Making the Transition: Improving Coordination, Lowering Readmission, and Expanding the Care Team through Data-Driven Risk Stratification at Discharge

Transcription

1 Making the Transition: Improving Coordination, Lowering Readmission, and Expanding the Care Team through Data-Driven Risk Stratification at Discharge Jennifer McNay, MD Cindi Goddard, MPH, BSN, RN

2 Mercy Health Our Spirit Our Mission As the Sisters of Mercy before us, we bring to life the healing ministry of Jesus through our compassionate care and exceptional service. Our Vision We are the people of Mercy Health Ministry. Together, we are pioneering a new model of care. We will relentlessly pursue our goals to get health care right. Everywhere and every way that Mercy serves, we will deliver a transformative health experience. Values & Charism Dignity Justice Service Excellence Stewardship Bias for Action anticipating and responding to need; getting things done Entrepreneurialism having the courage to take risks, innovative spirit Hospitality welcoming and accepting, gracious; forgiving Right Relationships speaking your truth with honesty; resolving differences; holding each other responsible; working together Fullness of Life sense of joy; love of life, even during suffering

3 Mercy By the Numbers

4 Mercy Health Accountable Care Core Strategy Primary Care Transformation Care Management Integration Performance Engineering QUALITY COST/UTILIZATION IMPROVED CARE

5 Mercy s Risk Experience Mercy s own health plan 1994 Commercial Medicare Advantage Direct Contracting with Employer Groups 1995 CMS Physician Group Practice Demonstration Medicare Advantage & Commercial Payor Risk and Delegation 2010 CMS Shared Savings ACO (1) 2013 to current CMS Shared Savings ACO (2) 2015 to current Employer Group ACO Arrangements with Boeing (2015) and Wal-Mart (2016) Current State: >300,000 managed lives

6 Many Tools in Place: Daily Visit Planner 6

7 Many Tools in Place: Frail Risk Stratification Criteria for care management stratification report Monthly Stratification of Entire Population NOT the Readmission Risk in post-discharge period, but overall risk Embedded into EPIC as a Score Call in Get in Across the Care Continuum so all are aware of risk Pull all Information Below to Compile Frailty Risk Score 1. Comorbidities 2. Utilization Patterns 3. Length of Stay History 4. Lack of Appropriate Utilization 5. Predictive Modeling Tool: High risk for Hospitalization 6. Demographics = Overall Risk Score

8 Ambulatory At Risk flag Call in get in

9 Mercy Care Management Hospital-based Utilization Review 1996 Delegated Utilization Management Prior Auth and Concurrent Review (Separated from Hospital-based Utilization Review) 1996 Medical Data Management 1998 Ambulatory Case Management Separated from Hospital Case Management Mercy Nurse On Call: 24/7 Telephonic Triage Mercy Disease Management Program Pharmacotherapy Management Risk Adjustment URAC Accreditation for Nurse On Call and Complex Case Management NCQA Accreditation for Disease Management New Medical Analytics Department 2010 Telemonitoring for Disease Management 2013 Integration of Care Management with Mercy Primary Care

10 Care Management Integration Created Distributive Model of Case Management Not Embedded but Distributed Assignment of Primary Case Manager(s) per clinic site based on risk distribution Focus on Risk populations, not segmented by payor 24/7 Access to Nurse Triage Mercy s Centralized URAC Accredited Nurse On Call Redirection allows triage nurse to page physician when algorithm points to ED and nurse knows patient advice could be downgraded appropriately Chronic Disease Telemonitoring Data Management Suite of data analysis and reporting opportunities and tools Bring the data to the Clinic make it actionable Creation of Readmission Risk Stratification

11 Mercy Primary Care and Care Management Working Together Creation of Triple Aim Teams 1) Monthly team assignment of the measures that are pertinent to scope of work 2) Focus on the measures that you can affect 3) Close the gaps in care, cost, and variation 4) Continues success of Physician Led, Professionally Managed model to each business unit 5) Adds Case Management to the teams to help manage utilization, identify frail patients, and optimize work 6) Includes feedback to clinic leadership to mitigate upcoming issues/concerns 7) Ongoing dialogue between meetings

12 Mercy Primary Care and Care Management Priorities: Prevent unnecessary ED utilization Clinic workflow standardization Streamline use of Daily Visit Planner Increase Medication Adherence Prevent readmissions

