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Heart Failure Readmission Reduction Project & Summit. Susan Schow, MPH Epidemiologist Maine Health Data Organization March 30, 2010 . Heart Failure Readmission Reduction Project and Summit. MQF- funded project using Chapter 270 data to explore link between:

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heart failure readmission reduction project summit

Heart Failure Readmission Reduction Project & Summit

Susan Schow, MPH

Epidemiologist

Maine Health Data Organization

March 30, 2010

heart failure readmission reduction project and summit
Heart Failure Readmission Reduction Project and Summit
  • MQF- funded project using Chapter 270 data to explore link between:
  • Hospital performance on HF-1 measure,
  • Hospital performance on Care Transitions Measures, and
  • Medicare’s Hospital 30-day Readmission Rates for Heart Failure
heart failure readmission reduction project and summit1
Heart Failure Readmission Reduction Project and Summit
  • Evaluation of data and visits to selected hospitals to:
    • provide opportunity to better understand the relationship between measures, patient experiences, and long-term outcomes
  • Share data, results of visits, and lessons learned with healthcare community (including hospitals, long term care, and home health)
  • “A rising tide lifts all boats”
mhdo s hospital quality data chapter 270 mandated reporting
MHDO’s Hospital Quality Data:“Chapter 270” Mandated Reporting
  • Collect quality data measures from hospitals:
    • CMS core measures (AMI, HF, PN, SCIP) (July 2005)
    • Nursing Sensitive Indicators (Jan. 2006)
    • Healthcare Associated Infection data (Jan. 2007)
    • Care Transition Measures (Jan. 2008)
    • Nurse Perceptions of Culture of Safety (Jan. 2009)
heart failure 1 measure
Heart Failure 1 - Measure
  • The HF-1 measure focuses on self-care teaching and six areas that need to be addressed prior to discharge:
    • Medications
    • Diet
    • Activity
    • Follow-up
    • Weight monitoring
    • Management of worsening symptoms
care transition measures ctm
Care Transition Measures (CTM)
  • CTM (3-question patient survey) measures appropriate transitional care as evaluated from patient perspective
  • CTM is strongly associated with post discharge use of both hospital and emergency services
  • Currently 18 months of CTM data available
data evaluation
Data Evaluation
  • Evaluation of HF-1 Discharge Instruction measure showed an area for potential improvement
  • Evaluation of CTM data showed variation in patient perception of preparation for transition
  • Identified hospitals with mean scores significantly different than their peer group for both measures
heart failure readmission reduction project and summit2
Heart Failure Readmission Reduction Project and Summit
  • Recognized opportunity to improve the level of “transitional care” given to patients prior to discharge
  • Dovetails with CMS publishing 30-day Readmission Rates for Heart Failure
hospital visits by mqf s qi nurse
Hospital Visits by MQF’s QI Nurse
  • Selected nine hospitals for visit (9 of 36 acute care hospitals = 25%)
  • Ensured equal representation by peer grouping and by district
  • Dual goals:
    • Identifying best practices by asking top performers to share process improvement strategies at summit
    • Identifying opportunities for improvement through on–site process review meetings with heart failure teams
readmissions
Readmissions
  • 20% of Medicare Beneficiaries readmit within 30 days of discharge
  • 33% readmit within 90 days; 56% within year
  • Readmissions have a 0.6 day longer LOS than other patients in the same DRG
  • Medical causes dominate readmissions
  • Estimated cost to Medicare: $15 to $18.3 billion in annual spending

Sources:1 Jencks, S., Williams, M., & Coleman, E. (2008). “Rehospitalizations among Patients in the Medicare Fee-for-Service Program,” NEJM, Volume 360:1418-1428, April 2, 2009, Number 14.2 Medpac (June 2007). "Report to the Congress: Promoting Greater Efficiency in Medicare,“ pp 103-120.

key area for improvement
Key Area for Improvement
  • 50% of all patients re-hospitalized within 30 days of medical discharge had no bill by a physician between discharge and rehospitalization
  • 52% of CHF patients had no bill by a physician between discharge and rehospitalization
  • Potential implications:
    • Seeing a physician post discharges may have a protective effect on readmitting to the hospital.
    • Critical window within the 30-day period
cms plans
CMS Plans
  • Process:
    • Provide risk-adjusted readmission rates confidentially to hospitals
    • Followed by publicly report readmissions rates
    • Followed by payment reform (reduce payments)
  • Medicaid is likely to consider similar approaches
  • Other payers will follow
  • State public reporting is moving forward in many states:
    • Public reporting will be helpful to hospitals in addressing performance improvement

Source: Medpac (June 2007). "Report to the Congress: Promoting Greater Efficiency in Medicare.“ p. 105.

