Centers for Medicare Medicaid Services Care Transitions Theme to Reduce Medicare Patient Re-Admissions

1. Centers for Medicare & Medicaid Services Care Transitions Theme to Reduce Medicare Patient Re-Admissions Traci Archibald, OTR/L, MBA Care Transitions Theme Specialist

2. Why Target Re-Admissions? A study on Medicare Fee for Service beneficiaries revealed: Almost 1 out of every 5 discharges (19.6%) are re-admitted within 30 days 34% of discharges were re-admitted within 90 days. Estimated cost to CMS for unplanned Re-admisions - $17.4 Billion (2004) 2

3. What is an Unplanned Re-hospitalization? A hospitalization within 30 days of discharge that was not foreseen at discharge. Most frequent reasons: AMI, heart failure, pneumonia, sepsis, dehydration, post-operative infection, gastrointestinal bleeding. Unplanned re-hospitalizations are almost always urgent or emergencies. They often signal failure of the transition from hospital to another source of care.

4. Brief Overview of the Intentions of the Care Transitions Theme To measurably improve the quality of care for Medicare beneficiaries who transition among care settings through a comprehensive community effort; and To reduce readmissions following hospitalization and to yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries. 4 The Care Transitions Theme is a pilot that was competitively awarded to 14 QIOs. Project runs from August 1, 2008- July 31, 2011. The Care Transitions Theme is a pilot that was competitively awarded to 14 QIOs. Project runs from August 1, 2008- July 31, 2011.

5. Care Transitions Theme Activities Define a community Zip code overlap Recruit and convene providers- Community Building Target inefficient service patterns Claims data/patterns Provider Input Root cause analyses related to specific situations 5 Chart reviews can help dramatically with performing a root cause analyses. Can be done a all 30 day readmissionsChart reviews can help dramatically with performing a root cause analyses. Can be done a all 30 day readmissions

6. Care Transitions Theme Activities (continued) Implement evidence-based interventions Reduce unplanned 30d hospital readmissions for the community 6 To achieve the aims, Care Transitions QIOs will: Conduct a �root cause analysis� to identify the major contributing factors associated with the local rates of re-hospitalization. Develop and/or implement intervention strategies to address driving factors To achieve the aims, Care Transitions QIOs will: Conduct a �root cause analysis� to identify the major contributing factors associated with the local rates of re-hospitalization. Develop and/or implement intervention strategies to address driving factors

8. Drivers of Readmissions Low Patient Activation Lack of Standard or Known Process Inadequate Transfer of Information 8 These 3 drivers were identified based on data analyzed across all 14 participating QIOs regarding metrics such as patient satisfaction and knowledge, reasons for readmissions, ED visits, post- discharge follow-up care. QIO�s also conducted interviews with providers in community forums to identify gaps across the transition. There may be additional drivers that we have not identified. 1- the patient and/or family is not engaged in the healthcare process. 2- there are gaps in processes within a provider or provider group. For example- not having a focused plan of care for CHF patients, or not having a uniform discharge transfer tool. 3- there is not an existing process to communicate information between providers at discharge. This includes both the next care provider and the PCP. These 3 drivers were identified based on data analyzed across all 14 participating QIOs regarding metrics such as patient satisfaction and knowledge, reasons for readmissions, ED visits, post- discharge follow-up care. QIO�s also conducted interviews with providers in community forums to identify gaps across the transition. There may be additional drivers that we have not identified. 1- the patient and/or family is not engaged in the healthcare process. 2- there are gaps in processes within a provider or provider group. For example- not having a focused plan of care for CHF patients, or not having a uniform discharge transfer tool. 3- there is not an existing process to communicate information between providers at discharge. This includes both the next care provider and the PCP.