13 Mercy Primary Care and Care Daily Visit Planner Due to Done Report Additional enhancements now include hot link from inside EPIC Detailed Outcome Reports Frail Risk Stratification and Flag in EPIC Call In/Get In Management Loops in the Front Office Staff Connects Case Manager to Patient-Focused Outreach Population Health Management Guide Lessons Learned- Meaningful data, put actionable information in the hands of those making the work happen, understand role differentiation and impact potential at every level

14 Challenge. In April, 2014: Create a transitional program for Mercy patients discharged from acute setting For 34 different hospitals across 4 states Which discharge ~35,000 Medicare patients per year Involving over 250 Integrated & Non-Integrated Primary Care Offices.by July 1.

15 Where to Start? Transitional Care Management Billing Codes Long history of population management and risk stratification Culture of Core Work of Care Management Knew we had to leverage EPIC & Integrated Primary Care/Hospitals/Care Management Model development: Dr. Mary Naylor Transitional Care Model Dr. Eric Coleman, University of Colorado Care Transitions Program Project RED (Re-engineered Discharge) Boston University

16 Transition Program Design Creation of Readmission Risk Stratification Embedded in EPIC Correlates to Readmission Risk Pulls from Problem List, Social History, Demographics, Face-to-Face Diagnoses Dynamic Score Refreshes when chart is accessed Static capture in Clarity Database Score of 0-24

17 Transition Program Design Begin with Transitions from Acute Inpatient to Home Targeting those who are most vulnerable to a breakdown in care Older adults Multiple Chronic Conditions Potential for gaps in communication Continuity of care critical Limited access to needed services Disease agnostic

18 Mercy s Transitional Management Plan Piloted in Two Largest Communities 7/1/ /31/2014 Mercy Communities Go-Live 1/1/2015 Eligible patients MCR & Medicare Advantage (MA) patients Mercy facility discharge Re-admission Risk Score > 8 Discharged to Home First contact by Care Manager unless appointment scheduled within 2 business days PCP sees patient within 7 days or less No Shows are responsibility of PCP s clinic office

19 Hospital to Home Inpatien t Care Manage r Discharge Planning Assure Safe Discharge TCM Scripting/ Pt Prep Follow-Up Appt Made with PCP PCP Ambulato ry RN Case Manager Transition Assessment Medication Reconciliation Communicate Issues to PCP Resolve Resource Needs Receive Care Mgmt Communication of Immediate Needs Face to Face Follow Up Chronic Care Management

20 How Did We Execute? Assure the Tool Works Provider Buy-In Easy to Spot the Patient Leverage Care Management Integration Data Management of Process and Outcomes

21 Readmit Rate Assure the Tool Works: Admission Risk Correlation Fitted Line Plot Readmit Rate = Risk Score 0.4 S R-Sq 29.8% R-Sq(adj) 26.8% Risk Score 20 25

22 Quality: Provider Buy-In: Incentives Help Drive Success Quality, Service, Safety Incentive for all Adult Medicine Providers 1. Annual Wellness Visits (AWV) Utilization of Annual Wellness Visit codes on Medicare (not MA) patients >65 yrs, with Diabetes, Congestive Heart Failure, Coronary Artery Disease. Visits billed by collaborating APC qualify. a. >25% utilization on qualified patients b. >35% utilization on qualified patients 0.75% 1.5%

23 Provider Buy-In: Incentives Help Drive Success Quality, Service, Safety Incentive for all Adult Medicine Providers 2. Transitions of Care Utilization of Transition Care Management codes or E&M visits within 7 days post discharge for Medicare and Medicare Advantage patients 65 yrs, flagged as high risk ( 12) for readmission discharged from a Mercy inpatient/observation hospital stay. Codes can be billed by PCP/Partner/ Collaborating Advanced Practitioner and/or involved Specialist to satisfy measure. a. >50% utilization on qualified patients b. >75% utilization on qualified patients 0.75% 1.5%

24 Provider Buy-In: Incentives Help Drive Success Population Health Compensation Target Discharge F/U 7 days Target 90% All patients discharged from a Mercy facility have KEPT an appointment with the physician within 7 days a. E and M Visit by Care Team with 7 days b. Re-admission risk 8 c. ACO (and MA risk contracts as available) d. Includes regular and observation stays e. Excludes Ortho, Surgery, OB/Gynecology, Oncology, Psychiatry f. Excludes discharges to SNF, LTAC, Rehab hospital g. Source: Medical management report