transitional care
Transitional Care
  • Set of actions to ensure coordination and continuity of care as patients transfer between locations or levels of care
  • Patients vulnerable:
    • Functional loss, pain, anxiety or delirium
    • Unprepared for what will transpire and their roles in process (caregivers also unprepared)
literature
Literature
  • “Comprehensive Discharge Planning With Post Discharge Support for Older Patients with CHF”
  • Evaluated effects on CHF readmission rates (meta analysis: 18 studies, 8 countries)
    • Found 25% relative reduction in risk of readmission
    • A trend towards 13% relative reduction in all cause mortality
    • Improvement in Quality of Life scores (in a smaller subset of studies)
    • Without increase to cost of medical care
  • Specific to CHF patients, >=55 years old, moderate to severe symptoms and LV systolic dysfunction

1 Phillips C,.et al, JAMA, 2004

responsible for care beyond your care setting
Responsible for Care Beyond Your Care Setting
  • Ensure safe and effective transfers to the receiving care setting mandated per standards by:
    • Joint Commission for Accreditation of Healthcare Organizations
    • DHHS Conditions for Participation
  • Gaps in performance measurement identified by Institute of Medicine
    • to assess quality across multiple care settings
  • Patient and Caregiver are often the only common thread weaving across settings
    • Uniquely positioned to report on quality of care transition
development of care transition measures survey
Development of Care Transition Measures Survey
  • Focus groups = four domains identified
    • Info Transfer
      • Confusion over appropriate Rx regimen
    • Patient and Caregiver Preparation
      • No understanding of what takes place in next care setting and their role
      • Care plans developed requiring caregivers participation without conferring with caregivers
    • Support for Self-Management
      • Inability to access practitioners with knowledge of recent care impedes patients’ ability to manage own care
development of care transition measures survey1
Development of Care Transition Measures Survey
  • Focus groups = four domains (continued)

4. Empowerment to Assert Preferences

      • Patients attempt to assume more active role in care or to assert preferences repeatedly discouraged by practitioners or institutions
  • CTM Development
      • Rigorous psychometric testing
        • Validated for poorer outcome patients (underserved, sicker and older populations)
      • Aligns with the tenets of patient-centered care
      • Items “actionable” to help guide quality improvement
      • Scores responsive to changes in care process
care transition measures
Care Transition Measures
  • NQF endorsed 3-question survey of patients conducted 48 hrs to 6 weeks post discharge
    • Q1 - “The hospital staff took my preference and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital”
    • Q2 - “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health”
    • Q3 - “When I left the hospital, I clearly understood the purpose for taking each of my medications”
ctm uses likert 4 point scale
CTM: Uses Likert 4-Point Scale
  • Responses to questions:
    • “Strongly Disagree” = “1”
    • “Disagree” = “2”
    • “Agree” = “3”
    • “Strongly Agree” = “4”
    • “Don\'t Know” / “Don\'t Remember” / “Not Applicable” = “99”
    • Left answer blank = “9”
ctm score associated with post discharge use of hospital and ed
CTM Score Associated with Post Discharge Use of Hospital and ED
  • Shown to discriminate between patients who did and did not have subsequent ED visit/ rehospitalization for index condition
  • Q2 - “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health”
    • Significantly associated with subsequent emergency visits
      • Of those who agreed, 15.5% had ED visit
      • Of those who disagreed, 38.5% had ED visit

1 Coleman, E., et al, Medical Care, March 2005

ctm score associated with post discharge use of hospital and ed1
CTM Score Associated with Post Discharge Use of Hospital and ED
  • Studied specifically for diabetes and CHF patients following discharge because:
    • High likelihood of requiring follow-up care
    • High likelihood of requiring medication adjustment as result of hospitalization
    • Need for ongoing self-management
  • Correlation between CTM scores and subsequent use of ED
    • Predictive of return to ED within 30 days
    • p = 0.004 (hint: p-value scores <0.05 are significant )

1 Coleman, et al, Home Health Care Services Quarterly, Vol. 26, No. 4, 2007

hcahps similar but different
HCAHPS® - Similar But Different
  • Hospital Consumer Assessment of Health Plan Survey (HCAHPS®) primarily addresses patient satisfaction
  • CMS developed with the Agency for Healthcare Research and Quality (AHRQ)
  • Since 2007, Inpatient Prospective Payment System (IPPS) hospitals must submit HCAHPS to receive full annual payment (reduced by 2% for non-reporting). Critical Access Hospitals may voluntarily report
hcahps similar but different1
HCAHPS® - Similar But Different
  • The two HCAHPS discharge questions are typically summed up under the category of :
    • “Were patients given information about what to do during their recovery at home?”
  • Discharge related questions:
      • Q19: During your hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital?
      • Yes, No
    • Studies say having opportunity to speak with doctors/nurses not rated as important as opportunity to actively prepare for care in next setting and role in self-care.
hcahps similar but different2
HCAHPS - Similar But Different
  • Discharge related question:
    • Q20:During your hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
    • Yes, No
  • Studies identify patient’s frustrations centered more on identifying whom to contact for symptoms rather than knowing the symptoms
  • Understanding medication instructions is not assessed by HCAHPS
  • Not known whether HCHAPS items predict recidivism (CTM does)

