3/16/2016. Preventing Readmissions Through Compliant Patient Transitions. Transition of Care Statistics. Care Transitions The Regulatory Environment

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1 Preventing Readmissions Through Compliant Patient Transitions Deborah L. Carlino, RN, MBA, CHC, CHRC Director of Healthcare Compliance and Audit - Rutgers, The State University of New Jersey Melanie A. Sponholz, MSPT, CCEP, CHC, CHPC Corporate Compliance Officer Home Solutions Michael P. McKeever, CPA, FHFMA, CHC, CHRC Director, Internal Audit Saint Peter s Healthcare System Transition of Care Statistics 1 in 5 patients discharged from hospitals to home experience an adverse event within 3 weeks. 66% of these were adverse drug events. 1 in 5 Medicare patients is readmitted within 30 days of discharge. Study estimated that 80% of serious medical errors involve miscommunication during the hand-off between medical providers. Care Transitions The Regulatory Environment 1

2 Regulatory Environment COP Discharge Planning Identification Evaluation Discharge Plan Transfer or Referral Reassessment of the Process Discharge Planning Process Qualified personnel who have: Appropriate experience Knowledge of social and physical factors that affect patient s functional status Knowledge of community based facilities, services and support Knowledge of patient s unique support needs Discharge Locations Nursing Facilities Skilled Nursing Facilities Long-term Acute Care Rehabilitation Home Health Hospice Home w/support 2

3 Statutory Requirements List of Medicare-certified HHA s and SNF s serving the patient s geographic location and who have requested inclusion on the list Must disclose any financial interest in any of the entities on the list Cannot steer patients to a preferred provider List must be updated annually But What About CJR? From the Federal Register (Vol. 80, No. 226, 11/24/15, p ): We believe that allowing hospitals to disclose those providers and suppliers who best contribute to improved efficiency and better outcomes does not limit beneficiary choice, provided that beneficiaries are fully informed of any financial dealings that could create a conflict of interest. We therefore believe that identifying these preferred providers/suppliers is consistent with Section 1861(ee)(2)(H)of the Act, as it does not specify or limit qualified providers/suppliers that may provide post-acute care, What About CJR? (continued) and we believe that our requirement that beneficiaries must be notified of financial arrangements is both consistent with and required by that section. We further believe that the proposed requirement to notify beneficiaries of all preferred and non-preferred providers/suppliers, coupled with the requirement to identify CJR collaborators that we are finalizing in this rule, provides beneficiaries with sufficient information to allow them to avoid improper steering or referral. 3

4 CJR The Least You Need to Know Hospitals may list providers and suppliers who contribute to improved efficiency and better outcomes You must inform beneficiaries of any financial dealings that could create a conflict of interest Providers must not limit access to or specify choice of qualified providers and suppliers of post acute care beneficiaries must be notified of ALL providers and suppliers Be sure to check your own state laws related to self-referral The Impact of IMPACT Improving Medicare Post-Acute Care Transformation Act of 2014 Requires the standardized reporting of patient assessment data with regard to quality measures and resource utilization, along with other measures Applies to: Long Term Care Hospitals (LTCH s) Skilled Nursing Facilities (SNF s) Home Health Agencies (HHA s) Inpatient Rehabilitation Facilities (IRF s) TJC s Perspective Multidisciplinary communication, collaboration, and coordination Clinical involvement and shared accountability during all transitions Comprehensive planning and risk assessment throughout hospital stay Standardized transition plans, procedures and forms Standardized training Timely follow-up, support and coordination after the patient leaves the care setting If readmitted within 30 days, gain an understanding of why Evaluation of transitions of care measures 4

