Reducing Readmissions and Safe Transitions Collaborative: Implementing Re-Engineered Discharge (RED) In 19 Colorado Hospitals White Paper

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1 Reducing Readmissions and Safe Transitions Collaborative: Implementing Re-Engineered Discharge (RED) In 19 Colorado Hospitals White Paper Executive Summary Objective: To implement the 11 action steps of Boston Medical University s Re-Engineered Discharge (RED) intervention and track all-cause and same-cause readmission rates with select target populations in 19 Colorado hospitals. Intervention: From Jan. 1, 2012 through Dec. 31, 2013, the Colorado Hospital Association (CHA) facilitated a quality improvement collaborative with 19 Colorado hospitals to implement the RED intervention with select target populations. In this effort, CHA provided hospitals with education on best practices and created a network for shared learning. Each hospital tracked its all-cause and same-cause readmission rate, and the percentage of compliance with the 11 action steps and conducted a post-discharge survey with patients who received the intervention via a phone call. A total of 20 hospitals were recruited to participate in RED during the initial stages of the project. One hospital withdrew from participation, making a total of 19 hospitals that completed the two-year collaborative. Results: A total of 19 Colorado hospitals implemented the Project RED intervention with a total of 7,679 patients. Participating hospitals reported a 30 percent relative reduction in the all-cause readmission rates, dropping from 13.3 percent to 9.3 percent and a 43 percent relative reduction in same-cause readmission rates, dropping from 6.5 percent to 3.7 percent. CHA estimated that this project saved approximately $2.6 million by averting 311 all-cause readmissions (including samecause readmissions) over seven quarters of intervention across 19 hospitals. On average this accounted for a total of 44 prevented readmissions per quarter. There was no statistical correlation found between the action steps and a reduction in readmissions. The collaborative saw notable improvement in compliance over the intervention period with step 1 and 4 (education on the patient s diagnosis, including national guidelines, and organizing post-discharge services), step 9 (assess the patient s level of understanding, i.e., teach-back ) and step 11 (contact the patient to reinforce discharge plan two to three days after discharge). The collaborative hospitals showed consistently high compliance with step 5 (confirm the medication plan) and step 10 (give the patient a written discharge plan at the time of discharge). Limitations: Each hospital was able to select a target inpatient group for the intervention specific to their patient population. Hospitals self-reported their all-cause and same-cause readmission rates, process measures and post-discharge survey data. Despite instructions and clear definitions, hospitals varied in how they collected and reported data. Individual hospitals reported varying levels of success in reducing readmissions. Conclusion: As a whole, the cohort of participating hospitals reduced both same-cause and allcause readmissions over the 24-month period of the intervention as compared to the cohort s baseline rate from the previous year. The results of the two-year effort benefitted hospital patients and their communities and demonstrated the significant impact of a coordinated statewide effort. Likewise, the cost-savings resulting from the project are substantial. These cost-savings contribute 1 P a g e

