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AHA/HRET HEN: Data and Coaching Webinar: Reducing Readmissions

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  1. AHA/HRET HEN:Data and Coaching Webinar:Reducing Readmissions Data Review June 4, 2012 1:00 – 2:00 PM, CDT

  2. Welcome and Overview • Welcome, thank you for joining us today! • Housekeeping: • This webinar is being recorded and will be archived. • You will receive a PDF of today’s presentation, later this week, as well as a link to fill-out the evaluation, a summary of Q&A and a link for the recording. • For questions: please reach out to your state lead – or email us: HEN@aha.org. • Agenda: • Readmission Measures • Content Review • Hospital Story • Teach Back

  3. Polling Questions (#1 and #2)How Many of You are Joining Us From: • Hospital type? • A. General Medical / Surgical • B. Teaching • C. Rural • D. Children’s • E. Long-term Care • F. Psychiatric • Hospital size? • A. CAH • B. Not CHA, <100 beds • C. Not CAH, 100-299 beds • D. Not CAH, 300+ beds

  4. Objectives: Readmission Data and Measures • Review data requirements • Discuss measures listed in the HRET Encyclopedia of Measures • Review measure definitions and interpretation examples • Discuss options for organization-defined measures

  5. Introductions • Janine Douglass, MPH, CIC, HRET • Bruce Spurlock, MD, Cynosure Health • Charisse Coulombe, MS, MBA, HRET • Denise Remus, PhD, RN, Cynosure Health

  6. Readmission Data Management Strategy Charisse Coulombe, MS, MBA Data Director, HRET

  7. Readmission Opportunity? Do you know what your readmission rates are? Overall? For AMI, HF and/or Pneumonia? Compared to other hospitals in your area? State? National?

  8. What is Your AIMS Statement? Reduce AMI readmissions by 20% by December 31, 2013 By the end of 2013, reduce readmissions for heart failure patients by 30% Reduce same-hospital readmissions by 20% by December 31, 2013

  9. Measures are used to assess the impact of changes To demonstrate hospitals have reduced their readmissions rates over the two-year period To monitor that interventions to reduce readmissions are working Part of the PDSA cycle Why is Readmission Data Needed?

  10. At a minimum, 1 process measure and 1 outcome measure: Process: Measures interactions between healthcare practitioner and patient; a series of actions, changes or functions bringing about a result Outcome: Measures change or the end result of healthcare intervention What Readmission Data is Needed?

  11. Technical manual to ensure the hospital's measure definitions align with the comprehensive data system (CDS) Comprehensive details about measure characteristics: Topic Measure Name Definition Numerator, Denominator Calculation specifications Source(s) Encyclopedia of Measures

  12. Process Measures – recommended: Completion of Discharge Bundle (Project BOOST) Completion of Patient Care Plan (Project RED) Formal Assessment of Patients Risk of Readmission (Project RED / BOOST) Patients Receiving Complete Discharge Education Verified by Teach-Back or Other Means (Project Red / BOOST) Preventable Readmissions

  13. Process Measures – alternate: Evaluation of LVS Function (HF-2) Heart Failure (HF) Discharge Instructions (HF-1) (Readmission) Pediatric Asthma: Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver (CAC-3) Psychiatric Patients - Post Discharge Continuing Care Plan Transmitted- Overall Rate (HBIPS-7) Psychiatric Patients with Post Discharge Plan - Overall Rate (HBIPS-6) Timely Transmission of Transition Record (Inpatients) Preventable Readmissions

  14. Identification of high risk patients by using a formal risk assessment tool Process Measure: Formal Assessment of Patient Risk of Readmission Numerator: Number of patients who were assessed for risk of readmission using the formal tool Denominator: All eligible patients Readmission Process Measures

  15. Completion of Bundle/Care Plan/Discharge Instructions Research has shown that all elements of the discharge process must be completed Readmission process measures look to see if all elements are completed If elements are consistently being missed/skipped, opportunity to have the readmission team review the process to see where issues are. Readmission Process Measures

  16. Has your hospital selected your readmission process measure(s): A. Yes, selected and actively tracking B. Yes, only selected (the measure) C. No, still researching Polling Question (#3) 16

  17. Outcome – recommended: Readmission within 15 days (All Cause) Readmission within 30 days (All Cause) Outcome – alternate: Acute Myocardial Infarction (AMI) Patients - Readmissions within 30 days (All Cause) Heart Failure (HF) Patients - Readmissions within 30 days (All Cause) Pneumonia (PN) Patients - Readmissions within 30 days (All Cause) Preventable Readmissions

