3/11/15. The Race Against Avoidable ACEs: Overview and Objectives. Performance Improvement at Cedars-Sinai

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1 The Race Against Avoidable ACEs: Cedars-Sinai s strategy for improving healthcare quality through population care management and coordinated care transition programs CAHQ Spring Conference March 16, 2015 Cedars-Sinai Performance Improvement Team Avi Handa, Salima Jamal, Carey Li Overview and Objectives Provide a broad overview of the organizational ACE Avoidance and Population Health Management vision Highlight the collaborative effort between Inpatient and Outpatient Pharmacist teams on safe medication transitions Share the success of managing care transition from hospital to home through the Enhanced Home Health program 1 Performance Improvement at Cedars-Sinai Design/ Innovation Thinking Cost Effectiveness Population Health Quality Operations Safety 2 1

2 Framework for Optimizing Performance 3 Creation of New Metric: Acute Care Episode (ACE) To ensure that our efforts resulted in meaningful reduction of hospital utilization and costs, we developed a new metric: an ACE, or Acute Care Episode. ACEs account for inpatient admissions and observation stays. 4 Population Health at Cedars-Sinai Con$nuum of Care Development Clinical Program Development Popula-on Health Lives Patient and Physician Engagement Managing the Care Process Patient Value- Based Contrac-ng Physician & Community Network IT Support Engagement IT/Predictive Modeling 5 2

3 Stratification of Population Health Patients Most Complex Fragile Chronic Disease Management Acute Care Management Wellness Promotion and Preventative Care 6 Building a Foundation: The ACE Avoidance House CS Integrated Program for Highest Risk Patients End Stage Renal Disease (ESRD) Congestive Heart Failure (CHF) Weight Management Surgical ACE Reduction Disease Management Programs Outpatient Parenteral Antibiotic Therapy (OPAT) Healing at Home NP House Calls Enhanced Care Program (ECP) Post Discharge Medication Reconciliation Ambulatory Care Management & Total Care Management (for Medicare Advantage) Daily Admissions Debrief Primary and Specialty Care Supportive Care Medicine ED Assist Pain Management and Mental Health 7 Program Highlight: Safe Medication Transitions Improving patient education and understanding about medications to ensure safe medication transitions 8 3

4 Medication List Accuracy, Adherence, and Literacy Identify High- Risk Patients Validate Medication History Assess Adherence and Literacy Educate Patient Notify MD Regarding DRPs Identified along with Recommend -ations Post- Discharge Follow-Up within 72 Hrs: -Med Rec -Adherence & Literacy Reinforcemen t -Education Additional Calls up to 30 Days Based on Risk Assessment 9 Identification of High Risk Patients High Risk Criteria: Age over 65 More than 10 chronic medications Therapeutic duplicates Congestive Heart Failure (CHF) Pharmacists Clinical Review Hospitalists and Physician Clinical Review 10 Literacy and Adherence Increase medica$on literacy Increase medica$on adherence Improve clinical outcomes Lower health care spending Bruce Stuart, F. Ellen Loh, Pamela Roberto and Laura M. Miller. Increasing Medicare Part D Enrollment in Medication Therapy Management Could Improve Health and Lower Cost. Health Affairs. 2013; 32(7)

5 Measurement of Medication Adherence Medication Adherence (MMAS-4) ⁴ 1. Do you ever forget to take your medicine? 2. Are you careless at times about taking your medicine? 3. When you feel better do you sometimes stop taking your medicine? 4. Sometimes if you feel worse when you take the medicine, do you stop taking it? Scoring: 1 point for every YES answer 0 High adherence Intermediate adherence Low adherence Morisky D, Green L, Levine D. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24: Bruce Stuart, F. Ellen Loh, Pamela Roberto and Laura M. Miller. Increasing Medicare Part D Enrollment in Medication Therapy Management Could Improve Health and Lower Cost. Health Affairs. 2013; 32(7) Measurement of Medication Literacy Medication Literacy 1. Name all of your medications? 2. Explain the indications for all of your medications? 3. What are the doses for all of your medications? 4. What are the frequencies for all of your medications? Scoring: 1 point for each category that pa$ents could not answer about all of their medica$ons 0 High literacy Intermediate literacy Low literacy 13 Determining Post-Discharge Follow-Up Needs Adherence Literacy High literacy Intermediate literacy Low literacy High adherence No post-dc f/u needed Educate pt. No post-dc f/u needed Post-DC f/u needed Intermediate adherence Educate pt. No post-dc f/u needed Educate pt. No post- DC f/u needed? vs. Post-DC f/u needed? Use clinical judgment Post-DC f/u needed Low adherence Post-DC f/u needed Post-DC f/u needed Post-DC f/u needed 14 5

