Henry Ford Health System Care Coordination and Readmissions Update

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1 Henry Ford Health System Care Coordination and Readmissions Update September 2013 BACKGROUND Most hospital readmissions are viewed as avoidable, costly, and in some cases as a potential marker of poor quality care. In 2008 Henry Ford Health System (HFHS) began to develop the infrastructure required to measure and monitor readmission rates and to analyze root causes of readmissions. Early steps for improvement included creating a system-wide Readmissions Registry, providing 24-hour phone assistance to discharged patients, standardizing hospital discharge instructions, identifying patients at high risk for readmission, and developing strategies to reduce readmissions in high-risk patients. Patients at high risk of hospital readmission share common social and medical factors. Social factors range from poverty, limited community resources, and inadequate or no health insurance to transportation challenges and language barriers. Medical factors include multiple comorbidities and use of 6-12 or more prescription medicines. Clearly many causes of hospital readmissions stem from a combination of medical-social factors as well as the need for health care providers and community partners to close gaps in transitions of care and coordination of care. Financial Penalties for Excessive Readmissions As part of the national Hospital Readmissions Reduction Program, established by the Affordable Care Act of 2010, the Centers for Medicare and Medicaid Services (CMS) began to reduce payments to hospitals with excessive readmissions, effective October Fiscal Year - % of Medicare Payments at Risk FY % FY % FY % HFHS Estimated Impact at Current Performance $2.2 million $4.3 million $6.4 million For HFHS, CMS penalty fees for the federal fiscal year (FY) 2013 total $2.2 million (penalty percentage range 0-1%: Henry Ford Hospital assessed 1%, Henry Ford Wyandotte Hospital 0.79%, Henry Ford Macomb Hospital 0.71%, and Henry Ford West Bloomfield Hospital 0.17%). CMS penalty fees for FY 2014 apply to excessive readmissions for acute myocardial infarction, heart failure, and pneumonia. For FY 2015, CMS added three more conditions to the readmissions penalty list: COPD and arthroplasties of the total hip and total knee. Although much work remains to be done, HFHS achieved a reduced penalty fee for FY2014 for three of four hospitals (Henry Ford Hospital.80%, Henry Ford Wyandotte Hospital.57%, Henry Ford Macomb Hospital.33%, and Henry Ford West Bloomfield Hospital.23%). 1

2 HFHS CARE COORDINATION INITIATIVE To address medical, social, and financial aspects of the complex issues surrounding hospital readmissions, HFHS leadership established the Care Coordination Initiative in This initiative aims to standardize coordination and transitions of care throughout Henry Ford Health System to provide seamless care to each patient at every stage and point of care. The components of care coordination involve every area of a patient s process of care. For patients with multiple comorbidities and complex diseases, care coordination may involve dozens of components requiring ongoing, accurate communication between caregivers and the patient and family. Care Coordination Objectives and Measures The objectives of the HFHS Care Coordination Initiative are to: Provide each patient seamless, quality clinical care at every point of care Partner with community agencies and others to improve patient and family access to health resources Eliminate unnecessary readmissions to HFHS hospitals Improve care transitions from the time of hospital discharge through the post-acute care setting Ensure that patients have a good understanding of their discharge instructions, new medications, and symptoms that need follow up by their physician Measures for the Care Coordination Initiative are hospital readmission rates overall and by specific disease category. All measures are based on 30-day readmission rates: All-cause unplanned readmissions Acute myocardial infarction (AMI) Congestive heart failure (CHF) Pneumonia 2

3 Chronic obstructive pulmonary disease (COPD) for FY2015 Total hip and total knee arthroplasty for FY2015 System Results HFHS All-Cause 30-Day Readmission Rates YTD* 2013 Target Henry Ford 15.6% 15.1% 12.9% 14.2% Hospital Macomb 11.1% 10% 10.5% 9.2% Hospital Wyandotte 13.1% 11.8% 11.2% 10.0% Hospital West Bloomfield 10.4% 9.4% 8.6% 9.0% Hospital HFHS 13.1% 12.6% 11.4% 11.2% *June Note: The national 30-day all-cause hospital readmission rate averaged 19% from HFHS Readmission Rates January 2011 to June 2013: 13.1%-11.2%, a 6% better rate difference compared to the average national rate of 18.4% in

4 Acute Myocardial Infarction Readmission Rates Congestive Heart Failure Readmission Rates Pneumonia Readmission Rates COPD Readmission Rates Specialized Teams for High-Risk Populations The HFHS Care Coordination Initiative involves multiple projects and teams focused on specific disease states and crucial points of patient care transitions. Some projects are system-wide whereas others start at one hospital with the goal to spread identified best practices across HFHS. Transition Nurse Coordinators: The Transition Nurse Coordinator Program was implemented to help patient populations at high risk of readmission. Nurses follow patients closely during hospitalization and follow up with phone calls after hospital discharge to provide additional transition of care resources and ensure patients follow up with their primary care physician. Transition Nurse Coordinators are currently available for heart failure and pneumonia/copd patients. Heart Failure Readmission Team: This team includes cardiologists, nursing, case management, and pharmacy. Interventions to reduce heart failure readmissions include a Transition Nurse Coordinator for follow-up phone calls after patient discharge, heart failure class for inpatients and discharged patients, primary care physician appointment scheduled within 7 days of discharge, standardized education materials, and Home Care referrals with TeleHealth monitoring. 4