2 to improving the affordability of health care by reducing unnecessary spending in the health care system. Funding: UnitedHealthcare Background In 2010, 14.8 percent of fee-for-service Medicare beneficiaries in Colorado were re-hospitalized within 30 days of discharge from the hospital 1. Some re-hospitalizations may be unnecessary and, thus, represent avoidable harm and costs for patients. Colorado hospitals began developing strategies to improve care and reduce 30-day readmissions 2. In 2011, there were few care transition projects in practice in Colorado 3, 4, 5. Key strategies to reduce readmissions at the time included transitional nurses and home visits. Those interventions were costly to hospitals, especially those with limited resources such as rural and critical access hospitals (CAHs). Late in 2011, CHA partnered with UnitedHealthcare to build a collaborative around reducing readmissions for patients treated in the hospital without requiring additional staff or home visits. CHA researched several interventions and selected Boston Medical Center s RED 5 as the ideal intervention methodology for CHA members. The RED initiative, which was tested in a general medical population, required a team approach based on patient education, comprehensive discharge planning and was administered within the hospital setting. The RED intervention is designed to re-engineer the hospital workflow process and improve patient safety by using a nurse discharge advocate who follows 11 discrete, mutually-reinforcing action steps shown to improve the discharge process and decrease hospital readmissions. Through the partnership with UnitedHealthcare, CHA was awarded a $1.1 million dollar grant to facilitate a 24-month long (Jan. 1, 2012 Dec. 31, 2013) collaborative geared towards the widespread implementation of the RED intervention. The collaborative was structured to consist of two phases. Phase one utilizes RED as its foundation to improve the discharge processes within the inpatient setting, while phase two focuses on improving care transitions by building community partnerships. The Association s goal for the RED intervention was to reduce 30-day all-cause readmission rates by 10 percent and 30- day same-cause readmission rates by 20 percent from baseline. While 20 hospitals were originally recruited, a total of 19 Colorado hospitals participated in the two-year program and included 13 urban hospitals, one rural and five CAHs. Each facility signed a memorandum of understanding (MOU) and agreed to implement the 11 action steps of RED, submitted their all-cause and samecause readmission rates quarterly and submitted answers from patients sampled in a postdischarge follow-up phone survey. Hospitals were funded for a two-year period for participation. Support dollars helped hospitals by providing additional resources, addressing staff requirements and training to prepare for the implementation of the 11 action steps. Methods Population Identification and Data Collection To ensure relevance to each participating facility, hospitals were asked to select a target inpatient population of their choice. The majority of hospitals chose to focus on heart failure patients, however several selected pneumonia patients, insurance provider or all patients. It was most common for smaller CAHs to choose all inpatients for their target population due to their lower patient counts. Each hospital was given a six-month grace period to set up their intervention between the time of the baseline period and the start of the implementation period. Data were collected by the hospital monthly for the 11 action steps of RED and the post-discharge survey. Data for all-cause and same-cause readmission rates were collected by all participating hospitals and self-reported to CHA on a quarterly basis. As hospitals began the process at slightly different times, 2 P a g e

3 all readmission data were reported at 6-, 9-, 12-, 15-, 18-, 21-, and 24-months post implementation. Hospitals were asked to report all-cause and same-cause readmission rates for 12 months of baseline data prior to the start of the intervention for their selected target population. Data Analysis Data analysis was provided by CHA s (CHIDA). The overall baseline rate for 19 hospitals was calculated by combining the total number of readmissions for the cohort and dividing by the combined patient populations of all participating hospitals. Some hospitals used a more unique sample of patients while others used total discharges for the entire patient population. While some hospitals used only primary diagnosis of the chosen population, other hospitals measured all patients who had the selected diagnosis as a primary or secondary diagnosis. Quarterly readmission rates were thus calculated for each hospital by dividing the submitted all-cause and same-cause readmission numbers by the reported patient population particular to each hospital. Process compliance was measured by dividing the total number of yes responses by the total number of patients interviewed. In order to calculate changes in readmission rates for each hospital, hospitals submitted baseline readmission rates for their chosen population for 12 months preceding the start of the project. For all hospitals beginning the project in January 2012, the baseline period was January to December This rate was multiplied by the patient population of each quarter to generate the expected number of readmissions and then compared to the actual observed number of readmissions. The difference between these numbers represents the estimated numbers of avoided readmissions. Savings Estimation The estimation of savings was conducted using all patients in the CHA s Inpatient Discharge Database in 2012 that visited any one of the 19 participating hospitals and had been flagged as a readmission. The Association used all patients, since the analysis looked at all-cause readmission and, thus, covered any possible diagnosis. The Inpatient Discharge Database reports charges but not reimbursement rates of care. These were derived from a different dataset also maintained by the CHA DATABANK program. DATABANK contains hospital-reported data on financial and utilization metrics, including contractual allowances by payer across all diagnoses. We paired the claims data from the Inpatient Discharge Data to the income statement information reported in DATABANK for the hospitals in the collaborative. By matching the charges and payer type listed on the claim to the contractual allowances reported on the hospital income statement, we estimated the reimbursement for each patient, and thus, the amount that would be saved if the readmission were averted. By taking the median amount for all Colorado urban, CAH and rural hospitals, CHA analysts were able to calculate a final estimation for cost-savings per readmission of $8,300. For each hospital in the collaborative, for every quarter, CHA multiplied the number of avoided readmissions by the average cost for a readmission. By summing this for the seven quarters, CHA analysts could arrive at a total estimated cost-savings. Results Outcome Data During this time, 7,679 patients were recorded as receiving at least some part of the 11 step intervention. Overall, this project is estimated to have prevented approximately 311 readmissions over seven quarters of intervention across the 19 hospitals, with an average of 44 averted readmissions per quarter. Before the intervention began, 1,241 readmissions were observed at baseline among the 19 hospitals, averaging 310 all-cause readmissions per quarter in CHA 3 P a g e