  18. Numerator: Number of patients who were readmitted to the facility within 30 days of their index discharge Denominator: Number of patients who were discharged alive from the facility for that month (all those patients that have the potential for returning to a hospital within 30 days) Readmission Outcome Numerator and Denominator

  19. Admission: Patient is admitted to hospital with an inpatient status Index discharge: Patient is discharged from the hospital (alive) Readmission: Patient comes back to hospital (within a pre-determined amount of time) and is admitted with an inpatient status All Cause Readmission: When patient is readmitted to the hospital for any reason (related or unrelated to index discharge diagnosis/DRG) Readmission Terms

  20. Inpatient Readmissions: Patient’s index discharge and subsequent readmission to the inpatient setting Patient admitted to observation within 30 days of discharge Not counted as a readmission but should evaluate Patient seen in Emergency Room within 30 days of discharge Not counted as a readmission but should evaluate Patient Encounters

  21. Readmissions are counted in the index discharge month. If the patient’s index discharge is March 31, 2012 and they return to the hospital on April 15th, the readmission counts in the March numerator, not April. This is why the data collection deadline are 2 months out (you need to give the patient 30 days to come back to the hospital). What Month are Readmissions Counted In?

  22. Index Discharge is counted in the March denominator Readmission is counted in the March numerator How are Readmissions Counted? Index Discharge March 15, 2012 Readmission April 4, 2012 20 days from index discharge to readmission

  23. Index Discharge is counted in the March denominator Readmission is not counted in the March numerator How are Readmissions Counted? Index Discharge March 15, 2012 Readmission April 17, 2012 > 30 days from index discharge to readmission

  24. Index Discharge counted in March denominator Only 1 of the readmissions would count in the March numerator (answers the CMS question – was the patient readmitted within 30 days: Yes/No) Index Discharge March 15, 2012 Readmission April 4, 2012 Readmission April 10, 2012 How are Readmissions Counted? 20 days from index discharge to readmission 26 days from index discharge to readmission

  25. Index Discharge counted in March denominator Only 1 of the readmissions would count in the March numerator (answers the CMS question – was the patient readmitted within 30 days: Yes/No) Index Discharge March 15, 2012 Readmission April 4, 2012 Readmission April 10, 2012 How are Readmissions Counted? 20 days from index discharge to readmission 26 days from index discharge to readmission

  26. Readmission Rate 50 patients discharged alive in the month of March – Denominator 5 patients readmitted within 30 days - Numerator 5/50 * 100 = 10% Readmission Rate

  27. Bob’s index discharge is March 1st and is readmitted on March 15th He is in March numerator and denominator. Allie’s index discharge is March 15th and is readmitted on May 2nd She is in the March denominator but not in the numerator. Rita’s index discharge is March 20th and is readmitted on April 14th She is in the March numerator and denominator. Scenarios

  28. Sheila’s index discharge is March 12th and is readmitted on March 15th and April 14th She is in March numerator and denominator. The April 14th admission is not counted towards March. Tori’s index discharge for heart failure is January 1st and was readmitted on January 15th, January 25th and February 10th She is counted as a readmission based on the 1/1 since 1/15 and 1/25 fall within the 30 days. 2/10 is the admission that “resets” the readmission count. If Tori is readmitted within 30 day, she will be counted as a readmitted patient. Scenarios

  29. Has your hospital selected your readmission outcome measure(s): A. Yes, selected and actively tracking B. Yes, only selected (the measure) C. No, still researching Polling Question (#4)

  30. The 30-day readmission measures focus on Medicare fee-for-service patients and patients admitted to Veterans Administration (VA) hospitals, at least 65 years of age, with a principal diagnosis of AMI, HF, or PN on the index discharge CMS has access to hospitals’ administrative Medicare claims so if your Medicare patient is discharged and readmitted to a different inpatient hospital, CMS counts that readmission How Does CMS Count Readmissions on Hospital Compare?

  31. Medicare Payment Advisory Committee identified those 3 diagnosis readmissions as common, costly and often preventable According to CMS: Readmission for any cause is an adverse event Hard to exclude quality issues and accountability based on diagnosis (e.g. HF patient that gets a Hospital Acquired Infection during the index stay and is readmitted with sepsis) Why is CMS Looking at All Cause AMI, HF and PN Readmissions on Hospital Compare?

