White Paper. Reducing Hospital Readmissions: Solutions in Action

Transcription

1 White Paper Reducing Hospital Readmissions:

2 According to the Dartmouth Atlas report titled After Hospitalization: Readmissions, Among Medicare Beneficiaries, hospital readmissions cost Medicare more than $26 billion annually, $17 billion of which is avoidable, meaning it would not be necessary if patients received the right care. Many patients are readmitted simply because they live in an area where the hospital is used more frequently as a site of care for illness. The root cause and mitigation of this problem goes far beyond hospital walls. $17B is avoidable The Centers for Medicare and Medicaid Services (CMS) has instituted escalating penalties for hospitals with higher than expected readmissions and reducing readmissions has become a focal point of healthcare reform, mainly through value-based payment and the advent of population health management and continuum of care initiatives. Starting in fiscal year 2013, CMS withheld 1 percent of its payments for approximately 5,000 acute care hospitals. And by 2017, this reimbursement reduction will increase to 2 percent. In the first year alone, this 1 percent equated to about $850 million for all U.S. hospitals. In order to gain back a portion of the 1 percent funds withheld, a hospital will have to earn points for either achieving the high performer results on Clinical Process of Care and Patient Experience of Care measures against national competitors or by showing improvement from its baseline score. This is now a major financial issue for U.S. hospitals that they must address in a comprehensive and proactive way, or face the consequences to their bottom line. Hospital readmissions cost Medicare more than $26 billion annually. $17 billion is avoidable. Source: Dartmouth Atlas report, After Hospitalization: Readmissions Among Medicare Beneficiaries In this briefing we will examine: Challenges that impact readmissions Risk factors for readmissions Government and private initiatives to reduce readmissions Resources and best practice case studies that have been successful 2

3 Framing the Problem Again referencing the Dartmouth Atlas report, the American healthcare model for the most part had been one that generally focused on volume over value. The previous way of doing business and the incentives were built around filling beds to maximize payment. As stated previously, many patients visit the hospital initially, and then as follow up, because in their area, the hospital is used more frequently as a site of care for illness. Higher initial admissions generally encourages higher readmissions. And hospitals can be costly and dangerous places the longer one stays in the hospital, the more likely they are to get an infection. These overutilization issues, and the subsequent readmission challenges, also point to the fragmented care of our current system. Discharged patients have historically suffered the consequences of inadequate discharge planning, poor care coordination between the hospital and community clinicians and a lack of effective longitudinal community-based care. These include: Heart failure Myocardial infarction Pneumonia Chronic obstructive pulmonary disease (COPD) Coronary artery bypass surgery Coronary angioplasty (PTCA) and vascular procedures The penalty or incentive as it is termed was 1 percent payments for 2013, going up to 2 percent in 2014 and topping out at 3 percent in It is expected that Medicare expenditures will be reduced by $41 billion if the CMS goals for reducing readmissions and hospital-acquired conditions are met. There has also been significant work done to identify patients that are at high risk for readmissions. The table below illustrates several in terms of three specific factor areas: Patient, Event and Medication-related. +50% More than 50 percent of Medicare patients do not see a primary care clinician or specialist within two weeks of leaving the hospital. Source: Dartmouth Atlas report, After Hospitalization: Readmissions Among Medicare Beneficiaries Risk Factors for Readmissions Patient Factors Age: over 80 History of depression ESRD > 5 chronic conditions High-risk DRG conditions (i.e., HF, AMI, COPD) All of this has led to the crisis of hospital readmissions costing Medicare more than $26 billion annually. If indeed $17 billion of this is avoidable if patients received the right care, what strategies need to be implemented to begin to turn the tide? In general, policy and payment initiatives must account for delivery and reimbursement systems. Planning and coordination, including improved discharge planning and connecting patients with primary and follow-up care, are needed. Better education of patients and caregivers about what they need to do when they get home must also be part of the equation. + Event Factors Previous admission(s) within 30 days No patient/family education with initial discharge No post-discharge appointments with appointment with PCP< 30 days LOS >2x DRG On the policy side, the move from a volume-based system to one focused on value has been made official by several policy decisions over the past several years. The Hospital Readmissions Reduction Act is a mandatory Department of Health and Human Services (HHS) provision under the Affordable Care Act. It reduces Medicare inpatient payments for hospitals with higher than expected risk-adjusted 30-day readmission rates for certain conditions which have the highest readmission rates and account for more than 25 percent of all readmissions. Medicine-related ADEs related to high-risk agents: warfarin, antiplatelet, hypoglycemics Presence of medication discrepencies > 5-10 routine medicines Poor adherence Source: Riddle, s. Pharmacy One Source, 1. Marcantonio et al. Am J Med. 1999;107: Jencks et al. N Engl J Med. 2009;360:

