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Improving Transitions from Hospital to Community Care: Models that Work. David G. Schulke Vice President, Research Health Research and Educational Trust [email protected] (202) 626-2319 October 18, 2011. The Health Research and Educational Trust (HRET).

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Improving transitions from hospital to community care models that work

Improving Transitions from Hospital to Community Care: Models that Work

David G. SchulkeVice President, Research Health Research and Educational Trust

[email protected]

(202) 626-2319

October 18, 2011

The health research and educational trust hret
The Health Research and Educational Trust (HRET) Models that Work

HRET’s mission is to transform health care through research and education.

AHRQ has retained HRET to support state-based Learning Networks with trainings for providers that wish to use AHRQ’s patient safety tools.

Primary tools supported include Project RED (readmissions reduction), HCAHPS (patient satisfaction), VTE prevention, ED flow management.

Overview of presentation

Review research behind new financial incentives to reduce readmissions in the Patient Protection and Affordable Care Act (ACA).

Examine the importance of patient centered care and the relationship between hospitals and other providers in the community.

Describe proven strategies hospitals use to improve care and protect against financial penalties, focusing on Project RED.

Overview of Presentation

The discharge process and post hospital care influence rehospitalization rates
The Discharge Process and Post-hospital Care readmissions in the Patient Protection and Affordable Care Act (ACA).Influence Rehospitalization Rates

  • 19% of Medicare inpatients are readmitted by 30 days.

  • Only half of the patients re-hospitalized within 30 days saw their doctor before their readmission.

  • As many as 90% of rehospitalizations within 30 days appear to be unplanned.

  • Cost to Medicare estimated at $17 Billion/year.

    Source: Jencks et al N Engl J Med 2009;360:1418-28

How many readmissions should be prevented
How Many Readmissions readmissions in the Patient Protection and Affordable Care Act (ACA).Should be Prevented?

  • What proportion of readmissions are truly “preventable,” with good care? No one knows.

  • Evidence suggests many rehospitalizations result from poor practices and are preventable--

    • Many rehospitalized before seeing a physician

    • High inter-hospital and inter-state variation

    • Randomized clinical trials testing interventions achieve 30+% reduction in readmissions

Business case for hospital action on readmissions
Business Case for readmissions in the Patient Protection and Affordable Care Act (ACA).Hospital Action on Readmissions

  • ALOS for rehospitalized patients is 0.6 day (13.2%) longer than the stay for patients in the same DRG who were not hospitalized in the previous 6 months

  • Medicare payment for rehospitalizations is 4% lower than for index hospitalization

  • For hospitals with excess readmissions: Penalty of 1% of all Medicare PPS payments in FY 13 (rising to 3% in FY15)

  • Value-based purchasing penalty of 1% of all PPS payments (grows to 2% in future years)

  • If your system has competitive pricing pressure: these are all inefficiencies others are driving out of their systems

Federal penalties for avoidable readmissions
Federal Penalties for Avoidable Readmissions readmissions in the Patient Protection and Affordable Care Act (ACA).

  • Penalties on hospitals with readmissions above expected rates for targeted conditions (AMI, CAP, CHF), starting October 1, 2012

  • Penalties will reduce hospital payments by at least $7 Billion over 10 years

    • Exempt: Sole community hospitals, Medicare-dependent rural hospitals, low volume conditions

  • CMS proposes more conditions for 2014—

    • Chronic Obstructive Lung Disease

    • Coronary Artery Bypass Graft surgery

    • Percutaneous Coronary Interventions

    • Vascular Procedures

Potential financial impact of readmissions penalty at a small community hospital
Potential Financial Impact of Readmissions Penalty at a Small Community Hospital

Laurens County Health System (76 acute, 14 SNF beds) and SCHA modeled potential annual effect of penalties:

Financial incentives medicare hospital value based purchasing
Financial Incentives: Small Community HospitalMedicare Hospital Value Based Purchasing

  • Medicare VBP program pays hospitals for actual performance on quality measures, not just reporting measures, beginning FY13

  • The VBP program will apply to all acute-care PPS hospitals (VBP demonstration for CAHs)

  • Funded by reducing all Medicare DRG payments by 1%, redistributed to best performers

    • A hospital that meets or exceeds the performance standards will be eligible to earn back the initially withheld money (or more if others perform poorly)

Value based purchasing higher scores with strong discharge and follow up processes
Value Based Purchasing: Higher Scores with Strong Discharge and Follow up Processes

  • H-CAHPS accounts for 30% of hospital VBP score

  • Four patient perceptions measured by H-CAHPS are better predictors of readmissions than core clinical measures:

    • “During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?” and

    • “During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”

    • “How do you rate the hospital overall?”

    • “Would you recommend the hospital to friends and family?”