1 Parry, C, et al, Medical Care, March 2008

ctm 3 sufficient number of surveys
CTM-3: Sufficient Number of Surveys
  • CTM sampling patterned after the HCAHPS survey:
    • CMS requires at least 300 completed HCAHPS surveys over four quarters:
      • “necessary to ensure adequate statistical power to compare hospitals to one another and to national benchmarks”
    • For those not collecting 300 completed surveys, CMS notes that:
      • Results are based on between 100 and 299 completed surveys or
      • Results are based on less than 100 completed surveys

1From: Mode and Patient-mix Adjustment of the CAHPS® Hospital Survey (HCAHPS) April 2008

the 5 stages of data where is your facility
The 5 “Stages of Data”Where Is Your Facility?
  • Denial
      • “Those aren’t MY numbers”
  • Anger / Resentment
      • “Who got those numbers?”
  • Bargaining
      • “How about if we re-run it again??…”
  • Depression (?!!)
      • “Why are we even doing this?…”
  • Acceptance
      • “How can we get better?”

“Stages of Grief” – E. Kubler-Ross – adapted by M. Albaum MD

parametric and nonparametric data analysis
Parametric and Nonparametric Data Analysis
  • HF-1 data is interval (continuous) data
    • Intervals between any two adjacent values on a measurement scale are same
    • Use parametric statistics (mean, std. deviation, etc.)
  • CTM data is ordinal (categorical) data
    • Values represent a rank ordering of observations rather than precise measurements (e.g., CTM data scores of 1=strongly disagree, 2=disagree, 3=agree, 4=strongly agree)
    • You can count and order ordinal data, but you cannot perform mathematics on it
    • Use non-parametric statistics
ctm data non parametric statistical analysis
CTM Data Non-parametric Statistical Analysis
  • Used binomial distribution comparing proportion of patients answering with score = 4 to the proportion answering anything else (scores = 1, 2, 3)
  • So compared proportion answering “strongly agreed” to those answering anything else (i.e., “agree,” “disagreed,” “strongly disagreed”)
  • Maine is an overachiever (as usual) 
ctm data non parametric statistical analysis1
CTM Data Non-parametric Statistical Analysis
  • Using binomial distribution (for non-parametric data)
    • Calculated proportion (“strongly agreed”) and upper and lower confidence intervals for:
      • Each hospital;
      • Each peer group of hospitals, and
      • Maine statewide
    • For each CTM question (1, 2, 3) and for Total CTM score
hospital data evaluated by hospital peer groupings
Hospital Data: Evaluated by Hospital Peer Groupings
  • Peer Group A
    • 250–606 beds (MMC, EMMC, CMMC, MGMC)
  • Peer Group B
    • 79–233 beds (Aroostook, Mercy, Mid Coast, Pen Bay, SMMC, St Joseph, St Mary, York)
  • Peer Group C
    • 53-70 beds (Cary, Franklin, Goodall, ME Coast)
  • Peer Group D
    • 38-55 beds (Inland, Miles, NMMC, Parkview, Stephens)
hospital peer groupings continued
Hospital Peer Groupings - Continued
  • Peer Group E = Critical Access Hospitals
    • 25 beds or less (Blue Hill, Bridgton, CA Dean, Calais, Down East, Houlton, Mayo, Millinocket, MDI, Pen Valley, Red-Fairview, Rumford, Sebasticook, St Andrews, Waldo )
  • Peer Group F = Psychiatric Hospitals
    • Acadia, Dorothea Dix, Riverview, Spring Harbor
  • Peer Group H = Rehabilitation Hospitals
    • New England Rehabilitation
ctm correlation with readmissions
CTM Correlation With Readmissions
  • Performed correlation analysis using Pearson correlation coefficient - a measure of the extent to which two variables “vary together.” The value of any correlation coefficient must be between -1 and +1.
  • Used CTM Total score probability from each hospital
  • Compared to CMS 30-day Risk-adjusted Readmission Rate for Heart Failure from Hospital Compare website
ctm correlation with readmissions1
CTM Correlation With Readmissions
  • Best correlation coefficient R = 0.00347 (for CTM Question 1)
  • CTM Correlation (R)
    • Q1 = 0.00347
    • Q2 = 0.00196
    • Q3 = -0.01469
    • Total CTM = -0.00230
why no correlation seen
Why No Correlation Seen
  • Dates for data sets not comparable:
    • CTM = January 2008 to July 2009
    • Readmission Rates = July 2005 to June 2008
  • Literature indicates CTM predictive of risk/performance at the level of the patient, but not at level of the hospital?
    • If able to identify specific patient CTM survey results and track patient readmission status
    • “Gold standard”
chf burden nursing facilities residential care facilities and home care
CHF Burden: Nursing Facilities, Residential Care Facilities, and Home Care
  • Medicaid Policy Cooperative Agreement Project – “Congestive Heart Failure Prevalence in Maine Long Term Care”
  • Prepared by Catherine McGuire, Cutler Institute and Muskie School of Public Service
nursing home admissions
Nursing Home Admissions
  • For State Fiscal Year 2009, there were 16,073 admissions to nursing homes. The majority of admissions (88%) are from hospitals
  • CHF was indicated on 23% admissions
  • CHF prevalence was consistent for admissions from:
    • hospitals,
    • other nursing homes,
    • and other sources
  • Admissions from home and assisted living/ residential care were less likely to have a CHF diagnosis
nursing home discharges
Nursing Home Discharges
  • In SYF 2009, there were 17,947 discharges; 24% had a CHF diagnosis
  • The majority of discharges from nursing facilities are to home (52%)
  • Residents discharged to hospital or deceased were more likely to have a CHF diagnosis:
    • Thirty percent of residents who died had a CHF diagnosis
    • Only 20% discharged home and 15% discharged to some other destination had CHF
residential care admissions
Residential Care Admissions
  • During SFY 2009, there were 1,891 admissions to residential care facilities
  • CHF was indicated on 15% admissions
  • The majority of admissions (38%) are from home
  • CHF prevalence:
    • Higher for admissions from the hospital and nursing homes (just over 20%)
    • Lower for admissions from home
residential care discharges
Residential Care Discharges
  • The majority of discharges (45%) from residential care facilities are to nursing facilities
  • In SYF 2009, there were 2,078 discharges, 17% had a CHF diagnosis
  • Residents who died were more likely to have a CHF diagnosis (26%):
    • 17% discharged to the hospital had a CHF diagnosis
    • Only 9% discharged home and 12% discharged to some other destination had a CHF diagnosis
adults in the community home health
Adults in the Community / Home Health
  • SFY 2009, 13% of the 5,738 home health consumers assessed had CHF
  • Wide variation was observed by program
    • a high of 23% for Private Duty Nursing Level II
    • a low of 0% in the physically disabled waiver program (serves a younger population of consumers with disabilities)
slide56