4 Working Toward Solutions Some very early proactive efforts designed to reduce readmissions have taken on added significance as the movement toward a value-based system and reduced payments begins to take hold in a more widespread manner. The Agency for Healthcare Research and Quality (AHRQ), is a public health service agency in the U.S. Department of Health and Human Services (HHS), whose mission it is to produce evidence to make healthcare safer, higher quality, more accessible, equitable and affordable, and to work with the HHS and other partners to make sure that the evidence is understood and used. AHRQ collaborated with Boston University Medical on a seven-year research program that resulted in a program dubbed Project RED (Re-Engineered Discharge). Patients involved in the original research program experienced a 30 percent lower readmission rate which resulted in a 39 percent reduction in cost of care. The preliminary work included intensive study of the discharge process, borrowing methods from engineering. The RED toolkit was updated and re-released in The process focuses on integrating all aspects of a patient s pre-, during and post interactions with providers and caregivers. The active commitment of the patient is also a vital, necessary component of the success of this program. It features 11 mutually reinforcing components: Project RED (Re-Engineered Discharge) Mutually reinforcing components: 1. Medication reconciliation 2. Reconcile discharge plan with National Guidelines 3. Follow-up appointments 4. Outstanding tests 5. Post-discharge services 6. Written discharge plan 7. What to do if problem arises 8. Patient education 9. Assess patient understanding 10. Discharge summary to PCP 11. Telephone reinforcement The hospital undertakes these actions during and after the hospital stay to ensure a smooth and successful discharge. The RED process also includes several components, such as the Discharge Preparation checklist, which again ensures that the patient understands what is expected, and encourages their active participation in the process. Patients who were part of the RED process cost facilities an average of $412 less within 30 days after discharge than patients who did not participate in this process. The Project RED resources and toolkit are available free of charge online at projectred/toolkit.html A Case Study Amerinet member Verde Valley Medical Center, a 99-bed facility with 11 senior behavioral clinics located 15 miles from Sedona, Ariz., like many similar facilities throughout the country, was struggling with how to reduce readmissions in its facility. Realizing it would take a concerted, integrated effort, especially in a relatively rural setting, they began the process of community integration in August 2011, instituting quarterly meetings that included membership from local skilled nursing facilities, assisted living facilities, durable medical equipment providers, hospice, home care, acute rehab, senior centers and care agencies to help ensure smoother care, coordination and movement between inpatient and outpatient settings. According to Suzanne Ballard, quality director at Verde Valley, although she was familiar with many of the providers, she had not had a chance to integrate with them and fully understand the services that they could offer. The teams were divided into three units: Strategic, Discharge Planning and Education. They initially discussed their challenges and barriers and how they could coordinate better quality of care enhancement for patients. An early result of the meetings was the addition to the team of the system director of pharmacy, after it was discovered that many patients and facilities were having difficulties getting prescriptions filled because only two pharmacies in the area stayed open past 7 p.m. The team put several procedures in place including establishing a relationship with Walgreens to extend hours and provide vouchers. This would ensure that patients were receiving the proper medications before discharge and allow for later discharges as well. One of the first pillars of the program was the establishment of a Transitions of Care program through the formalization of a relationship with the Verde Valley Caregivers group, a strong volunteer network that assists 20 new patients per month. They visit the patients in the hospital and within 24 hours of discharge and perform tasks such as med reconciliation and home safety checks, while providing transportation to follow-up appointments, therapy, dialysis, etc. Verde Valley also established the CHF (Congestive Heart Failure) Wellness Program, a six-week multidisciplinary outpatient heart failure teaching and exercise program for all heart failure patients. It provided early identification of heart failure patients presenting to the emergency department or early after admission and involved an advanced practice nurse for patient management and long-term follow up, including telemedicine services. Readmits for CHF have consistently been below 2 percent, with a 0 percent readmission rate during many months. Another pillar of the program is the Community Care Network which focuses on patients at risk for readmission and frequent emergency department visitors. It uses a volunteer health coach to visit patients after discharge, involves telemedicine technology in many cases 4

5 and the engagement of a nurse practitioner, who teaches healthcare coach classes and serves as a liaison between the primary care physicians and patients in their homes. Beginning in January 2014, Verde Valley added a Discharge Clinic to see patients within five days of discharge, a practice meant to further reduce the time to see a practitioner, assess any potential issues and further prevent readmissions. This was done, in part, after a root cause analysis of 2012 readmits revealed the average number of days between the admission and readmission was six days and that more than 55 percent of patients waited greater than seven days for an appointment. There was also a discharge nurse added to the process to support the discharge process and engage the scheduling department to schedule follow-up appointments at time of discharge. Verde Valley Medical Center s Reduced Readmission Rates 12% 10% 8% 6% 4% 2% 11.7% 8.2% 6.4% 2.6% In summary, as is often said, building towards a comprehensive, consistent and sustainable plan to reduce readmissions is a journey, but it is also one that must be consistently improved upon and adjusted. At its core, it relies upon building a team and establishing working relationships within the facility and also within the community that builds linkages and a continuity of care that engages people where they live as well as in the healthcare setting. Keeping patients and their care as the true north and ultimate focus of your efforts and maintaining a vision to be champions of quality every day will help drive success and sustainability for your healthcare facility and the patients and communities you serve. Contact Amerinet Customer Service or info@amerinet-gpo.com About Amerinet, Inc. As a leading national healthcare solutions organization, Amerinet collaborates with acute and non-acute care providers to create and deliver unique solutions through performance improvement resources, guidance and ongoing support. With better product standardization and utilization, new financial tools beyond contracting and alliances that help lower costs, raise revenue and champion quality, Amerinet enriches healthcare delivery for its members and the communities they serve. To learn more about how Amerinet can help you successfully navigate the future of healthcare reform, visit Amerinet, Inc. Two CityPlace Drive, Suite 400 St. Louis, MO Jan 2012 Jan 2013 July 2013 The all cause readmission rate The readmit rate for Medicare patients Part A and B So what did this all mean? Over the course of 19 months (January 2012 through July 2013), the all cause readmission rate at Verde Valley went from 11.7 percent to 6.4 percent, a nearly 50 percent reduction. In terms of Medicare Part A and B patients, the readmit rate went from 8.2 percent to 2.6 percent. 5