25 Easy to Spot: Added column to My Lists

26 Colored box Easy to Spot: Appearance in EPIC Header Does not change with score

27 Easy to Spot: Accurate & Rich Daily Discharge Reports for Case Managers Delivered daily to Inbox Delivered to the geographic care management unit for that PCP and Hospital Community Includes Risk Score, DC information, Risk Flag, Next PCP Appointment Date

28 Leverage Care Management Integration Primary Care Coordination Triple Aim Meeting Feedback Individual PCP Reporting of Success Case Management Facilitation of Rescheduling for Urgent Issues Community PCP Dept PCP Disch Month Eligible Discharges Scheduled % Sched Kept % Kept % of Total Elig Disch w/ Kept Appt Avg Days from Disch to Comp Appt Springfield Sgfmc Family Medicine Buffalo Agee, Mary % % % 3.88 Springfield Sgfmc Internal Medicine Fremont Dela Rosa, Nelson M % % 66.67% 4.97 Springfield Sgfmc Family Medicine Buffalo Diamond, Linda K % % % 2.17 Springfield Sgfmc Internal Medicine Sgc Suite 300 Dopp, Patrick M % % % 6.26 Springfield Sgfmc Primary Care W Republic Ellis, Scott A % % % 5.02 Springfield Sgfmc Internal Medicine Sgc Suite 300 Farris, Fred W % % % 6.22 Springfield Sgfmc Family Medicine Lebanon 331 Glas, Ronald D % % 50.00% 6.83 Springfield Sgfmc Family Medicine E Sunshine Graham, Marcia K % % % 8.00

29 Results: Pre vs Post-Intervention Transition Care Management Patients with Risk for Readmit Score of 8 or Greater Follow-Up Appointment Compliancy Pre-Intervention Post-Intervention % with Follow-Up 0-7 Days Post-Discharge 38% 64% % with Follow-Up 0-14 Days Post-Discharge 56% 76% % with Follow-Up 0-30 Days Post-Discharge 68% 81% 30 Day All-Cause Readmission Rates Pre-Intervention Post-Intervention Readmission Rate 13.3% 8.4% Follow-Up Within 0-7 days 11.2% 6.9% Follow-Up Within 8-14 days 7.1% 10.1% Follow-Up Within days 18.0% 14.6% No Follow-Up 17.3% 10.6% Pre-Intervention = Non-Pilot Sites, 7/1/ /31/2014 Post-Intervention = All Sites Live, 1/1/ /30/2015

30 Results: Readmissions Post- Intervention 16% 14% 30 Day Readmission Rates for High Risk Patients with 7 day, 8-14 day, day, and No Follow-Up Patients with Readmit Risk Score of 8 or Greater 1/1/2015 through 11/30/ % 12% 10% 8% 6% 6.9% 10.1% 10.6% 0-7d Follow-up 8-14d Follow-up 15-30d Follow-up No Follow-up 4% 2% 0%

31 Outreach and Follow-Up Outreach Post-Discharge and Follow-Up Post-Discharge Outreach Reach Rate 86-90% Once Reached-Declined to Participate in Assessment 3-4% PCP Follow-Up Within 7 Days of Discharge Scheduled 81% Kept Scheduled Appointment 79% Didn t Schedule 19% Reasons Not Scheduled for Follow-Up #1 Provider Cannot see Patient within 7 days #2 Patient States they Prefer to Schedule Themselves #3 Patient Declines any PCP Follow-Up Appointment

32 Transitional Opportunities Found Medication issues -24% of patients Case Managers facilitating earlier appointments due to symptoms Appropriate DME and Home Care facilitation Coordination of specialist and PCP appointments Transportation arrangements to appointments Helping patient find a PCP if not already established

33 Lessons Learned It takes dedicated focus and teamwork Handoffs and transitions are vulnerable times for patients Focus your care management resources on the highest risk patients Provider buy-in is crucial Patients may not see the need for follow-up Do not let the process become stale

34 Next? Additional fruit to pick (items in green already under way or about to launch) Primary Care Offices perform TCM outreach and follow-up for non-high risk patients Patients not hitting a risk score threshold gut feeling of risk Patients declining post-acute care services Transition to and from Inpatient Rehab and Skilled Nursing to Home Surgical Discharges/Specialty follow up

35 Sister Catherine McAuley doing ordinary things extraordinarily well