Reducing Avoidable Hospital Readmissions and Improving Care Transitions Collaborative

1. Reducing Avoidable Hospital Readmissions and Improving Care Transitions Collaborative

2. Scope of the Problem • Unplanned readmissions cost Medicare $17.4 billion in 2004 (N Engl J Med, 2009) • 20% of Medicare beneficiaries are readmitted within 30 days of hospital discharge without having seen a physician for follow-up care (N Engl J Med, 2009) • Future Penalties - Hospitals with higher-than-expected readmissions will have a 1 percent (growing to 3 percent) reduction in Medicare payment for all discharges.

3. Health Research and Educational Trust (HRET)

4. PROJECT RED (Re-engineered Discharge)

5. Project RED • Patient-centered, standardized approach to discharge planning and discharge education • Designed to re-engineer the hospital workflow process and improve patient safety by using 11 discrete, mutually reinforcing action steps shown to improve the discharge process and decrease the likelihood of hospital readmissions • Developed and piloted at Boston Medical University (Brian Jack, M.D.)

6. 11 Action Steps • Educate the patient about his or her diagnosis throughout the hospital stay • Make appointments for clinician follow-up and post-discharge testing • Discuss with the patient any tests or studies that have been completed in the hospital and discuss who will be responsible for following up the results • Organize post-discharge services • Confirm/reconcile the medication plan • Reconcile the discharge plan with national guidelines and critical pathways. • Review the appropriate steps for what to do if a problem arises • Expedite transmission of the discharge summary to the physicians (and other services such as the visiting nurses) accepting responsibility for the patient’s care after discharge • Assess the degree of understanding by asking them to explain in their own words the details of the plan (teach-back) • Give the patient a written discharge plan at the time of discharge • Provide telephone reinforcement of the discharge plan and problem-solving 2-3 days after discharge.

7. Process Mapping

8. Results Patients that have a clear understanding of their after-hospital care instructions are 30% less likely to be readmitted OR utilize the Emergency Department than patients that lack this information.

9. Colorado’s Project

10. Phased Approach • Phase I • More Inpatient Focus (Project RED) • Building Infrastructure • Spread from pilot population to hospital-wide • Phase II • More Transitions of Care Focus • Partnering with other Healthcare Providers • Physicians • Nursing Homes • Palliative Care

11. After Hospital Care Plan (AHCP)

12. Options for Implementing AHCP • Manual • Software Package (Boston Medical University) • Internal IT Development

13. Metrics • Baseline Readmission Data • Baseline Readmission Rate for Target Population • ALOS for Target Population • Process Metrics • Adherence • Outcome Metrics • Patient Satisfaction • Patient Comprehension / Compliance • Avoidable Readmission and ED Utilization

14. Participating Hospitals To Date • Centura Health System • Avista Adventist Hospital • Littleton Adventist Hospital • Porter Adventist Hospital • St. Anthony North Hospital • St. Mary Corwin Medical Center • Exempla Health System • Exempla Good Samaritan Hospital • HealthONE System • The Medical Center of Aurora • Critical Access Hospitals • Conejos Community Hospital • Rio Grande Hospital • Melissa Memorial Hospital • Sedgwick County Health Center • Yuma District Hospital • Other Non-Affiliated Hospitals • Boulder Community Hospital • Colorado Acute Long Term Hospital • Community Hospital • Denver Health • Longmont United Hospital • Platte Valley Medical Center • San Luis Valley Regional Medical Center

15. Project Partners • United Healthcare • Agency for Healthcare Research and Quality (AHRQ) / Health Research & Educational Trust (HRET) • State Associations (TX, GA, IN, OR) • Health Plans • Health Team Works • CIVHC

16. Strategic Alignment

17. Triple Aim +1

18. CIVHC • Serve as statewide convener and integrator • Facilitate advisory groups to identify best practices, break down silos and scale up solutions • Develop metrics and dashboard to measure progress toward Colorado goals • Provide data that allows the market to measure value • Integrate efforts with federal reform • Promote integrated and multi-pronged statewide efforts

19. Elimination of Avoidable Harm CHA Board of Trustees unanimously approved a new initiative which aims to achieve an elimination of avoidable incidents of harm in Colorado hospitals by 2015. • CHA will immediately focus its efforts and zero target goal in the following areas: • Reduction in Mortality • Reduction in Infections • Reduction in Readmissions

20. Questions? Crystal Berumen, MSPH VP, Patient Safety and Health System Integration Colorado Hospital Association 720.330.6067 (direct) Crystal.berumen@cha.com