4 analysts estimated that the RED intervention project saved approximately $2.6 million by averting a total of 311 readmissions. Of the 19 analyzed hospitals, nine reported reductions in both all-cause and same-cause readmissions, four reported reductions in same-cause only, and six did not reduce either. Quarter Number of Readmissions Prevented By Quarter Expected Actual (Observed) Readmissions Readmissions Prevented Readmissions (Expected Observed) Baseline --- 1, months months months months months months months Total 311 Table 1: The number of readmissions prevented by quarter for the 19 reported hospitals in the collaborative Table 1 outlines the overall prevented readmissions by quarter, calculated from the 2011 baseline. Prevented readmissions are the difference between the expected readmissions and the actual number of readmissions seen that quarter, calculated using the baseline rate. Figure 1: Cost-savings estimates in U.S. dollars for the 19 participating hospitals 4 P a g e

5 Figure 1 shows the summary of cost-savings by peer group. CHA estimated that this project saved approximately $2.6 million by averting 311 readmissions. For each hospital every quarter, the Association multiplied the number of avoided readmissions by the median cost per readmission. By summing this for the seven quarters, CHA arrived at a total estimated cost-savings. CHA took the median amount for all Colorado urban, CAH and rural hospitals to arrive at a final estimation for cost-savings per readmission of $8,300 and multiplied it by the 311 averted readmissions for a total cost-savings of $2.6 million. Figure 2: 30-day all-cause readmission rates for 19 reported hospitals in the collaborative Figure 2 outlines the quarterly all-cause readmissions rates summed from the 19 participating hospitals. Overall, hospitals reported a 30 percent relative reduction in all-cause readmission rates, reducing all-cause readmissions from the baseline of 13.3 percent to 9.3 percent after 24 months. The 30-day all-cause readmission rate was calculated by dividing the total number of non-elective inpatients returning as an acute-care inpatient to the same facility within 30 days of the index discharge with any diagnosis by the total number of hospital discharges. The collaborative surpassed the 10 percent reduction goal rate of 12 percent. 5 P a g e

6 Figure 3: 30-day same-cause readmission rates for 19 reported hospitals in the collaborative Figure 3 outlines the quarterly same-cause readmissions rates summed from all 19 hospitals. Overall, the hospitals reported a 43 percent relative reduction in same-cause readmissions, dropping from 6.5 percent to 3.7 percent at 24 months after the project began. The 30-day samecause readmission rate was calculated by dividing the total number of non-elective inpatients returning as an acute-care inpatient to the same facility within 30 days of the index discharge with the same diagnosis as the index discharge by the total number of hospital discharges. The collaborative surpassed the 20 percent reduction goal rate of 5.2 percent. Process Data Overall, the collaborative saw notable improvement in compliance over the intervention period with step 3 (discuss with the patient any pending in-hospital tests and follow-up with the results), step 9 (assess the patient s level of understanding, i.e., teach-back ) and step 11 (contact the patient to reinforce discharge plan two to three days after discharge). The collaborative showed a consistently high compliance with step 5 (confirm the medication plan) and step 10 (give the patient a written discharge plan at the time of discharge). Amongst the 19 hospitals, 7,679 patients in the collaborative were given the intervention. 6 P a g e

