Home and Back: Rehospitalization and Elders Sally May, RN, BSN, CH-GCN June 12, 2014 14 th Annual Geriatric Health Conf

1. Home and Back: Rehospitalization and Elders Sally May, RN, BSN, CH-GCN June 12, 2014 14th Annual Geriatric Health Conference Grand Forks, ND

2. “I would like you to meet . . .” Paul 70 y.o., did not refill Rx led to 5-day hospital stay Charles 80 y.o., inability to purchase meds led to 2nd hospital stay for HF Clara 86 y.o., sent home without Rx led to 2nd hospital stay

3. Framework for Today It is a discussion! Be prepared to share your experience Agree to disagree All teach – all learn Leave in action

4. Objectives: Questions to “run on” What challenges you regarding the impact of rehospitalizations on the elderly? What would it take to reduce rehospitalizations in this community? What action could you take to improve the activation levels of the individuals you serve? How can we support each other in reducing rehospitalizations in this community?

5. Objective Question Describe the impact of rehospitalization on the elderly and their families. What challenges you regarding the impact of rehospitalizations on the elderly?

6. The Literature: Hospitalization “The hospitalization, not the illness, may be the deciding factor in the functional ability of the frail, elderly at discharge” Boyer N, Chuang JL, Gipner D. An acute care geriatric unit. NursManage 1986;17(5):22-25 Functional decline Complications unrelated to the problem that caused admission or its specific treatment The cascade of dependency Creditor MC. Hazards of Hospitalization of the Elderly. Ann Intern Med. 1993;118:219-23. Decline in cognitive function Wilson RS, Hebert LE, Scherr PA, Dong X, Leurgens SE, Evans DA. Cognitive decline after hospitalization in a community population of older persons. Neurology. 2012;78:950–6.

7. The Literature: Geographic Variation • Geographic variation in Medicare spending and treatment decisions Fisher ES,Wennberg DE, StukelTA,Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138(4): 273–87. • Differences do not consistently correlate with differences in quality or health outcomes Fisher ES,Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138(4): 288–98. • Patients’ preferences had greater effect on end-of-life care than on traditional Medicare FFS spending Baker LC, Bundorf MK, Kessler DP. Patients’ preferences explain a small but significant share of regional variation in Medicare spending. Health Affairs. 2014;33(6): 957–96.

8. The Literature: Acute Care Utilization • 50% of people diagnosed with HF will die within 5 yrs Roger VL, Weston SA, Redfield MM, Hellermann-Homan JP, Killian J, Yawn BP, Jacobsen SJ. Trends in heart failure incidence and survival in a community-based population. JAMA. 2004;292:344–50. • 52% of health care providers hesitant to have end-of-life care discussions with HF patients • Reasons: Provider discomfort, perceived patient/family unreadiness, fear of destroying hope, or lack of time Dunlay SM, Foxen JL, Cole T, Feely MA, Loth AR, Strand JJ, Swetz KM, Wagner JA, Redfield MM. Abstract 352: Clinician attitudes and self-reported practices regarding end of life care in heart failure. Circulation: Cardiovascular Quality and Outcomes. 2014;7:A352 • 51% of deceased Medicare beneficiaries visited ED in last month of life • More than ½ of these patients admitted to and died in hospital • 75% visited ED in the last six months of life Smith AK, McCarthy E, Weber E, StijacicCenzer I, Boscardin J, Fisher J, Covinsky J. Half Of Older Americans Seen In Emergency Department In Last Month Of Life; Most Admitted To Hospital, And Many Die There. Health Affairs. 2012;31(6): 1277-85. • .

12. The significance for Medicare beneficiaries?

13. The Literature: Rehospitalization 1 in 5 Medicare beneficiaries readmitted within 30 days 1 in 3 beneficiaries readmitted within 90 days 2 of 3 patients with medical conditions were either rehospitalized or died one year after discharge 90% of rehospitalizations were unplanned Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-28. In 2008, 10% of hospital stays potentially preventable 60% of potentially preventable hospital stays were for patients age 65 and older Stranges, E., Stocks, C. Potentially Preventable Hospitalizations for Acute and Chronic Conditions, 2008. HCUP Statistical Brief #99. November 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb99.pdf

17. Question What challenges you regarding the impact of rehospitalizations on the elderly?

18. Objective Question Identify the challenges to reducing hospitalizations for community-dwelling elders. What would it take to reduce rehospitalizations in this community?

19. The Literature: Rehospitalization ArbajeAI, Wolff JL, Yu Q, Powe NR, Anderson GF, Boult C. Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling Medicare beneficiaries. Gerontologist. 2008 Aug;48(4):495-504.

20. The Literature: Readmission Risk • Readmission risk prediction • Poorly understood • Complex endeavor • Most current readmission risk prediction models perform poorly Kansagara D, Englander H, Salanitro A, Kagen D, Theobald C, Freeman M, Kripalani S. Risk prediction models for hospital readmission: A systematic review. Jama;306(15):1688-98. • If 2 of 3 patients with medical conditions either rehospitalized or die one year after discharge • May be wiser to consider all Medicare patients high risk of rehospitalization Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-28.

21. The Literature: Rehospitalization ArbajeAI, Wolff JL, Yu Q, Powe NR, Anderson GF, Boult C. Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling Medicare beneficiaries. Gerontologist. 2008 Aug;48(4):495-504.

