Risk Factors for Readmission

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1 Strategies for Identifying and Decreasing for Pamela Roberts, PhD, OTR/L, SCFES, FAOTA, CPHQ, FNAP Cedars Sinai Medical Center California Hospital Association Center for Post Acute Care Annual Conference Huntington Beach, California January 29, 2015 Critical Elements: The Road to Compliance Risk Factors for Readmission Functional status on Admission to CIIRP is strongly associated with readmission before planned discharge from CIIRP. Efforts to reduce hospital readmissions should consider patient functional status as an important and potentially modifiable risk factor. Unmet need for new ADL disabilities after return home from the hospital is particularly vulnerable to readmissions Patients functional needs after discharge should be evaluated and addressed Reference: The Gerontologist, Vol 53(3), Approximately 11% of SCI patients experience Return to Acute (RTAC) during the course of rehabilitation for a variety of medical and surgical reasons. RTAC s are associated with longer rehabilitation length of stay. Efforts to reduce readmissions to acute care should include greater scrutiny of older, lower functioning patients with burn injury who are evaluated at admission to inpatient rehabilitation. 1

2 Retrospective study of stroke 783 stroke patients from admitted to IRF Examined 60 who returned to acute care hospital Two significant risk factors were low motor FIM and enteral feeding Trends but not significant Younger age Longer onset time from stroke to IRF admit Presence of a tiered comorbidity Reference: Roberts P, DiVita M, Riggs R, Niewczyk P, Bergquist B, & Granger CV (2014). Risk factors for discharge to an acute care hospitalfrom inpatient rehabilitation among stroke patients. PMR, 6: Reference: Asher A, Roberts PS, Bresee C, Zabel G. Riggs R, and Rogatko A (In press). Transferring inpatient rehabilitation facility cancer patients back to acute care (TRIPBAC). PM&R. Quality Measure for for IRFs Among post acute rehabilitation facilities providing services to Medicare fee forservice beneficiaries, 30 day readmission rate ranged from 5.8% for patients with lower extremity joint replacement to 18.8% for patients with debility Higher motor and cognitive functional status were associated with lower hospital readmission rates across six impairment categories (stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders and brain dysfunction NQF #2502 All Cause Unplanned Readmission Measure for 30 days Post Discharge from Facilities Measure estimates the risk standardized rate of unplanned, all cause readmissions for patients discharged from an IRF who were readmitted to short stay acute care hospital or a long term care hospital within 30 days of an IRF discharge Measure is based on data for 24 months of IRF discharges to non hospital post acute levels of care or to the community Ottenbacher KJ, Karmarkar A, Graham JE, Kuo F, Deutsch A, Reistetter TA, Snih SA, and Granger CV (2014). Thirty day hospital Readmission following discharge from postacute rehabilitation in fee for service medicare patients. JAMA; 311(6): Quality Measure for for IRFs Calculation: Predicted number of readmissions at the facility divided by the expected number of readmissions for the same patients multiplied by the mean rate of readmission in the population Quality Measure for for IRFs Exclusions: IRF patients who died during the IRF stay IRF patients less than 18 years old IRF patients who were transferred at the end of a stay to another IRF or short term acute care hospital Patients who were not continuously enrolled in Part A FFS Medicare for the 12 months prior to the IRF stay admission date, and at least 30 days after IRF stay discharge date Patients who did not have a short term acute care stay within 30 days prior to an IRF stay admission date IRF patients discharged against medical advice (AMA) IRF patients for whom the prior short term acute care stay was for nonsurgical treatment of cancer IRF stays with data that are problematic (e.g., anomalous records for hospital stays that overlap wholly or in part or are otherwise erroneous or contradictory) 2

3 Practical Strategy Considerations Critical Elements: The Road to Compliance Strategies to Prevent Standardized IRF SBAR hand off Lack of standardization of hand off for: Bladder and bowel function/management Pain management Completion of acute Care Plans Lines/Drains/Airways Tests/procedures completed prior to admission Skin/Pressure Ulcers Out of bed/activity level Transfer level, use of special eqiupment/technique Dangers of Discharge Initiatives to Reduce MiPAD Medical Passport Follow up telephone calls within 24 hours Physician Assistant/Nurse Practitioner assisting recent CSMC discharges in medical oversight Frailty Assessment Foundation identifying Frail outpatients to prevent admissions and if admitted to prevent readmissions Medication Reconciliation (source verification) throughout the continuum Case Manager throughout the continuum 3

4 MiPAD Table of Contents Multidisciplinary Information and Personal Assistance Diary (MiPAD) Goal: Improve information and education throughout the continuum of care Tool used to have all education in one place including triggers to include certain information 1. Introduction A) Handbook B) Group Therapy C) Team Members D) Survey 2. My Condition A) Diagnosis Specific Packet B) Health and Well Being C) Medications 3. My Safety A) Precautions B) Safety in the Home C) Disaster Preparedness 4. My Discharge a) Home Exercise Program b) Equipment c) Training d) Family Conference 5. My Contacts a) Medical Passport b) Support Services c) Business Card Holder MiPad (Multidisciplinary information and Personal Assistance Diary) within 30 Days of IRF Discharge Identification of readmissions due to scalp wounds for patients status post craniotomy Discussion with Neurosurgical Institute regarding scalp wound education upon discharge Determined that there was no standardized way to address scalp wounds within the Institute or among the Brain Tumor Center of Excellence neurosurgeons Example of Readmission Issue Identified Through the Brain Tumor Center of Excellence, developed standard protocol to address followup instructions regarding scalp wounds/care of scalp/incision site including follow up telephone triage and weekly electronic report for readmissions specific to Brain Tumor index admission Medical Passport/Portable Profile Medical Passport is an educational intervention that focuses therapeutic inputs from the interdisciplinary care team on the transition from hospital to home and promotes patient and caregiver self management 4

5 Collaboration Care Coordination Discharge Risk Assessment Tools Assess if patient s family members are competent caregivers Assess patient s home environment (e.g. prevention of falls and injuries) Patient Engagement Transition between hospital and home Coordinate appointments Diet/nutrition and exercise/activity plan Referral Network Referrals for post acute care Referrals for physician follow up Technology (e.g. Telehealth) Communication with Physicians Direct e mails to physicians about readmissions Transitions of Care Checklist Transition of Care Checklist should include: Reconciled medications Feeding/eating instructions Weight parameters Recommended exercises/activities Report on the patient s functional/communication/cognitive status Contact information for the patient s most recent care provider Follow up appointments Follow up on outstanding tests Information of what to do if problem arises Personal Health Record Educate patients and assess understanding Send discharge summary to primary care physician Reinforce the discharge plan via telephone Summary: Interventions to Reduce 30 Day Questions 5

6 Contact Information Pamela Roberts, PhD, OTR/L, SCFES, FAOTA, CPHQ, FNAP Program Director Physical Medicine and Rehabilitation and Neuropsychology Work: Cell:

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