7 Components of RED Step 1. Educate patient about relevant diagnoses throughout hospital stay Step 2. Make appointments for clinician follow-up and postdischarge testing Step 3. Discuss with patient any pending in-hospital tests or studies completed and who will follow-up with results Step 4. Organize post-discharge services Colorado s Reducing Readmissions & Safe Transitions Collaborative (n = 7,679 patients) Jack et al., 2009 Annals of Internal Medicine Intervention group (n = 373 patients) 78.2% 242 (79%) 65% 346 (94%) 40.9% - See Figure 8 - Step 5. Confirm medication plan 88.3% 197 (53%) Step 6. Reconcile the discharge plan with national guidelines and critical pathways 78.2% - Step 7. Review appropriate steps for what to do if a problem arises 75% - Step 8. Transmit discharge summary to physicians and services accepting responsibility of 69.5% 336 (91%) patient s care Step 9. Assess the degree of understanding by asking the patient to explain in his or her own 66.1% - words the detail of the plan Step 10. Give the patient a written discharge plan at the time of 93% 306 (83%) discharge Step 11. Call the patient to reinforce discharge plan two to three days after discharge 67.8% 228 (62%) Table 3: Compliance rates with the various steps of the process as compared to the results of the Jack et al. (2009) paper Table 3 compares the compliance rates with the 11 action steps of the RED intervention in the collaborative to those listed in Jack et al. (2009). The CHA collaborative saw higher compliance rates than Jack et al. (2009) with educating patient about relevant diagnosis, confirming the medication plan, giving a written discharge plan to the patient at discharge and conducting a follow-up phone call to confirm the discharge plan post-discharge (2009). 7 P a g e

8 Post Discharge Survey Discharge Year Did the patient feel he/she received all the answers to any questions prior to leaving the hospital? 94.6% 96.5% Did the patient get his/her prescriptions filled per the discharge instructions? 97% 97.3% Does the patient have a follow-up appointment scheduled? 85.2% 86.5% Did the patient feel he/she were able to follow the given instructions when he/she was at home? 98% 98.2% Did the patient feel that he/she knew how and when to take each medication? 95.7% 95.9% When the patient left the hospital was he/she given information about when to seek medical attention? 95.4% 99% Did the patient feel there were additional forms of support that would have been helpful when he/she was discharged from the hospital? 10.7% 5.3% When the patient left the hospital, did he/she know and understand the purpose for all the medications prescribed to him/her? 92.3% 89% Table 4: Yearly results of the post-discharge survey for all 19 participating hospitals Table 4 shows the proportion of respondents during the post-discharge follow-up call receiving different types of services and support during the hospital visit. Both the proportion of patients who reported that they received all the answers to their questions prior to discharge as well as the proportion of patients who were given information about when to seek medical attention increased from 2012 to The proportion of patients who felt that additional support was needed decreased by almost half in the same time period. Figure 4: Patient disposition location Figure 4 shows the yearly summary of patient disposition from hospitals in the study. Not all sampled hospitals had the patient disposition identified. The majority of patients were discharged to home care or a skilled nursing facility. 8 P a g e

9 Figure 5: Compliance with step 1 and 4 (education on the patient s diagnosis, including national guidelines) over 24 months Figure 5 shows the rate of increased compliance over the 24-month period for the 19 hospitals in the collaborative for action step 1 and 4 (education on the patient s diagnosis, including national guidelines). Figure 6: Compliance with step 9 (assess the patient s level of understanding, i.e., teach-back ) over 24 months Figure 6 shows the increase in compliance over the 24 months for the 19 hospitals in the collaborative for action step 9 (assess the degree of understanding by asking the patient to explain in his or her own words the details of the care plan). 9 P a g e

10 Figure 7: Compliance with step 11 (provide patient with a follow-up call) over 24 months Figure 7 shows the increase in compliance over the 24 months for the 19 hospitals in the collaborative for action step 11 (calls the patient to reinforce discharge plan, review medications and solve problems). Figure 8: Overall proportion of patients provided with one of the six post-discharge services offered as part of Project RED 10 P a g e