22. Increased Readmission Risk

23. Community (n=58) Skilled Nursing Facility (n=23) Home Health (n=7) Hospice (n=1) Legend Readmitted

24. Diagnosis-Specific Readmissions(January 1, 2012 to December 31, 2012)

25. 50% of readmissions 1-10 days after discharge

26. 0-3 Days • 19.2% • 4-10 Days • 37.1% • 11- 30 Days • 43.8% Community (n=58)

27. Question What would it take to reduce rehospitalizations in this community?

28. Objective Question Explain how patient/family activation potentially reduces acute care utilization. What action could you take to improve the activation levels of the individuals you serve?

29. “I would like you to meet . . .” Paul 70 y.o., did not refill Rx led to 5-day hospital stay Charles 80 y.o., inability to purchase meds led to 2nd hospital stay for HF Clara 86 y.o., sent home without Rx led to 2nd hospital stay

30. The Patient Experience Abrupt transitions between settings Brief hospital days Sudden self-management with minimal preparation Poor communication between care providers

31. The Care Model: Patient Activation

32. Patient Activation • To take an active role in health care • Requires the knowledge, theskill,andconfidence in ability to manage their health care Hibbard JH, Mahoney ER, Stockard J and Tusler M. "Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Patient Activation." Health Services Research, 39(4): 1005–1026, 2004. • The Goal: Patient self-management • To live well with chronic conditions • It is not more patient education Adams KG, Greiner AC, Corrigan JM, eds. Report of a summit. The 1st annual crossing the quality chase summit: a focus on communities; Jan 6-7, 2004. Washington, DC: National Academies Press; 2004. • Teaching problem-solving skills BodenheimerT, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469-75

33. Patient Activation: What it is • Learning to become an effective self-manager is a lot like learning to swim. . . . both activities, one needs to work at building confidence, skills, and knowledge. It is a processthat unfolds over time. Judy Hibbard, DrPh, University of Oregon http://www.insigniahealth.com/company/leadership-team/judy-hibbard-drph

34. The Patient Activation Continuum “The doctor knows my medicines” “Doctor, I have a question . . .” “I take a blood pressure pill . . .”

35. More Activated Patients Receive Better Care AARP & You, “Beyond 50.09” Patient Survey. Study population age 50+ with at least one chronic condition. http://www.aarp.org/health/medicare-insurance/info-03-2009/beyond_50_hcr.html

36. Patient Activation: The Importance • As activation levels increase, individuals become: • More adherent to medications • More likely to eat healthier and engage in physical activity • More present in the workforce and more satisfied in the jobs • Less likely to use the ER • More engaged with their clinicians • Patients who are more knowledgeable, skilled, and proactive when they arrive for a clinical interaction are more likely to leave with their needs met Greene J, Hibbard JH, Sacks R, Overton V. When seeing the same physician, highly activated patients have better care experiences than less activated patients. Health Affairs, 32, no.7 (2013):1299-1305.

37. Health Literacy • “The degree to which individuals have the capacity to obtain, process, and understandbasic health information and services needed to make appropriate health decisions.” Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of education. Washington, DC: National Center for Education Statistics. • Only 12% of literate Americans are proficient in understanding health information Minnesota Partnership for Health Literacy

38. Teach Back: What it is • An evidence-based communication technique used to help patients remember and understand important information • Involves: • Asking the patient to explain in their own words or demonstrate the information discussed • Gives the patient ownership regarding his or her healthcare

39. Question What action could you take to improve the activation levels of the individuals you serve?

40. Objective Question Describe how current community resources could be employed to reduce rehospitalization of community-dwelling elders. How can we support each other in reducing rehospitalizations in this community?

41. The Literature: Community Opportunity • No single intervention alone regularly associated with reduced risk for 3-day rehospitalization 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. • A safe transition from a hospital to the community and nursing home • Centers on the patient • Transcends organizational boundaries Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-28. • Coordinated efforts to identify and meet the social needs of patients lead to • Lower health care use • Lower health care costs • Better outcomes for patients Shier G, Ginsburg M, Howell J, Volland P, Golden R. Strong social support services, such as transportation and help for caregivers, can lead to lower health care use and costs. Health Affairs. 2013;32(3): 544–51

42. The Literature: Community Opportunity • Rehospitalization rates are often used to reflect hospital performance . . . useful indicator of the performance of our health care system Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-28. • For patients with chronic illness, the episode of care has no definite end • Improving care for elderly patients will require attention to the overall systems of care in a community • Markers of local health care systems’ ability to coordinate care for patients Goodman DC, Fisher ES, Chang CH and the Dartmouth Atlas of Health Care. After hospitalization: A Dartmouth Atlas Report on post-­‐acute care for Medicare Beneficiaries. Hanover, NH: Dartmouth College. 2011.

46. North Dakota Pilot Community Paramedic Project

47. Community Paramedic Model • Enhanced utilization of an existing healthcare resource under the current scope of practice • Coordinated and integrated care with: • Clinics • Hospitals • Public Health Departments • Home Health Agencies • Long Term Care Facilities

48. ND Advance Care Planning Initiative Partnership of 60 individuals from 30+ organizations and government agencies Vision: To create a culture across ND where continuous (on-going) advance care planning is the standard of care Goal:The development and implementation of a comprehensive advance care planning program by December 2016 Objectives: • Organize for sustainability • Identify an advance care planning model for ND • Develop a standardized end of life care document • Develop education plan for healthcare consumers and professionals Save the Date: Partnership Meeting, August 27, 2014, Bismarck

49. Question How can we support each other in reducing rehospitalizations in this community?