Discharge process must address breakdowns leading to avoidable readmissions
Discharge Process Must Address Breakdowns Leading to Avoidable Readmissions

Breakdowns include:

  • Inadequate communication with primary care physicians

  • Inadequate education of patient

  • Drug therapy

  • Poor coordination with other community providers

Process breakdown poor transfer of information to primary care physician
Process Breakdown: Poor Transfer of Information to Primary Care Physician

  • 25% pts require additional outpt work-ups: 1/3 incomplete (Source: Archives of Internal Medicine. 2007; 167: 1305-11)

  • 41% inpatients discharged w/ pending test result

    • 2/3 of physicians unaware of results

    • 37% of tests actionable and 13% urgent

      (Source: Annals of Internal Medicine. 2005; 143(2): 121-8)

  • Discharge summary not readily available:

    • Only 12-34% at first post-discharge appt; 51-77% at 4 weeks

  • Discharge summary lacking key components:

    • Hospital course (7-22%)

    • Discharge medications (2-40%)

    • Test results (33-63%)

    • Pending tests (65%)

    • Follow-up plans (2-43%)

      (Source: JAMA 2007; 297(8): 831-41)

Process breakdowns poor pre discharge patient education
Process Breakdowns: Poor Pre-discharge Patient Education Care Physician

  • Poor transfer of information to patient:

    • 37% able to state purpose of all medications

    • 14% knew the common side effects

    • 42% able to state their diagnosis

  • Result:

    • Poor patient understanding of how to use medications after hospital discharge

    • Patient doesn’t understand warning signs that warrant an emergency call to their physician

    • Lack of clarity on patient’s end of life care preferences lead to unwanted rehospitalization

      Source: Courtesy of Michael Paasche-Orlow, MD, Mayo Clinic Proceedings. August 2005; 80(8):991-994

Adverse drug events in the transition from hospital to home
Adverse Drug Events in the Transition from Hospital to Home Care Physician

  • Studied 400 consecutive hospital patients discharged home.

  • 19% of patients had an adverse event (AE) within 3 weeks of discharge home.

  • 66% of AEs were adverse drug events

  • Most ADEs were preventable or ameliorable, unlike other Adverse Events.

  • Clinical process improvements suggested by the authors:

    • Identify unresolved problems at discharge

    • Patient education re: treatment plan

    • Post-discharge monitoring and follow up

      (Source: Forster et al, Annals Int Medicine, Feb 2003)

Rates of rehospitalization within 30 days after hospital discharge
Rates of Rehospitalization within 30 days Care Physicianafter Hospital Discharge

Source: Jencks SF, et al. N Engl J Med 2009;360:1418-1428

Hospital Admissions of Short Stay Care Physician

Nursing Home Residents

2006 Medpar Data

Hospital Admissions of Home Health Patients Care Physician

OASIS data in 2008 AHRQ National Healthcare Quality Report

Implications Care Physician

Nursing home, home health agency, hospice, pharmacy, and physician practices influence your hospital admission rates

Coordinating with these providers can help your hospital escape penalties for patient care breakdowns

Reducing readmissions cannot be done as effectively with interventions only within the hospital’s walls

Hospitals should improve their discharge process, but also talk with referral partners to see how to work better together

Mathematica study of effective care coordination march 2009
Mathematica Study of Effective Care Coordination (March 2009)

  • Most claims of high impact care coordination interventions are unproven

  • Mathematica concluded 3 types of change packages are proven effective:

    • Transitional care interventions (Naylor and Coleman)

    • Self-management education interventions (Lorig and Wheeler)

    • Coordinated care interventions (a few sites from the Medicare Coordinated Care Demonstration)

Mathematica study key components of effective transitional care
Mathematica 2009) Study: Key Components of Effective Transitional Care

  • Engage patients early in hospitalization

  • Give patients comprehensive post-discharge instructions on medications, self-care, and symptom recognition and management

  • Assist patients in setting up and keeping follow-up physician appointments

  • Follow patients post-discharge

Impact of project red reengineering the hospital discharge
Impact of Project RED: Medicine, Feb. 2009)Reengineering the Hospital Discharge

  • RED reduced health spending vs. control group

    • More patients reported seeing their PCP

    • Inpatient and ED care reduced by 30%

    • Net: Saved $412/patient (~$19/month)

  • Three key components in Project RED:

    • Discharge Advocate educates hospital patient

    • Give “After Hospital Care Plan” to patient, PCP

    • Pharmacist calls patients 2-4 days post-discharge (most hospitals struggle to arrange pharmacist calls)

Red 11 point checklist
RED 11-point Checklist Medicine, Feb. 2009)

RED has eleven mutually reinforcing components:

Medication reconciliation

Patient education

Follow-up appointments

Outstanding tests

Post-discharge services

Reconcile discharge plan with national guidelines

What to do if problem arises

Written discharge plan

Assess patient understanding

Discharge summary sent to PCP

Telephone reinforcement

Red component 1 reconcile the medications
RED Component #1: Medicine, Feb. 2009)Reconcile the Medications

Reconcile the patient’s home medication list upon admission to the hospital

Review each medication; make sure that the patient knows why they take it

Discuss new medications each day with medical team and with patient

Red component 2 educate the patient
RED Component #2: Educate the Patient Medicine, Feb. 2009)

Educate patient throughout the hospital stay

The Project RED intervention starts within 24 hours of the patient’s admission to the hospital and continues daily until completion of the post-discharge telephone follow up call to the patient

