Doctor communication• Responsiveness of hospital staff• Pain management• Discharge information• Communication about medications• Overall rating of hospital

http://www.mdahq.citymax.com/f/nikolas_matthes.pdf slide 16 of PP presentation listed:Value‐based Purchasing

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FY 2015

Value-Based Purchasing

30%

30%

20%

20%

Proposed “Efficiency” CategoryRedistribution of Domain Weighting

Patient Experience of CareOutcome MeasuresEfficiencyClinical Processes of Care

Retrieved 1/31/13 www.StratisHealth.com, the Medicare Quality Improvement Organization

Higher Per Capita Spending Doesn’t Translate into Higher Life Expectancy

Source: 2006 CIA Fact Book Life Expectancy-Per Capita Spending

Time For Disease Management

• COPD was predicted to be #3 cause of death by 2020• It reached this milestone in April 2011 according to CDC

• Population >65 will increase 73% by 2025– Baby Boomers are over 80 million strong.

• PCP shortages of 20-27% by 2025.– Allergists, PCP, anesthesiologists.

• There are over 100 Million patients in the US classified as having chronic conditions

Kallstrom, T. “The Long Term Implications of the Affordable Care Act”. AARC Times, Oct 2012. pg 20-21

Pulmonary Issues Aren’t Going Away!

RT as a Physician Extender• Work in PCP office assessing patients

RT as Case Managers• Teach self management• Modify patients behavior at home• Coach, encourage and give advice• Regular communication between patient and RT• Identify unmet health needs• Keeps patients:

– Out of Hospital– Out of ED– Out of Physician office

HARP(Hospital admissions risk program)

• Melbourne, Australia study• Patient focused and self management of care through acute

and community health sectors

Case Managed COPD Control Group

ED Visits 10% ED Visits 45%

Admits 25% Hosp Admits 41%

Hospital LOS 18% Hosp LOS 51%

Bird, S et al. “An integrated Care Facilitation model Improves QOL & reduces use of Hosp resources by pts w/ COPD & CHF”. 2010:16(4):326-33.

RT Case Managers

COPD/Asthma Enrolled ER Before ER after Hosp before Hosp after

319 305 134 94 37

Part time position for a Respiratory Case Manager for COPD and Asthma

Total cost saving: $106, 874

Was then granted permission to hire 2 full Time positions.

Dwan, J. “Outcomes of an Asthma/COPD Case Manager Program.” RC Nov 2002.

Questions a Manager needs to ask

• Is reducing the hospitals readmission rate and being an active team player in the P4P a priority for your hospital? And you?

• Do you know your hospitals 30 day readmission rate?• Do you believe that you and your staff have the capability to make

improvements?– This is a cross roads for change.

Do you know?

www.whynotthebest.orgThis is the way to find out how much your hospital is being penalized.

Clinical Conditions

Top performers US National Average

What is your readmission

rate?

Heart Failure 17.3% 24.73% ?

Heart Attack 15.2% 19.97% ?

Pneumonia 13.6% 18.34% ?

Source: The Commonwealth Fund’s website Why Not the Best? Derived from Medicare’s Hospital Compare database.

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Comparing Hospitals

22

Change is Here!!

• Gone are the days of performing breathing treatments, doing vent checks, attending code blue, then clocking out

• RT’s are professional, licensed, highly skilled clinicians who specialize in Pulmonary disease as well as Cardiac conditions. As leaders, we MUST support ongoing development in clinical skills, intervention delivery, documentation, adopting the credential of RRT as the minimum standard for new-hires, immersing RT staff in patient advocacy, the patient care team/care continuum, while SHUNNING complacency. Strive to keep moving forward with improved patient outcomes, data collection to support your claims, separation with staff who do not perform on a DAILY BASIS, because they represent YOU. They represent all of us!

Various Initiatives. No Silver Bullet!

Project BOOST - Better Outcomes for Older adults through Safe Transitions

Project RED – Re-Engineered Discharge

Hospital 2 Home

Transitional Care Model (TCM)

STate Action on Avoidable Rehospitalizations (STAAR) initiative

STAAR (State Action on avoidable Re-hospitalizations)

• STAAR– Launched in 2009.– Aimed to reduce rates of avoidable re-hospitalizations in 4 States:

MA, MI, OH, WA.– 2 years into a 4 yr initiative, 148 hospitals working in partnership with

500 cross continuum team partners.