5 Pneumonia/COPD Readmission Team: Guidelines for medical management of COPD patients are in process of being standardized across the continuum of care from inpatient care, at discharge, and follow-up outpatient appointment. This effort aims to decrease medication-related readmissions for the approximately 1,660 COPD patients discharged from HFHS hospitals each year. Interventions to reduce pneumonia and COPD readmissions include a Transition Nurse Coordinator and review of pneumonia admissions by Clinical Documentation Nurses to assure documentation is accurate and complete. Physician education has helped to increase referrals to Pharmacy s Antimicrobial Stewardship Team to assure appropriate usage of antibiotics. For COPD patients, criteria for observation stay have been developed. The discharge bundle for COPD patients emphasizes referrals to TeleHealth monitoring and access to inhalers at discharge. An inpatient pharmacist meets with COPD patients to ensure proper inhalers are ordered at discharge and that the patient understands how to use the medication. COPD patients who are homebound may be provided with a referral to the Visiting Physician Network. Emergency Department Case Managers/Social Workers: To assist patients in the emergency department (ED) who do not meet criteria for hospital admission but cannot manage their care at home independently, Henry Ford case managers/social workers provide placement assistance directly from the ED. Referrals and placements to skilled nursing facilities or home care services are completed during the ED visit. Patients are transitioned directly either to a skilled nursing facility or home care services for the necessary care that they require. Henry Ford Home Care TeleHealth Monitoring: Henry Ford Home Care provides TeleHealth monitoring for COPD and heart failure patients at high risk of readmission. TeleHealth allows daily remote assessment of heart rhythm, blood pressure, and weight with review by a Home Health nurse. Based on patient assessment, referrals to the Home Care staff or physicians are made for patients needing follow-up. This program has been successful with significant reduction in readmission rates for this high-risk patient population. High-Risk Patient Follow-up: Henry Ford Home Care provides front loading of patient visits for those identified at high risk for readmission. The first visit is completed within hours of the referral with additional visits as needed the first week. The Home Care nurse ensures that a follow-up appointment with the primary care physician has been made and that the patient has the resources to attend. The Home Care nurse also completes medication reconciliation to identify discrepancies in medications and to confirm that the patient understands how to administer the medications correctly. Medication Therapy Management: Patients with HAP insurance and/or whose physician belongs to the Henry Ford Physician Network may be referred to HAP s Medication Therapy Management program. In this program an ambulatory pharmacist contacts the patient to review medication adherence, identify challenges in the patient being able to correctly manage the medications, and work with the physician to address these issues either through a lower cost option, decreasing the number of prescriptions, or changing the medication. Henry Ford Home Care also offers medication dispensers for patients who have difficulty remembering when and 5

6 how to take their medications. The dispensers have been particularly effective with patients who have mild dementia or take many medications. Other Target Populations Skilled Nursing Facilities HFHS/Skilled Nursing Facility Care Coordination: This project aims to develop best practices in the processes of coordinating and transitioning care of patients between hospitals and skilled nursing facilities (SNFs). In 2012 HFHS hospitals had approximately 7,000 patient discharges to SNFs. Multidisciplinary team meetings are held at each hospital bimonthly with representatives from the most referred to SNFs. Readmission cases are reviewed to identify trends and implement strategies to improve quality and outcome measures. Each hospital s multidisciplinary team includes the case management director, Internal Medicine and Family Medicine physicians, Home Care manager, and SNF representatives. Handovers: Processes are being developed and implemented to ensure appropriate handovers occur when a patient transitions from the inpatient setting to a SNF. Verbal handovers have been implemented at several facilities. Epic Care Link: with the implementation of Epic, SNF staff will be able to access patient medical records through Epic Care Link. This allows read-only access for the specific patients admitted to the SNF to ensure patient information is appropriately relayed to the next level of care. Authorization for each facility is being coordinated through the Henry Ford Referring Physician Office. Collaborative Charter: A team charter identifying common goals for HFHS and individual SNFs is being developed by the System s chief medical officers, other physicians, case management director, Quality director, and SNF representatives. Outpatient Scheduling of PICC Line and PEG Tube Replacement: To avoid unnecessary emergency room visits for an SNF patient requiring a PICC line or PEG tube replacement, a process has been developed to schedule outpatient appointments with Interventional Radiology (IR). The SNF contacts IR directly for an appointment time and SNF arranges transportation for the patient. This process is being reviewed to expand to patients receiving Home Care services. Outpatient Scheduling of Head CT Post-fall: SNF patients who fall are required to be taken to the emergency room. This project aims to develop an outpatient appointment process for SNF patients who have fallen and require non-emergent head CT scans based on a physician or midlevel provider assessment at the SNF. 1 st Fill Program: To decrease readmissions based on an SNF patient s medication administration issues, this pilot program with the Boulevard Temple Skilled Nursing Facility provides the first 5 days of medications via Henry Ford s discharge pharmacy program to patients upon discharge from HFHS to the SNF. Based on pilot results, this program may be expanded to other SNFs. 6