5 Transitions of Care The CMS Innovation Center supports communities to improve care between transitions High risk of communication failures Procedural errors Strong evidence that hospital readmissions can be reduced with smooth transitions of care Case Study #1 63 year old male, hospitalized for A-fib and uncontrolled blood pressure, LOS 4 days. Discharged to home with HHA & Nursing. Readmitted 14 days later with same diagnoses. Inpatient Care A-fib stabilized by combination of IV and oral medications Dietary restrictions implemented Patient education for post-discharge lifestyle changes Oral medication initiated for hypertension 5

6 Transition of Care Considerations Discharge planning initiated at time of admission Social history Post-discharge goals Available support Financial planning Discharge options Interdisciplinary communications What May Have Gone Wrong Lack of coordination of dietary needs Insufficient support in the home No follow-up with primary care physician/specialist Leads to insufficient discharge orders No one owns the transition Incomplete medication reconciliation upon discharge No follow-up on recommended lifestyle changes Non-compliance with required medications Case Study #2 70 yr. old male admitted to hospital with changed mental status; confusion and loss of balance. Blood sugar upon admission 724 LOS 4 weeks and discharged to Sub-Acute Care facility and then Home Care 6

7 Course of care Dx of diabetes A1C 13.4 Inpatient Care Low blood pressure and unable to stabilize Endoscopy finds bleeding ulcers requiring cauterization Diagnostic testing reveals heart failure with 30% ejection fraction Inpatient Care Hospital course 4 weeks to stabilize all conditions and establish effective medication regimen PT/OT started due to secondary deconditioning Due to deconditioning and challenging home layout (stairs to enter and no full bath on the ground floor) patient discharged to short term rehab and potential homecare support Smooth Transition Starting during initial stay Interdisciplinary discharge planning initiated on day 1 including all support family, significant others Establish connection to post-acute medical provider Establish patient and care giver education Systematic tracking of all medications (including supplements) and medication reconciliation 7

8 Smooth Transition, con t. Appropriate discharge orders written to establish postacute care treatment Appropriate financial considerations explored for best case reimbursement for all providers Pre-Authorizations Patient/care giver awareness of any obligations; co-pay, coinsurance, in/out-network providers, etc. Transition of care communication; acute to post-acute Smooth Transition, con t. Post Inpatient follow-up Visit to post acute care provider scheduled and maintained within 7 to 14 days based upon complexity Appropriate follow-up testing to assess treatment plan and meet any reimbursement requirements Care Transitions Where Do You Fit In? 8

9 Role of Compliance Conduct a risk assessment of the organization s transition process Potential breaks or weak links in the communication plan Sufficient oversight of business associates and subcontracted providers How are care partners selected? TJC or other accreditation? Root Cause analysis of re-admissions Examine communication lines from a privacy and security point of view Role of Compliance Policy and Procedure Are documentation policies and procedures robust? Have team members been adequately trained? Are conflict of interest and freedom of choice policies in place and enforced? Are there frequent reviews of key policies and procedures? Medication reconciliation Hand off communication Are you closing the loop and measuring effectiveness? Role of Compliance Monitoring and Auditing Are the policies and procedures for transitions of care being followed? Is medical record documentation compliant? Billing Transition Care Management Chronic Care Management Contracting Revenue sharing agreement for transition care partners that do not receive reimbursement 9

10 The Future Accountable Health Communities Model CMS 5 Year model assessment The right care at the right time at the right cost Questions? Thank You Melanie A. Sponholz, MSPT, CCEP, CHC, CHPC, SVP, Chief Compliance Officer Home Solutions 1001 S. Grand Street Hammonton, NJ phone MSponholz@infusioncare.com Deborah L. Carlino, RN, MBA, CHC, CHRC, Director of Healthcare Compliance and Audit Office of Enterprise Risk Management, Ethics and Compliance Rutgers, The State University of New Jersey O carlindl@ca.rutgers.edu Michael P. McKeever, CPA, FHFMA, CHC, CHRC, Director, Internal Audit Saint Peter s Healthcare System 254 Easton Avenue New Brunswick, NJ ext mmckeever@saintpetersuh.com 10