6 Patient Education Goals of Therapy Medication Understanding Medication Adherence Use language at 6 th grade level or below Teach-back Methodology Address further questions 15 Post-Discharge Follow-Up within 72 Hours Patient discharged HOME Provide education on discharge medication regimen Instruct patient to pick-up new medications as soon as possible Instruct patient to take all meds as directed at discharge Re-educate patient on the importance of adherence Evaluate if patients need further follow-up 16 Post-Discharge Follow-Up within 72 Hours Pa$ent discharged to Skill Nursing Facili$es (SNF) Obtain MAR from SNF Reconcile discharge medication list vs. SNF MAR Perform Clinical Evaluation Identify DRPs Clarify discrepancies 17 6

7 Examples of Post-Discharge Follow-up Saves Reason for Admission 54 y/o w/ HTN & DVT admiked for sickle cell crisis & len parietal stroke 92 y/o w/ altered mental status found to have a UTI & toxic digoxin level, also w/ arrhythmias & low blood pressure Drug- Related Problems Iden$fied Post- Discharge and Pharmacist Interven$on Issue discovered: Pt had self- d/ced warfarin, amlodipine, and carvedilol Interven$on: Pharmacist contacted MD and confirmed that warfarin and an-- hypertensives should be re- started. Pharmacist contacted pt and instructed to take all meds as was prescribed at d/c; do not self- start, self- d/c, self- dose, or adjust any med w/o speaking to MD first; educated pt on the importance of compliance to avoid complica-ons Issue discovered: Pt had con-nued taking medica-ons that had been stopped, including digoxin, metoprolol, and zolpidem Interven$on: Instructed pa-ent to d/c these medica-ons Adverse Outcome Prevented Avoided poten-al occurrence of thromboembolism, readmission, and/or death Avoided poten-al drug toxicity, life- threatening arrhythmias, recurrence of confusion, and/or death Day Readmission Rates As Treated Population 25% 20% 15% 10% 5% 0% 22% (18/8 2) Did NOT receive interven-on 12% (5/41) Received interven-on Relative Risk Reduction: 45% 19 Program Highlight: Enhanced Home Health Ensuring high quality patient-centered care transitions from hospital to home 20 7

8 The Enhanced Home Health Program 7 Touch Points On-site Liaison MD Interface CS-Link access 24/7 On-Call Clinical Support Building Awareness Data Collection & Documentation 21 The EHH Population EHH Case Mix Index Type of Hospital Encounter CMI Medicine 35% Surgery 65% Enhanced Home Health Protocol Touch points to occur within the first two weeks of discharge Week 1 Pre-Discharge Hospital Visit with Home Health Liaison Hours prior to discharge Intro Phone Call Identify red flags Address questions/ anxiety Evening of Discharge Home visit Med rec Safety check Assessment & education Identify other disciplines that may be needed Day after discharge Tuck-in Phone call Identify red flags Schedule next home visit MD Follow up appointment? 1 st Friday patient is at home Home visit (2-3 in first week) Med compliance Vitals assessment Schedule next home visit 1 st weekend patient is at home Week 2-4 Home visit Med compliance Vitals Well-being assessment Tuck-in Phone call Address questions Schedule next home visit Home visit Med compliance Vitals Well-being assessment Tuck-in Phone call Address questions Schedule next home visit Monday-Thursday Minimum of 1 home visit 2 nd Friday patient is at home 2 nd weekend that patient is at home Weekly days post discharge 23 8

9 Goal: Reduce Average EHH Readmission Rate to 10% Average EHH readmission rate (Mar-14 Oct -14) = 11.1% 24 Empathy Interviews Patient s trigger point Pain Afraid Key findings Strong patient/nurse relationship Compassionate care Opportunities Accessibility to contacts Consistent patient education 25 Continued Performance and Process Improvements CS-Link (Epic EMR) Access Agency liaisons in the ED Home health agency and Attending Physician communications Alignment of patient education materials Real time feedback using patient interviews Agency clinical huddles Agency check-in meetings Organizational engagement through Grand Rounds Epic Home Health build 26 9

10 Q & A Questions? Thank you! 27 10