9. Theoretical Model 9

10. Problems that Result from Low Patient Activation Inadequate self-management Return to hospital (readmissions) Return to ED Medication Errors 10

11. Interventions to Address Low Patient Activation Care Transitions Intervention (CTITM) Coleman, et al. 2004, 2005, 2006. Other coaching models Patient Education models- ie. Teach-back Community Supports Personal health record (PHR) 11 Interventions can impact more than one driver. Many HHA incorporating coaching model into practice Interventions can impact more than one driver. Many HHA incorporating coaching model into practice

12. Problems Resulting from a Lack of Standard & Known Processes 1) Patients not getting adequate follow-up care 2) Physicians (PCPs) not aware of hospitalization 3) Home Care not utilized adequately 12

13. Problems Resulting from a Lack of Standard & Known Processes (continued) 4) Return to hospital (readmissions) 5) Return to ED 6) Palliative care not utilized and/or Hospice referral not made until last days 13

14. Best Practices Intervention Package (BPIP): Transitional Care Coordination Implemented by 11 QIO Communities Description: Comprehensive manual for home health agency leadership and staff to identify tools and processes to improve patient transitions; focus on the four pillars, or conceptual domains, of patient transition; includes tools and resources for patients and staff, guidelines and podcasts Resource: http://www.homehealthquality.org/hh/ed_resources/interventionpackages/default.aspx Evidence: Esslinger (2008): Preliminary data demonstrate modest improvements in hospitalization rata among participating HHAs and worsening among non-participating HHAs. Schade et al. (2009): Agencies w/ improvement more likely to report activities consistent with campaign and use of campaign interventions, regardless of participation status. Hospitalization Risk Assessment Emergency Care Planning Medication Management Frontloading Visits Patient Self-Management Disease Management Using clinical pathways Pt teaching about med management/ Red Flaggs/PHR Telemonitoring Hospitalization Risk Assessment Emergency Care Planning Medication Management Frontloading Visits Patient Self-Management Disease Management Using clinical pathways Pt teaching about med management/ Red Flaggs/PHR Telemonitoring

15. Problems Resulting from Poor Information Transfer Patients not getting adequate follow-up care Physicians (PCPs) not aware of hospitalization Un-necessary labs/procedures Home Care not continued Receiving provider not getting adequate information Advanced directives not followed 15

16. Intervention Strategies to Improve Communication across the Transition Enhanced information transfer at discharge Follow-up care established at discharge Medication management Plan of care Telemedicine Telephone follow-up Electronic health record / electronic medical record Universal transfer forms- many communities have collaborated to create a form useful across provider types. Increased timeliness of d/c summary, improved discharge instructions. Implemented by 14 QIO Communities Implemented by 4 QIO Communities Implemented by 10 QIO Communities Implemented by 4 QIO Communities Implemented by 4 QIO Communities Implemented by 8 QIO Communities Implemented by 3 QIO Communities Universal transfer forms- many communities have collaborated to create a form useful across provider types. Increased timeliness of d/c summary, improved discharge instructions. Implemented by 14 QIO Communities Implemented by 4 QIO Communities Implemented by 10 QIO Communities Implemented by 4 QIO Communities Implemented by 4 QIO Communities Implemented by 8 QIO Communities Implemented by 3 QIO Communities

17. What Have We Learned? In general community meetings are a catalytic point in project Community recruitment/engagement took longer than anticipated Have a coach ready to go. Focus on sustainability 17 Those QIOs that had a community meeting early on were more likely implement interventions sooner. Anticipated 3 months for community recruitment and has ranged from 3 months to almost 12 months to get the optimal level of providers engaged. Communities where the QIO hired a coach have had much more early success and faster implementation. Sustainability comes after a coach is proven to be effective at improving care, increasing satisfaction and reducing readmissions and providers can see the benefit to hire a coach. Some QIOs are working with volunteers or other funding sources ( eg. Area Agencies on Aging-AAA) but this has taken longer to organize and move forward. QIOs are working with communities to implement strategies and work through change processes. The goal is to demonstrate the benefits of these changes in order for the community to have incentive to continue the strategies into the future.Those QIOs that had a community meeting early on were more likely implement interventions sooner. Anticipated 3 months for community recruitment and has ranged from 3 months to almost 12 months to get the optimal level of providers engaged. Communities where the QIO hired a coach have had much more early success and faster implementation. Sustainability comes after a coach is proven to be effective at improving care, increasing satisfaction and reducing readmissions and providers can see the benefit to hire a coach. Some QIOs are working with volunteers or other funding sources ( eg. Area Agencies on Aging-AAA) but this has taken longer to organize and move forward. QIOs are working with communities to implement strategies and work through change processes. The goal is to demonstrate the benefits of these changes in order for the community to have incentive to continue the strategies into the future.

18. For More Information Please go to: http://www.cfmc.org/caretransitions