Reducing Unnecessary Hospitalizations: Focus on Transitions

1. Reducing Unnecessary Hospitalizations: Focus on Transitions Amy Boutwell MD MPP IHI-CMWF Reducing Re-hospitalizations Initiative Institute for Healthcare Improvement

2. “The $15 Billion Dollar U-Turn” • 17.6% of Medicare admissions are readmissions within 30 days • Accounting for $15 B in spending • Not all re-hospitalizations are potentially preventable, not all avoidable, but many are (accounting for $12B in Medicare spending) • HF, Pna, COPD, AMI lead the medical conditions • CABG, PTCA, other vascular lead surgical conditions • Disparities exist along racial and “burden of illness” lines • Individual delivery systems and health services researchers have demonstrated dramatic (40-85%) reduction of 30-day readmission rates for certain patient populations (esp. CHF)

3. Why Readmissions? Why Now? • MedPac June 2007 report highlights avoidable hospitalizations as an area of high-cost, low-quality; recommends hospital-specific re-hospitalization data be collected and publically reported • Exploration of aligning payment to stimulate improvement in performance on avoidable re-hospitalization rates • Some health care systems want to “get out ahead” on this issue • Some states are looking for immediate “wins” and cost savings • CMS announcement of Care Transitions focus in the 9th SOW • Approx. 12 -18 QIOs will be selected to identify *communities* in which to coordinate care and improve transitions with the *specific aim* to reduce re-hospitalizations (August 1, 2008)

4. Why Readmissions? Why Now? • MedPAC June 2008 report outlines steps toward delivery system reform that focuses on overcoming limitations of current FFS payments • Vision of moving toward payment for care across provider types and time • MedPAC June 2008 recommendations: • Confidentially report to hospitals and physicians readmission and resource utilization rates to allow risk-adjusted performance comparison with peers for 2 years and then make data publically available • Reduce payment to hospitals with high readmission rates for a set of conditions; allow hospitals and physicians to share in savings gained from improved processes (gainsharing, or shared accountability) • Conduct a voluntary pilot to test bundled payments for hospitalizations for a set of conditions

5. What can be done, and how? • There exist a wealth of approaches to reduce unnecessary readmissions that have been locally successful Which are high leverage? Which can go to scale? • Success requires engaging clinicians, providers across organizational and service delivery types, patients, payers, and policy makers How to align incentives? How to catalyze coordinated effort?

6. Opportunities: Avoidable Hospitalizations • Potentially preventable hospitalizations • Ambulatory care sensitive conditions • Hospitalizations occurring as a result of these conditions may have been prevented by either timely access to quality outpatient care or adoption of healthy behaviors • Re-hospitalizations • Process of discharge aims to establish care in a new setting • Unplanned re-hospitalization usually signals failure of that process • Methods exist to define “potentially preventable” re-hospitalizations

7. Prevalence and Drivers of Re-hospitalizations • Preliminary 2007 Medicare data analysis finds: • 20% beneficiaries are re-hospitalized at 30 days • 35% are re-hospitalized at 90 days • 67% are re-hospitalized or deceased at 1 year • Among medical patients re-hospitalized at 30 days: • 50% no bill for MD service between discharge and re-hospitalization • Among surgical patients re-hospitalized at 30 days: • 70% were re-hospitalized with a medical DRG Source: Jencks, Williams, Coleman preliminary data pending peer-review

8. Evidence: Reducing Re-hospitalizations • Growing evidence of the effectiveness of following: • High quality in-patient care • Manage medical co-morbidities (in medical and surgical inpatients) • Early assessment of discharge needs • Enhanced patient and caregiver self-management engagement • Early post-acute follow up with MD or RN (home visit, phone call) • Hospital-based post-acute follow-up (phone calls, nurse visit) • Appropriate referral for home care services • Appropriate patient centered end of life/palliative care discussions • Remote monitoring • Improved transfer processes between acute hospitals and post-acute facilities

9. Improving Care for Patients with Chronic Illness: Evidence: Re-hospitalizations • 81% of patients requiring assistance with basic functional needs failed to have a home care referral • 64% said no one at the hospital talked to them about managing their care at home Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices. Marblehead, MA: HCPro, Inc.; 2006.

10. Evidence: Reducing Re-hospitalizations • Excellent research and experience of innovators highlight the effectiveness of enhanced care delivery during transitions: • Transition coaching (Coleman) • Advanced NP coordination roles (Naylor) • Guided care model (Bolt) • Nurses that “wrap around” primary care for high –risk populations (CMS demonstrations) • Enhanced primary care coordination with home health (NYVNA) • IHI Transforming Care at the Bedside (Ideal Transition Home for HF)

11. High-Leverage Opportunities for Action • Improved Transitions for All Patients • Transitions “out” of the hospital • Reception “in” to home (activated home health, office practice) • Reception “in” to skilled nursing (activated post-acute rehab, NH) • Proactively address the needs of “high risk” patients • Create inventory of evidence-based “wrap around” or enhanced services • State-specific assessment of plausibility of financing • Engage population in being active, informed consumers • Web-based tool, AARP campaign (medications), Partnership for Healthcare Excellence campaign (consumer activation) • Consider focus on patients and families/caregivers in disease-specific advocacy organizations to promote self-management, proactive role in care, esp at transitions

12. Conditions to Support Systemic Improvement • Create incentives to work across traditional settings of care • Create incentives to coordinate between providers • Create incentives to communicate with patients/caregivers (HCAHPS) • Encourage efficiencies in coordination and communication (electronic records, email and phone interactions, group mgt) • Decrease barriers to change (“carrot,” gainsharing) • Implement catalyst to change (“stick,” transparency, payment reduction) • Finance low-cost community / outpatient services to avoid expensive hospitalizations

13. Opportunities to Improve Care at Transitions