Collaborative Approach to Improving Care and Reducing Readmissions Edna Clifton, MBA, BSN, RN Associate Director, Care Coordination Health Services Advisory Group (HSAG) March 14, 2017
Presentation Objectives Identify the Centers for Medicare & Medicaid Services (CMS) strategy goals. Define the focus of Quality Innovation Network’s (QIN’s) work. Recognize where Florida’s readmission rates rank with the nation’s rates. Examine the goals of community coalitions. Identify projects that have successfully reduced readmission rates. 2
CMS Quality Strategy Goals Better Care, Healthier People, Healthier Communities, Smarter Spending Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- 3 Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-Strategy-Goal-Card.pdf
Health and Human Services’ (HHS) Efforts to Improve Healthcare Tying payment to value through alternative payment models of all Medicare fee-for-service (FFS) 85 % payments tied to quality or value by 2016 through alternative payment models 30 % by the end of 2016 of all FFS payments tied 90 % to quality or value by 2018 through alternative payment models 50 % by the end of 2018 Source: Burwell, Sylvia M. Setting Value-Based Payment Goals- HHS Efforts to Improve US Healthcare, 4 4 New England Journal of Medicine, January 26, 2015.
Policy Development Comprehensive Care for Joint Replacement, Coronary Bypass Grafts, Acute Myocardial Infarction, and Cardiac Rehabilitation Proposed Rule for Discharge Planning Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) and Value-Based Purchasing (VBP) for Skilled Nursing Facilities (SNFs) 5
Medicare’s Call for Action to Communities Build and sustain community coalitions focused on improving coordination of care between settings. Strengthen communication with community coalition partners in an open, non-competitive forum. Reduce hospital readmission rates for Medicare FFS patients by 20% by 2019. Improve medication safety to prevent adverse drug events that contribute to significant patient harm. 6
QIN-QIO Areas of Focus Cardiac Health Healthcare Acquired Disparities in Conditions in Diabetes Nursing Homes Support of Value-Based Clinicians in the Purchasing Quality Payment Program Patient is at the Programs center of care Antibiotic Coordination of Stewardship in Care Communities 7
What are the Readmission Rates?
Readmission Definition “We define a readmission as a subsequent inpatient admission to any acute-care facility which occurs within 30 days of the discharge date of an eligible index admission.” Source: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- 9 Instruments/MMS/downloads/MMSHospital-WideAll-ConditionReadmissionRate.pdf
Florida State 30-Day Readmissions Ranking January 1–December 31, 2015 We are here Source: This material prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services 10 (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. (11SOW-QINNC-00794-05/13/16)
Why All the Talk About Readmissions? • Poor care coordination and use of evidence-based approaches Quality • Large number of readmissions are preventable • Institute of Medicine (IOM) reports made Safety clear the consequences of poor transitions management • Centers for Medicare & Medicaid Services Cost (CMS) indicate $13B* in savings or $25B across all U.S. payers *MedPac 2007 Report to Congress; Promoting Greater Efficiency in Medicare; Chapter 5: Payment Policy for Inpatient 11 Readmissions Source: Riddle, S. M.. What Works for Preventing Hospital Readmissions? [PowerPoint]. http://www.wapatientsafety.org/downloads/Riddle_Readmissions_Programs_WPSC_2012-Final.pdf
How Can We Reduce Readmissions?
The Care Coordination Solution Define the Discharge Sustain or Problem Process Modify the Mapping Plan Hospice Home Health Measure Cause & Intervention Effect Skilled Nursing Results Diagram (Fishbone) Hospitals Physicians Data Driven Action Plan Root-Cause for Patients Analysis Improvement Evidenced- Cost-Benefit Based Analysis Solutions 13
Care Coordination Coalitions 14
The Building Blocks of a Community Coalition 15
Community Essentials Developed around collaborative care delivery Shared vision Sharedmission Shared resources Shared decision making Environment of trust 16
Care Coordination Establish coalitions to bring providers together to coordinate efforts to support the CMS call to action measures Assist coalitions to identify the root cause of their readmissions Analyze processes to identify gaps which cause the failure to achieve a smooth transition from one level of care to the other Develop interventions to correct the issues Measure effectiveness of the intervention Modify processes Re-measure 17
Best Practices
Best Practices: Program to Enhance Communication to Avoid Readmissions Osceola Community Patients were being sent from the skilled nursing facility (SNF) to the emergency department (ED) for an issue and it Issue: was not clearly communicated to the ED why the patient was sent there. With incomplete information, the ED treated the patient Dilemma: based on diagnosis and emergency medical services (EMS) information. The SNF community collaborated with local ED physicians to Solution: identify critical information needed to appropriately treat the patient for that episode. 19
SNF to ED Transfer Communication Sheet 20
Best Practices: Programs to Divert Readmissions to Appropriate Providers Jacksonville Community Dialysis patients were presenting in the ED with fluid Issue: overload because of missed treatments. Dilemma: Hospitals cannot dialyze patients on an outpatient basis. The hospital reached out to a nearby dialysis center Solution: to negotiate chair times for these patients and averting a readmission. 21
Best Practices: Programs to Divert Readmissions to Appropriate Providers (cont.) Brevard Community Patients discharged to home often become overwhelmed with Issue: changes in treatments and medications and tend to return to the ED for assistance. The patients are often readmitted because of adverse drug Dilemma: events and/or changes in their condition due to failure to follow treatment plans. Patients who had been transported by emergency medical services (EMS) to the hospital for their initial admission had follow-up visits from EMS within 8–24 hours of their discharge. Solution: Treatment and medications were reviewed and the patients’ living conditions were assessed for community services. Providing this support reduced hospital readmission. 22
Top 10 Evidence-Based Interventions 1. Enhanced admission assessment – Begin discharge planning on admission 2. Formal assessment of risk of readmission – Align interventions to patient’s needs 3. Accurate medication reconciliation at: – Admission – Any change of level of care – Discharge 4. Patient education – Assess health literacy 23 Source: www.hret-hen.org/topics/readmissions/13-14/2014-READSChecklist.pdf
Top 10 Evidence-Based Interventions (cont.) 5. Identify primary caregiver 6. Use teach-back to validate understanding 7. Send discharge summary within 24–48 hours 8. Collaborate with post-acute care and community 9. Schedule follow-up appointments before discharge 10.Conduct post-discharge follow-up calls within 48 hours of discharge 24 Source: www.hret-hen.org/topics/readmissions/13-14/2014-READSChecklist.pdf
Coming together is a beginning. Keeping together is progress. Working together is success. –Henry Ford
Thank you! Edna Clifton EClifton@hsag.com Office: 813.865.3579 Cell: 813.753.5379 26
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. FL-11SOW-C.3-02282017-01 27
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