Red component 3 reconcile discharge plan with national guidelines
RED Component #3: Reconcile Discharge Plan with National Guidelines

Example: Discharge medication orders for ACEIs/ARBs for Heart Failure patients

Communicate with medical team each day about the discharge plan

Recommend actions that should be taken for each patient under a given diagnosis

Schedule PCP appointment for the patient, to occur within 2 weeks after discharge

Review, with the patient, the provider’s location, transportation and plan to get to appointment

Consult with patient regarding best day and time for appointments

Discuss, with the patient, the reasons for and importance of all follow-up appointments and testing

RED Component #4: Make appointments for clinician follow-up and post-discharge testing

Red component 5 discuss with patient pending tests studies and who will follow up
RED Component #5: Discuss with Patient Pending Tests/studies and Who will Follow up

Explain tests and studies done while in the hospital and tell the patient which clinician is responsible for reviewing the results

Encourage the patient to discuss tests his/her PCP

Let the patient know that this information will be listed on the AHCP

Red component 6 organize post discharge services

RED Component #6: Tests/studies and Who will Follow upOrganize Post-discharge Services

Collaborate with case manager and social worker about patient needs and post-discharge services

Provide patient with contact information for these services (phone number, name of company, etc.)

Red component 7 give the patient a written discharge plan before discharge
RED Component #7: Give the Patient a Written Discharge Plan Before Discharge

The After Hospital Care Plan (AHCP) should include, in plain language understandable to the patient:

1) Principal discharge diagnosis

2) Discharge medication instructions

3) Follow-up appointments with contact


4) Pending test results

5) Tests that require follow up

Red component 8 review with the patient steps to take if a problem arises
RED Component #8: Review with the Patient Steps to Take if a Problem Arises

  • Review with the patient—

  • What’s an emergency vs. a common problem

  • What to do if a question or a problem arises

  • Where in After Hospital Care Plan to find contact information for the discharge advocate and PCP to answer questions after discharge

  • HCAHPS questions about the discharge process:

    • Q 19: “During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?”

    • Q 20: “During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”

Red component 9 teach the patient the ahcp and ask the patient to tell you the details of the plan
RED Component #9: Teach the Patient the AHCP, and ask the Patient to Tell You the Details of the Plan

Explain post hospital care and post-discharge medications in a way the patient understands, including how to take the meds and how and where prescription can be filled 

Communicate this information to the accepting physician

Deliver information to reach those with a low health literacy level

Include caregivers when appropriate

Utilize professional interpreters as needed

Red component 10 expedite transmission of the discharge summary to the pcp
RED Component #10: Expedite Transmission of the Discharge Summary to the PCP

Fax the discharge summary and AHCP to PCP within 24 hours after discharge

National Quality Forum Safe Practice SP-15:

“Reliable information from the primary care physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods”

“A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.”

Red component 11 telephone reinforcement of the after hospital care plan after discharge
RED Component #11: Telephone Reinforcement of the After Hospital Care Plan after Discharge

RED intervention calls for a pharmacist to call the patient within 72 hours after discharge

If pharmacist unavailable, have pharmacist help with “script” and available for back up

Why? Because most patients leave with drug therapy, most post-discharge adverse events are drug problems, and 2/3 of adverse drug events are preventable or ameliorable

Assess patient status

Review medication plan

Review follow-up appointments

Take appropriate actions to resolve problems

Compare your discharge process with red checklist to find improvement opportunities
Compare Your Discharge Process with RED Checklist to find Improvement Opportunities

Sample Current State Process

Discharge order

Discharge Instruction Form

Discharge teaching on day of discharge

No Discharge Advocate

No appt scheduled

No post DC phone call

No PCP DC Summary

Source: JCR

Project RED components

Med Reconciliation

National guideline used

Follow up Appointment

Outstanding Tests

Post DC services

Written DC Care Plan

Problem vs. Emergency

Patient Education

Assess Patient Learning

DC Summary to PCP

Post DC Phone Call

Ahrq s consumer version of the project red after hospital care plan
AHRQ’s Consumer Version of the Improvement OpportunitiesProject RED “After Hospital Care Plan"

  • Project RED research team created this tool to help--

    • Keep track of medications

    • Patients talk with hospital staff and primary care doctor

    • Family assist patients

  • Get it free from AHRQ:

H ealth care leader action guide
H Improvement Opportunitiesealth Care Leader Action Guide

  • Provides strategies for you to–

  • Examine your hospital’s current rate of readmissions

  • Assess and prioritize your improvement opportunities

  • Develop an action plan of strategies to implement

  • Monitor your hospital’s progress

  • Get it free at

Other ahrq and cms funded tools to help reduce avoidable readmissions continued
Other AHRQ and CMS-funded Tools to Help Reduce Avoidable Readmissions (continued)

TeamSTEPPS, a method for improving team communication and patient safety culture among hospital staff

Care Transitions Toolkit–free resources at QIO site:

QIO program Home Health Quality Improvement project’s patient risk assessment tool for Home Health Agencies:

QIO program originated toolkit for nursing homes:

Thank you! Readmissions (continued)

Your Questions and Comments are Welcome!