11 Figure 8 shows the overall proportion of patients provided with one of the six post-discharge services offered as part of Project RED across all 24 months of the intervention. The services were: 1. Diet/nutritional resources 2. Outpatient services (e.g., physical therapy, home health) 3. Medical equipment (e.g., oxygen) 4. Behavioral health services 5. Transportation resources 6. Linkage to primary care resources Discussion The RED intervention was successful at decreasing all-cause and same-cause readmission rates at participating hospitals in Colorado. With the evaluation of the 24 months of data, the participating hospitals reported a 30 percent relative reduction in the all-cause readmission rates, dropping from 13.3 percent to 9.3 percent, and a 43 percent relative reduction in same-cause readmission rates, dropping from 6.5 percent to 3.7 percent. CHA estimated that this project saved approximately $2.6 million dollars by averting 311 all-cause readmissions over seven quarters of intervention across 19 hospitals, an average of 44 prevented readmissions per quarter. There was no statistical correlation found between any particular action step and a reduction in readmissions. However, the collaborative saw notable improvement with step 1 and 4 (education on the patient s diagnosis, including national guidelines), step 9 (assess the patient s level of understanding, i.e., teach-back ) and step 11 (call the patient to reinforce discharge plan two to three days after discharge). The collaborative showed a consistently high compliance with step 5 (confirm the medication plan) and step 10 (give the patient a written discharge plan at the time of discharge). The 19 Colorado hospitals implemented the intervention with a total of 7,679 patients. There were notable limitations with the setup of the collaborative. Each hospital was able to select a target population that was specific to its patient population. Hospitals self-reported their all-cause and same-cause readmission rates, process measures and post-discharge survey data. The methodology of reporting the data was unique to each hospital. CHA found that, although clear definitions were provided in the data collection tool, there were still variations in the ways hospitals reported data. Common barriers to adoption of the RED intervention include staff turnover, lack of qualified staff and a lack of staff dedicated to discharge planning and RED implementation. Competing priorities from other quality improvement initiatives was indicated as an additional barrier, which caused constraints for multiple hospitals participating in the collaborative. Yet, despite these challenges, the 19 participating hospitals were able to implement and adopt the 11 action steps of the RED intervention and reduce their all-cause and same-cause readmission rates for their selected target populations. The results of the two-year effort benefitted hospital patients and their communities and demonstrated the significant impact of a coordinated statewide effort. Likewise, the costsavings resulting from the project are substantial. These cost-savings contribute to improving the affordability of health care by reducing unnecessary spending in the health care system. 11 P a g e

12 References 1. The Dartmouth Atlas of Healthcare (2014). Percent of Patients Readmitted Within 30 Days of Discharge, By Cohort. Cohort: All Medical Discharge, [web log post]. Retrieved October 6, 2014 from 2. Jencks, S., Williams, M., Coleman, E., Rehospitalizations among Patients in the Medicare Feefor-Service Program. The New England Journal of Medicine 2009; 360: Brock, J, et al., Association between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries. Journal of American Medical Association 2013; 309(4): Colorado Rural Health Center (2014). Improving Communications and Readmissions (icare) [web log post]. Retrieved October 6, 2014, from 5. Coleman, Eric A. MD, MPH. (2014). The Care Transitions Program Health Care Services for Improving Quality and Safety During Care Hand-offs. [web log post]. Retrieved October 6, 2014, from 6. Jack, B, et al., A Reengineered Hospital Discharge Program to Decrease Rehospitalization. Annals of Internal Medicine 2009; 150(3): P a g e

13 About CHA CHA represents 100 member hospitals and health systems throughout Colorado. The Association partners with its members to work towards health reform and performance improvement, and provides advocacy and representation at the state and federal level. Colorado hospitals and health systems are committed to providing coverage and access to safe, high-quality and affordable health care. In addition, Colorado hospitals have a tremendous impact on the state s economic stability and growth, contributing to nearly every community across the state with more than 71,000 employees statewide. For more information, visit About The Quality & Patient Safety Department CHA s Quality and Patient Safety Department is committed to improving health care quality and patient safety in hospitals across the state. CHA works to create a culture of safety among member hospitals by offering educational opportunities, technical support and guidance on a variety of evidence-based initiatives that both expand the quality of care and advance leadership's commitment to patient safety concerns. About The CHA is cognizant that data must be combined and analyzed quickly to derive meaningful and actionable information that will help hospitals continue to provide much-needed care and economic stability in their communities. To this end, CHA recently created a new center for health information and data analytics. A robust analytics function is crucial to informing CHA s advocacy on behalf of its members. The goal of the analytical function is to be proactive about changes and to use data to predict the effect of changes on hospital providers. 13 P a g e