“Proportion of Residents in All Facilities in the County on the 1st Thursday in April Who Have Congestive Heart Failure, Shaping Long-Term Care in America Project, National Institute on Aging, LTCFocUS.org,

cms heart failure 1 discharge instructions
CMS Heart Failure – 1Discharge Instructions

Heart failure patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following:

  • activity level
  • diet
  • discharge medications
  • follow-up appointment
  • weight monitoring, and
  • what to do if symptoms worsen
cms heart failure 1 discharge instructions1
CMS Heart Failure – 1Discharge Instructions

Rationale:

  • Non-compliance with diet/medications important reason for changes in clinical status
  • National guidelines strongly support the role of patient education
  • But despite this recommendation, comprehensive discharge instructions rarely provided to eligible older patients hospitalized with heart failure (per CMS National Heart Failure Project baseline data)
hf 1 correlation with readmission
HF-1 Correlation with Readmission?
  • Also performed correlation analysis using Pearson correlation coefficient
    • Used HF-1 Rates from each hospital
    • Compared to CMS 30-day Risk-adjusted Readmission Rate for Heart Failure from Hospital Compare website
      • R = 0.04 - No Correlation (hint: small correlation = 0.1 to 0.3)
  • Again dates not comparable:
    • HF-1 = June 2008 to July 2009
    • Readmission Rates = July 2005 to June 2008
  • If able to identify specific HF-1 patients and track for readmission status
    • “Gold standard”
literature1
Literature
  • “Public Reporting of Discharge Planning and Rates of Readmissions” also found no association between HF-1 and readmission rates
  • Only modest association between readmission rates and HCAHPS (discharge-related questions Q19 & Q20)
  • No association between performance on 2 discharge measures
    • HF-1 specific to CHF patients / HCAHPS measures all patients
    • Therefore, even if improve HF-1 rates, may not see effect in HCAHPS (or CTM)
  • Concludes readmission rates will not be reduced by improvement/public reporting on discharge planning measures
  • Suggests changes must occur in the ambulatory care setting

1 Ashish K. et al, NEJM, 2009

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