• Strategy– To provide technical assistance/coaching/teaching to front line teams

of providers working to improve the transition out of the hospital and into next care setting.

Ohio Hospital Association (OHA)

• OHA worked to decrease hospital readmissions through STAAR initiative

• 18 hospitals participated – Resulted in 8% greater reduction in STAAR hospitals readmissions

than other Ohio hospitals

Www.ihi.org/knowledge/pages/audio and video/ihi approach to reducing avoidable rehospitalizations.aspxSlide 7

INTERACT

• Interventions to Reduce Acute Care Transfers– Designed to improve care of nursing home residents by identifying

and managing situations that commonly result in transfers to the hospital

• Results of CMS Pilot– 50% reduction of hospitalizations in 3 NH’s with high baseline rates– 36% reduction in hospitalizations rated as potentially avoidable

Www.ihi.org/knowledge/pages/audio and video/ihi approach to reducing avoidable rehospitalizations.aspx

Merging Home Care and Hospital Readmissions

Reforming Payment for

Primary/chronic care

Reducing Hospital

Readmissions

Implementing Medical Home /Chronic Care Model

Reducing Hospital Readmissions Requires Improved Community Care

Chronic Care Requires Higher/different Payment

Lower Hospital Readmissions Provides ROI for Chronic Care Investment

2008-2010 Pittsburgh Regional health Initiative and Center for Healthcare quality and payment Reform

UCSF Medical Center

• Financial implication of Reducing Medicare Heart Failure ReadmissionsMedicare per case cost for heart failure $25,225 and with 30% reduction in readmissions at UCSF this resulted in approx $1 million annual savings to Medicare.

30 day readmission Rates for heart Failure with any diagnosis of Heart failure

2009: average 24%

2010: average 18%

2011: average 13%

Www.ihi.org/knowledge/pages/audio and video/ihi approach to reducing avoidable rehospitalizations.aspx

RED - Re-engineered Discharge

• Assign a discharge advocate to ensure all components are complete– This significantly reduced Emergency Department use and re-

hospitalization within 30 days by 30%.– This advocate intervention takes approximately 1hr to implement– The National Quality Forum (NQF) adopted RED as one of their “safe

practices” in 2006

Jack BW, Veerappa KC, Anthony D et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Internal Med. 2009; 150: 178-187.

Sample Findings: Cost breakdown

• Lost Revenue from ReadmissionsTotal readmissions (11/01/08-10/31/09) 4,804

Targeted reductions 30%

Reduced Readmits 1.441

Contribution Margin per readmit $3,410

Margin impact ($4,913,810)

Capacity Filled with normal case loadReadmits replaced with new volume 1,441

Contribution Margin per inpatient case $4,980

Margin Impact $7,176,180

Margin Improvement $2,262,370

Proactive/Preventative Patient Care

• “Hospital-acquired infections kill 99,000 Americans each year.”

• “That’s equivalent of a jumbo jet full of passengers crashing every other day.¹”

• 35,967 Deaths Annually from Hospital-Acquired Pneumonia²

1www.safepatientproject.org2Nicolau et al. “Redefing Success for VAP: 360-Degree approach”, JMCP June 2009, Vol. 15, No. 5

Reactive VS ProactiveRespiratory Issues from Retained Secretions

Reactive Behavior

Could result in:

Requiring of Invasive

procedures (Bronchoscopy, re-intubation)

Prolonged Ventilation, ICU

and Hospital LOS

Increased morbidity/mortal

ity

Increased Healthcare Costs

Suctioning only line of defense for MV pts.

Not preventively doing lung expansion and/or airway clearance on high risk patients

Not routinely assessing high risk pts.

No interventions until a problem occurs

Proactive Behavior

Could result in:

Prevention of respiratory

complications

Faster weaning

Decreased ICU/

Hospital LOS

Improved morbidity/

mortality

Health

care Savings

Discharge planning involvement

Early intervention with lung expansion and/or airway clearance therapies

Routine Assessments

Respiratory Protocols for ICU/floor pts.

