CMS National Conference on Care Transitions

1. CMS National Conference on Care Transitions December 3, 2010

2. How Project RED and the Care Transitions Project Reduced Readmissions in South Texas Robin Jones, RN Quality Care Coordinator Valley Baptist Medical Center-Brownsville Jennifer Markley, RN, BSN Senior Director, Medicare Quality Improvement TMF Health Quality Institute

3. CMS Care Transitions Project • Project began in August of 2008 • Data analysis was based on 2007 Medicare claims data • 14 communities in the U.S • Reduce hospital readmissions through improved quality of patient transitions

4. CMS Care Transitions Project • Goal is minimum 2% reduction 30-day rehospitalization rate by 28th month of the project (November 2010) • A comprehensive community-wide, cross-setting effort • Yield sustainable and replicable strategies

5. CMS Care Transitions Project This map shows the 14 states where Care Transitions projects are located.

6. Baseline Measurements TABLE 1: Hospital Disposition After Inpatient Hospitalization Quarter 1, 2008 based on Medicare Claims Data

7. Valley Baptist Medical Center-Brownsville • A faith based 280 bed licensed, not-for-profit acute care hospital, including a 37 bed off-campus Psych facility • Level 3 designated trauma center • JC accredited for hospital & lab and stroke-certified • Located on the southernmost tip of Texas, on the border with Mexico

8. Baseline Measurements –VBMC-B • CT Project hospital baseline rate of 23.3% all cause 30-day readmission rate (Q1 2008) • 28.1% Hospital Compare heart failure readmission rate • Data for discharges between July 01, 2006 and June 30, 2009 • (http://www.hospitalcompare.hhs.gov)

9. Solutions • Implementation of Project RED • Initial focus on HF patients, Telemetry Unit • May 2010, expanded to all diagnoses, Telemetry Unit • Community-wide partnership with downstream providers • Use of EHR to improve hand-off communication • Active involvement in Regional Workgroup meetings

10. Solutions • Education of medical staff including physicians • Medication reconciliation • Health literacy and patient safety • Chronic kidney disease

11. Implementation • All components of Project RED were implemented and monitored in facility’s 30 bed Telemetry floor • Team approach to administering all eleven components • Nursing, Care Management, Pharmacy and Core Measures Team all contributed to process

12. Teamwork • Nursing & Care Management • Educate the patient about his or her diagnosis throughout the hospital stay  • Discuss with the patient any tests or studies that have been completed in the hospital and discuss who will be responsible for following up on the results • Review the appropriate steps for what to do if a problem arises

13. Teamwork • Nursing • Provide follow-up telephone reinforcement • Assess degree of understanding (teach-back) • Provide patient with a written discharge plan • Make appointments for clinician follow-up and post-discharge testing

14. Teamwork • Care Management • Organize the post-discharge services • Expedite transmission of the Discharge Resume to the physicians and other services accepting responsibility for the patient’s care after discharge

15. Teamwork • Nursing, Pharmacy & Care Management • Confirm the Medication Plan • Nursing/Core Measures • Reconcile discharge plan with national guidelines

16. Monitoring for Effectiveness • Patients were asked a total of nine brief yes or no questions about their perceptions. Surveys were available in English and Spanish. • I was taught about my diagnosis during my hospital stay. • I have follow-up appointments with my physicians. • I have been told about test results or studies that have not been completed before I go home. • If I need home health care, medical equipment or other help or services after I go home, it has been arranged. • I understand what to do and who to call if a problem arises after I am home.

17. Monitoring for Effectiveness • Survey Questions continued: • I have received a written discharge plan that is easy to read and understand. • I have received a written discharge plan that has the information I need to take care of myself at home. • I have a written list of my discharge medications and know which medications are new or changed. • When the nurses were teaching me, they asked me to explain what I had learned in my own words.

18. Administering Patient Surveys • Case Management (CM) runner sends out daily Length of Stay (LOS) report to identify patients going home with no services to Case Managers, Tele Supervisor/Charge Nurse, and Quality Assurance • Floor staff is responsible for completing all components of RED prior to discharge

19. Administering Patient Surveys • CM runner delivers and retrieves patient survey and forwards completed surveys to Quality • CM updates the LOS report daily to reflect D/C plan and submit to CM runner and Quality

20. Patient Survey Results Data Averages based on 273 completed surveys between January and September 2010 • 93% of patients surveyed said that they had received education about their diagnoses • 94% of patients surveyed said that they had a follow-up appointment. 88% had a follow-up appointment scheduled within one week post-discharge • 99% of patients surveyed said that their written discharge plan had the information needed for self care and that it was easy to read and understand

21. CT Project Results TABLE 2: Hospital Disposition After Inpatient Hospitalization Quarter 1, 2010 based on Medicare Claims Data

22. CT Project Results for Harlingen HRR FIGURE 1: Percent of Discharges with a 30-day Readmission for HHRR • Hospital Disposition After Inpatient Hospitalization • Baseline compared to Quarter 1, 2010 based on Medicare Claims Data

23. CT Project Results for VBMC-B FIGURE 2: Percent of Discharges with a 30-day Readmission for VBMC-B • Hospital Disposition After Inpatient Hospitalization • Baseline compared to Quarter 1, 2010 based on Medicare Claims Data

24. CT Project Outcome Measures for VBMC-B FIGURE 3: Percent of Hospital Readmission Within 30 Days • Semi-annual rate ending in Quarter 1 2010 • A 3.6% decrease in all cause 30-day readmissions

25. CT Project Outcome Measures for VBMC-B FIGURE 4: O-1a: HCAHPS Medication Management • 4-quarter rolling rate ending in the listed quarter

26. CT Project Outcome Measures for VBMC-B FIGURE 5: O-1b: HCAHPS Discharge Planning • 4-quarter rolling rate ending in the listed quarter

27. CT Project Outcome Measures for VBMC-B FIGURE 6: O-2: Percent of Patients Seen by a Physician Between DC and Readmission

28. For more information about Project RED, contact • For more information about Project RED research: https://www.bu.edu/fammed/projectred/index.html • For additional information about dissemination: http://www.engineeredcare.com • For commercial inquiries: info@engineeredcare.com

29. For more information, contact: Jennifer Markley, RN, BSN, Senior Director, Medicare Quality Improvement TMF Health Quality Institute Phone: 512-334-1663 E-mail: jmarkley@txqio.sdps.org Care Transitions Web Site: http://CareTransitions.tmf.org This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, 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.  9SOW-TX-CT-10-67