  32. CMS uses a 3 year period for readmission calculation CMS uses risk adjusted methodology CMS counts multiple readmissions within the 30 day period as 1 readmission (answering the question – was the patient readmitted within 30 days, Yes/No) CMS counts your patients that are readmitted to other hospitals Planned/elective readmissions not counted for AMI patient population if they are readmitted for CABG or PTCA procedures CMS Readmissions on Hospital Compare

  33. CMS uses risk standardized readmission rates Number of Readmissions within 30 days predicted based on the hospital’s performance with its observed case-mix Number of Readmissions expected based on the nation’s performance with that hospital’s case-mix Hospitals are not able to replicate the RSRR independently Resource: http://www.qualitynet.org CMS Risk-Adjustment Readmission Methodology on Hospital Compare

  34. CMS plans to release updated data to Hospital Compare in July, 2012 Will include data from July 1, 2008 – June 30, 2011 CMS updated measure code to accommodate 25 diagnosis codes (increased from 10); accommodate 25 procedure codes (increased from 6) and includes 12 additional e-code slots Readmission Data Update to Hospital Compare 34

  35. A hospital collects readmission measures that are not included in the Encyclopedia of Measures or use different operational definitions Data system allows the hospital to create an organization-defined measure Hospital specifies the numerator and denominator definitions in addition to entering their data Organization-Defined Readmission Measure

  36. Baseline Timeframe flexible Can submit 1 year, 6 months , or whatever is available Data set that will be used for comparison to the measurement period(s) Measurement (2 years) Submitted in monthly increments Data set that will be compared to the baseline to determine if improvement is occurring What Readmission Data is Submitted?

  37. Current: Hospital directly enters all readmission data into CDS In Progress: State-level data warehouse readmission data gets uploaded to CDS by HRET Note: Only collecting aggregate hospital-level readmission data Readmission Data Collection & Submission

  38. Polling Question (#5) • What type of challenges does your hospital have related to collecting data on readmissions? • A. Billing data not processed in a timely fashion • B. Chart review only available (no electronic system to calculate readmission) • C. Readmission data not given to front-line staff/team in a timely fashion (within 20 days of close of month) • D. Difficulty in tracking patient (master patient index number not available, medical record numbers differ from admission to admission) • E. A combination of A, B, C and D

  39. Polling Question (#6) • Who is currently reviewing readmission data on a monthly basis? • A. Board of Directors/Quality Committee of Board • B. Senior leadership of your hospital/system (e.g. CEO, VPs) • C. Case Management only • D. Nursing only • E. Interdisciplinary Readmission Team • F. All of the Above • G. Combination of A, B, C, D

  40. Questions? ? … Thank you for joining us! We will now transition into the Coaching session of the webinar.

  41. AHA/HRET HEN:Data and Coaching Webinar:Reducing Readmissions Coaching Session June 4, 2012 2:00 – 3:00 PM, CDT

  42. Welcome and Overview • Welcome, thank you for joining us today! • Housekeeping: • This webinar is being recorded and will be archived. • You will receive a PDF of today’s presentation, later this week, as well as a link to fill-out the evaluation, a summary of Q&A and a link for the recording. • For questions: please reach out to your state lead – or email us: HEN@aha.org. • Agenda: • Content Review • Hospital Story • Teach Back 42

  43. Objectives • Discuss best practices in reducing readmissions • Lean how other hospitals have implemented tests of change and lessons learned • Identify improvement strategies to test in your organization

  44. Introductions • Janine Douglass, MPH, CIC, HRET • Bruce Spurlock, MD, Cynosure Health • Denise Remus, PhD, RN, Cynosure Health • Dean Schillinger, MD, UCSF Professor of Medicine and Director, Center for Vulnerable Populations, San Francisco General Hospital • Joan Carroll, RN, BA, CDMS, CCM, Director of Care Transitions, Lee Memorial Health System

  45. Bridging the Communication Gap to Prevent Readmissions: The “Teach Back Method” (a.k.a. “Closing the Loop”) Dean Schillinger, MD UCSF Professor of Medicine Director, Center for Vulnerable Populations San Francisco General Hospital

  46. Objectives • Provide 3 actionable tips to improve communication at discharge: • Reduce jargon • Assess for medication discordance • Use teach-back technique (aka teach-to-goal, closing the loop, show-me-approach)

  47. Medical Jargon GLUCOMETER HEMOGLOBIN A1c DIALYSIS ANGINA RISK FACTORS CREATININE

  48. Function of Jargon

  49. …clarified Angina Microalbuminuria Ophthalmology Genetic Creatinine Symptoms Jargon Terms … unclarified • Glucometer • Immunizations • Weight is stable • Microvascular complication • System of nerves • HbA1c • EKG abnormalities • Dialysis • Wide range • Risk factors • Kidney function • Interact • washed out of your system • receptors • short course • renal clinic • blood cells • increase your R • screening • vaccine • CAT scan • blood count • correlate • stool was negative • stool • baseline • respiratory tract • polyp • …from Patient’s own visit: • benign • blood drawn • blood count