Areas for Change in Potentially Preventable Readmissions

Improve Quality Of Inpatient Care1. Education

– Choose a champion – Customize patient education – Use teach back regularly

•especially with regard to understanding discharge instructions– Teach patient self Managed Care– Involve different disciplines to teach

•For example RRT required to teach respiratory methods

Currently an average of 8 minutes is spent on education of our patients in the hospital!

–We don’t get reimbursed on educationhttp://www.ama-assn.org/amednews/2011/02/07/prsa0207.htm

Areas for Change in Potentially Preventable Readmissions

Improve Quality Of Inpatient Care cont’d…2. Multidisciplinary rounds

1. Scheduled communication times to discuss patient as a team

2. Set up a discharge plan that is looked at and signed off on by all disciplines

RRT should always be involved with chronic lung pt discharge plan

3. Use Pulmonary Rehabilitation Facilities3. Within 3 days of discharge

4. Teach and explain medications and lifestyle changes, exercises etc It is shown when pts go to an LTACH before they go home there are

three times fewer readmission bounce backs

4. Establish follow up plan before discharge5. Provide pt meds at discharge

6. Have a dedicated advocate/coach for pt at discharge and beyond

Areas for Change in Potentially Preventable Readmissions

5. Early post discharge follow up– Remote monitoring/telehealth

• It was shown that an RN or RRT giving patient education over the phone reduced hospital admissions by 40% and ER visits by 41% for COPD patients.1

6. Reconciliation of Medication– Piedmont Hospital In Atlanta

• Improving their process fixed a 46% discrepancy rate.1

7. Need Proactive Thinking rather than Reactive – There is a lack of preventative healthcare– Symptoms treated, not the root cause

1. J. Bourbeau, M. Julien, et al, “Reduction of Hospital Utilization in Patients with Chronic Obstructive Pulmonary Disease: A Disease-Specific Self-Management Intervention,” Archives of Internal Medicine 163(5), 2003. S2. http://www.ama-assn.org/amednews/2011/02/07/prsa0207.htm

Get Involved

• Take on More! What projects can you Champion? What Committee Meetings Do you Need to be Represented at? EXAMPLE: Infection Prevention-do you Chair Hand Hygiene? Delegate attendance to multi-disciplinary meetings to trusted and respected front line staff. Respiratory Care is involved in EVERY patient care area; we need to be present to be seen

• Reaching Beyond your Comfort Zone Partner with Nursing, Finance, Materials Management to learn what is needed to be a contributor in your Hospital’s Business Model vs a Drain on the Budget.

• Shun Complacency

Our Role as a Care Provider has EXPANDED and the demands from our Department will continue to grow…

• DASH is a Homecare Respiratory Services program– Driven by novel respiratory software, protocols & improved reporting– Begins prior to discharge

• Risk evaluation• COPD order set includes DASH (Risk evaluation, Assessment &

transition)

28% readmission in Philadelphia for COPD pts

Incorporation of DASH has reduced it to <4%

DASH= Discharge + Assessment & Summary @ Home

PP AARC.org webcast August 28-12 Hospital to home efforts at reducing hosp readmissions. Greg Spratt BS, RRT, CPFT Kimberly Wiles BSRT, CPFT Becky andersonRRT

DASH

• COPD/CHF/Pneumonia all require specialization• Early on: < 10% were coming home with a follow up appointment• Now 90% get a follow up appt

– RT calls them at home and sets up appt with them

Changed Name from the Pulmonary Rehabilitation clinic to “COPD Independence Program”

PP AARC.org webcast August 28-12 Hospital to home efforts at reducing hosp readmissions. Greg Spratt BS, RRT, CPFT Kimberly Wiles BSRT, CPFT Becky andersonRRT

It takes the Village

• Re-hospitalizations are costly, frequent, and many avoidable.• These numbers can be reduced• Requires action beyond the level of the individual providers

– Provider, association, community and State levels are essential• Future of Healthcare is Beyond a single site• Patient centered vs task centered• Reconnect Physicians into the continuum of care• Outpatient services linked to home care data.

ACCOUNTABLE CHRONIC CARE

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Data Access

• There are many sources for obtaining data on Value Based Purchasing and Hospital Readmission Reduction:

www.medicare.gov

www.cms.gov

www.whynotthebest.org