CHF Longitudinal Workgroup Addressing readmissions from SNFs and other PAC settings 3/2/17
Readmission Rate from SNF by Hospital (CHF) 16 13.6% 14 12 Readmission Rate (%) 10 8 6 Mean = 6.3% 4 2 0% 0 0 10 20 30 40 50 60 70 80 Hospital
Top 10 Primary Readmission Diagnoses % Of Readmissions Primary Diagnosis 9.4% Unspecified septicemia 8.3% Acute on chronic diastolic heart failure* 7.0% Acute on chronic systolic heart failure* 4.8% Acute kidney failure 3.9% Acute on chronic combined diastolic/systolic heart failure* 3.6% Pneumonia, organism unspecified 3.3% Acute and chronic respiratory failure 3.1% Hypertensive heart and chronic kidney disease with heart failure* 2.8% Acute respiratory failure 2.4% Subendocardial infarction, Initial episode of care
Readmission Rate from SNF 45% 40% 35% 30% Readmission Rate 25% readm_rate 20% 15% 10% 5% 0% Skilled Nursing Facility (N=98)
Strategies to Reduce Readmissions from SNFs and other PAC settings Review for CHF Longitudinal Workgroup March 2 nd , 2017
General strategies • Multicomponent interventions more likely to have sustainable success 1,2,3 • Most successful multicomponent interventions include: 1. Attention to medication reconciliation and discontinuation of high- risk geriatric medications when not indicated 4 2. Elimination of safety hazards: minimize use of urinary catheters and other indwelling devices at time of discharge 4 3. Advanced care planning: include information about short and long term prognosis, expectations about PAC setting, discussion of goals of care 3
Examples of Successful Interventions • Interventions to Reduce Acute Care Transfers (INTERACT) – most rigorously studied of multicomponent PAC interventions 3 • Project ReEngineered Discharge (RED) • Both include 3 important components mentioned on previous slide, plus: – Tools to enhance inter- and intra-facility communication – Training to manage common medical conditions that may precipitate rehospitalization – Enhanced follow-up procedures
INTERACT Model • One study implemented model in 30 community-based nursing homes in Florida, Massachusetts and New York. Administrative support and an on-site champion required for participation. 2 • Facilities required to implement the following tools: – Stop and Watch Tool – The Situation, Background, Assessment, Recommendation Communication Form – The Resident Transfer Form and Transfer Checklist – Quality Improvement Review Tools for residents transferred to acute hospital
INTERACT Model • Following six months of biweekly training by an experienced nurse practitioner: – 17% reduction in self-reported hospital admissions compared to the same 6 month period from the year prior 2 – 24% reduction among the most engaged facilities 2 • All tools freely available at: http://interact2.net/
Project ReEngineered Discharge (RED) • Comprehensive transitions of care approach – Creation and review of personalized care plan with patients and families • Medication lists • Follow-up appointments • PCP contact information • Advanced directives – Project RED software integrated into electronic medical record of SNF – One study conducted in a 50-bed subacute unit in Boston observed a 8.7% reduction in the rate of hospitalization during the intervention 5 – More information here: https://www.bu.edu/fammed/projectred/index.html
In Conclusion • Effective interventions share certain features – Having multiple components that span the inpatient and outpatient setting – Delivery by dedicated transitional care personnel • Use limited resources to focus efforts on patients at higher risk of readmission 6, 7, 8 : – Advanced age – Polypharmacy – Decreased functional status
Sources 1. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann. Intern. Med. 2011; 155:520 – 528. Google Scholar 2. Ouslander JG, Lamb G, Tappen R, Herndon L, Diaz S, et al. Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II collaborative quality improvement project. J. Am. Geriatr. Soc. 2011; 59:745 – 753. Google Scholar 3. Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission: Current strategies and future directions. Ann Rev Med. 2014; 65: 471-485. Google Scholar 4. Borenstein J, Aronow H, Bolton L, Choi J, Bresee C, Braunstein GD. Early recognition of risk factors for adverse outcomes during hospitalization among Medicare patients: a prospective cohort study. BMC Geriatr. 2013:13. Google Scholar 5. Berkowitz RE, Fang Z, Helfand BKI, Jones RN, Schreiber R, Paasche-Orlow MK. Project ReEngineered Discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility. J. Am. Med. Dir. Assoc. 2013 Google Scholar 6. Evans RL, Hendricks RD. Evaluating hospital discharge planning: a randomized clinical trial. Med. Care. 1993; 31:358 – 370. Google Scholar 7. Koehler BE, Richter KM, Youngblood L, Cohen BA, Prengler ID, et al. Reduction of 30-day post discharge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J. Hosp. Med. 2009; 4:211 – 218. Google Scholar 8. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999; 281:613 – 620. Google Scholar
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