7 End-Stage Renal Disease ESRD Readmission Team: ESRD patient readmissions were studied for root cause analysis, finding that Behavioral Health issues, transportation problems, and lack of access for the uninsured were common. Patients with ESRD also were identified to have a high degree of cognitive impairment leading to difficulties in understanding the management of this complex disease. For ESRD patients who visit the emergency room for another reason, they often may need urgent dialysis. To avoid readmission in these cases, a process has been implemented whereby dialysis can be provided as an outpatient procedure in a hospital area and the patient transferred back to the emergency room afterward. Health Care Access Transportation Access with Detroit Area Agency on Aging (DAAA): HFHS is partnering with DAAA to support funding for non-emergency medical transportation for patients needing access to physician appointments, pharmacy services, and transportation home after hospital discharge. Collaborative Admission Reduction Efforts (CARE): Led by Emergency Medicine, CARE aims to address patient populations with more than 10 admissions in one year. An adopt a patient concept encourages ED residents to select 2-3 patients with >10 admissions/year and perform an in-depth retrospective review of data to identify trends and root causes. CARE also emphasizes education regarding the importance of earlier referrals to Palliative Care. Community Resources for Emergency Department Overuse (CREDO): Because a majority of readmission cases arrive first in the emergency room, identifying patients who overuse the ER and improving their health care is a goal of CREDO. Patients with 30, 70, or more than 90 ER visits annually are considered extreme users. A multidisciplinary team meets biweekly to review such patients and develop individualized care plans. Behavioral Health Initiative with MPRO: Aimed at addressing patients with chronic medical conditions in addition to behavioral health or substance abuse issues, this one-year initiative from August 2013 to July 2014 involves hospitals in Michigan s tri-county area, mental health facilities, community resources, home care agencies, and physician practices. Next Steps Arthroplasties of Total Hip and Total Knee: CMS has expanded readmission penalties to include excessive readmissions for arthroplasties of total hip and total knee. HFHS hospitals readmission rates for these conditions are being explored to identify areas for improvement. Epic Tool for High-Risk Assessment: As Epic becomes implemented across HFHS, its modified LACE risk tool for readmission can be utilized. This tool auto-populates the fields and flags whether a patient is high, moderate, or low risk for readmission. For patients identified at high risk, additional interventions can be provided such as home care referral, Telehealth monitoring, and scheduling a 7-day follow-up appointment prior to discharge. 7

8 Improving Inpatient Care Coordination: Several initiatives to improve coordination of care include bedside rounding and joint physical assessments between nursing, physicians, and the patient so that the patient stays informed about the care plan and discharge needs can be addressed early. Timely Primary Care Follow-up: Efforts are underway to provide primary care appointments within 7 days of discharge for all patients at high risk of readmission. Improve End-of-Life Care: HFHS is one of 11 organizations pioneering the Conversation Project to improve end-of-life care by encouraging families to talk about end-of-life care goals before someone is a patient in a hospital. The goal is to encourage the completion of advanced directives, educate on palliative care and hospice options to increase referrals for appropriate patients, and ensure patient wishes are followed for end-of-life care. Address Equity Issues: HFHS is starting a new task force with the Organization of Physicians, Academicians, and Executive Leaders (OPAL) to review readmissions related to equity. Improve Discharge Planning Process: In partnership with the Henry Ford Innovation Institute, the potential of technology is being investigated with the aim to improve the discharge process and patient understanding of care plans upon discharge. Economics of Changing Health Care Trends As efforts focus on improving care coordination and reducing unnecessary readmissions, many hospitals are experiencing significant reductions in admissions and thus less revenue in addition to CMS penalty fees for above-average readmission rates. Nationally the rising cost of health care for insurers and employers has resulted in shifting an increasing percentage to patients in the form of higher fees for insurance, higher copays for visits, higher deductibles for procedures and inpatient care, as well as higher copays for medications. Concurrently a large percentage of Americans remain underinsured or uninsured as a result of the Great Recession of For 2013, HFHS hospitals have recorded a 6% decline in admissions compared with a 2.5% inpatient decline overall in Southeast Michigan. In this same period a 19% reduction occurred in Medicare readmissions. Thus while care coordination for patients improves, hospitals face declining revenue and declining patient volumes. The associated cost of success in reducing hospital readmissions will serve to drive health systems growth strategies regionally while national work continues to address needed change in the payment system for health care services. 8